INTEGRATED GOVERNANCE AND PERFORMANCE REPORT NHS Lambeth Clinical Commissioning MAY 2016 Our Mission: Our Mission is to improve the health and reduce health inequalities of Lambeth people and to commission the highest quality health services on their behalf.
Contents 1
INTRODUCTION................................................................................................ 1
2
EXECUTIVE SUMMARIES ................................................................................ 2
2.1
CCG ASSURANCE ........................................................................................... 2
2.1.1 National CCG Assurance Framework ......................................................................... 2
2.2
COMPONENTS OF THE CCG ASSURANCE FRAMEWORK .......................... 2
2.2.1 Well-led Organisation.................................................................................................. 2 2.2.2 Delegated Functions ................................................................................................... 2 2.2.3 Financial Duties .......................................................................................................... 3 2.2.4 Performance ............................................................................................................... 4
2.3
STRATEGIC AND OPERATIONAL DELIVERY ................................................ 6
2.3.1 Programme Assurance Statements ............................................................................ 6
2.4
QUALITY ASSURANCE .................................................................................... 6
3
CCG ASSURANCE ........................................................................................... 7
3.1
National CCG Assurance Framework 2015/16 ............................................... 7
3.2
NHS Lambeth CCG Assurance 2015/16 ......................................................... 7
4
COMPONENTS OF THE CCG ASSURANCE FRAMEWORK .......................... 8
4.1
Well-led Organisation ...................................................................................... 8
4.1.1 Board Assurance Framework – ................................................................................... 8
4.2
Delegated Functions ...................................................................................... 14
4.3
Financial Management ................................................................................... 14
4.3.1 Financial Position ...................................................................................................... 14 4.3.3 QIPP ......................................................................................................................... 18 4.3.4 QIPP Performance .................................................................................................... 20
4.4
Performance ................................................................................................... 20
4.4.1 NHS England Top 8 Performance Measures and National Constitution Standards ... 21 4.4.2 RTT (Referral to Treatment Times for Lambeth Patients) ......................................... 23 4.4.3 Diagnostics (Lambeth Patients) ................................................................................ 23 4.4.4 A & E Waiting Times ................................................................................................. 25 4.4.5 Cancer Waiting Times............................................................................................... 25 4.4.6 Ambulance Response ............................................................................................... 26 4.4.7 Health Visitors........................................................................................................... 27 4.4.8 Improved Access to Psychological Therapies (IAPT) ................................................ 27 4.4.9 New Early Intervention In Psychosis 2 Week Standard ............................................. 27 4.4.10 Dementia Diagnosis Rate ......................................................................................... 28
4.4.11 Transforming Care .................................................................................................... 29
5
STRATEGIC AND OPERATIONAL DELIVERY – OUR PROGRAMMES ...... 32
5.1
Integrated Children and Young People (including Maternity) Programme 32
5.1.1 Programme Assurance Statement ............................................................................ 32 5.1.2 Integrated Children and Young People (including maternity) Programme Risk Register 33 5.1.3 Children and Maternity Programme Board Dashboard .............................................. 36 5.1.4 Key Deliverables ....................................................................................................... 37
5.2
Integrated Adults Programme (Elective, Long Term Conditions, Older
People, Urgent Care) ............................................................................................... 44 5.2.1 Programme Assurance Statement ............................................................................ 44 5.2.2 Integrated Adults (Elective, Long Term Conditions, Older People, Urgent Care) Programme Risk Register .................................................................................................... 45 5.2.3 Integrated Adults Dashboard .................................................................................... 48 5.2.4 Elective ..................................................................................................................... 50 5.2.5 Long Term Conditions/Medicines Optimisation ......................................................... 53 5.2.6 Older People ............................................................................................................. 71 5.2.7 Continuing Healthcare .............................................................................................. 76 5.2.8 Urgent Care .............................................................................................................. 78
5.3
Integrated Mental Health for Adults .............................................................. 82
5.3.1 Programme Assurance Statement ............................................................................ 83 5.3.2 Integrated Mental Health for Adults Programme Risk Register ................................. 84 5.3.3 Mental Health Whole System Dashboard.................................................................. 85 5.3.4 Key Deliverables ....................................................................................................... 87
5.4
Staying Healthy (Led by London Borough of Lambeth) ............................. 89
5.4.1 Programme Assurance Statement ............................................................................ 91 5.4.2 Staying Healthy Dashboard ...................................................................................... 92 5.4.3 Risk Register ............................................................................................................ 96 5.4.4 Key Deliverables ....................................................................................................... 97
5.5
Primary Care Development ......................................................................... 101
5.5.1 Programme Assurance Statement .......................................................................... 102 5.5.2 Primary Care Development Programme Risk Register ........................................... 102 5.5.3 Primary Care Programme Dashboard ..................................................................... 106 5.5.4 Key Deliverables ..................................................................................................... 107
5.6
Enabler Programmes ................................................................................... 112
5.6.1 Governance and Development Risk Register.......................................................... 112 5.6.2 Equalities ................................................................................................................ 115 5.6.3 ICT.......................................................................................................................... 116 5.6.4 Estates.................................................................................................................... 119 5.6.5 Workforce ............................................................................................................... 123
6
QUALITY ASSURANCE ................................................................................ 126
6.1
Provider Quality Report ............................................................................... 126
6.2
Complaints and PALS .................................................................................. 126
6.3
Serious Incidents ......................................................................................... 126
6.4
Never Events ................................................................................................ 126
6.5
Quality Alerts ................................................................................................ 127
6.6
Infection Control .......................................................................................... 127
6.7
Mixed Sex Accommodation......................................................................... 127
6.8
Freedom of Information (FOI)...................................................................... 128
6.9
Quality Premium........................................................................................... 129
6.10
Better Care Fund ....................................................................................... 132
Acronyms AMH
Adult Mental Health
CCG
Clinical Commissioning Group
BCP
Business Continuity Plan
CQC
Care Quality Commission
CQRG
Clinical Quality Review Group
CQUIN
Commissioning for Quality and Innovation Payment
CSU
Commissioning Support Unit
CTR
Care and Treatment Review
EIA
Equality Impact Assessments
EIP
Early Intervention in Psychosis
EPRR
Emergency Preparedness Resilience and Response
FPN
Fair Processing Notice
GSTFT
Guy’s and St. Thomas’ NHS Foundation Trust
IPSA
Integrated Personal Support Alliance
IST
Intensive Support Team
IT
Information Technology
KCH
Kings College Hospital NHS Foundation Trust
LCCG
Lambeth Clinical Commissioning Group
LCSB
Local Children’s Safeguarding Board
LWN
Living Well Network
NHSE
NHS England
PMO
Programme Management Office
PTL
Patient Tracking List
PCIF
Primary Care Infrastructure Fund
PRUH
Princess Royal University Hospital, Bromley
QIPP
Quality Efficiency Productivity and Prevention
SCR
Serious Case Review
SEL
South East London
SLaM
South London and Maudesley NHS Foundation Trust
UCC
Urgent Care Centre
SMI
Serious Mental Illness
LAC
Looked After Children
MECS
Minor Eye Condition Scheme
YOS
Youth Offending Service
BME
Black and Minority Ethnic
CWD
Children with Disabilities
CLAMHS
Children Looked After Mental Health Service
EQA
Equality Analysis
H@H
Hospital at Home
PLT
Protected Learning Time
IRT
Integrated Respiratory Team
1 INTRODUCTION NHS Lambeth Clinical Commissioning Group (CCG) comprises 47 member GP Practices organised into three localities. The NHS Lambeth CCG Governing Body is responsible for ensuring that the CCG has appropriate arrangements in place to exercise its functions effectively, efficiently and economically and in accordance with the CCG Constitution and our principles of good governance. Membership of the Governing Body is drawn from our Member Practices, appointed individuals with statutory roles and nominees from our key Lambeth partners. The Governing Body is supported by the Lambeth Clinical Network. The purpose of the Clinical Network is to provide the CCG Board members with sound clinical advice on commissioning care services, clinical pathways and best practice. The Clinical Network consists of care and clinical “subject matter experts” from within Lambeth including GPs, practice managers, nurses, pharmacists, opticians and social care colleagues. This report sets out how NHS Lambeth CCG is performing against its agreed objectives under the leadership of the NHS Lambeth Clinical Commissioning Governing Body. It is a tool for providing assurance to the Governing Body that objectives are being delivered or, where performance is behind plan, that mitigating actions are in place to address performance improvement. The 2015/16 Business Plan set out NHS Lambeth CCG’s corporate objectives. Later is this report, NHS Lambeth CCG’s Programme Boards and Enabler Work streams report on delivery of their 2015/16 objectives. The Integrated Governance and Performance Report provides a consolidate picture of delivery of NHS Lambeth CCG’s corporate objectives. NHS Lambeth CCG Objectives 2015/16 CCG Corporate Objectives Quality, Safety and Effectiveness
Sustainable Delivery & Governance
To improve health outcomes, address inequalities and secure a parity of esteem
To secure delivery of the NHS constitutional rights and pledges for all Lambeth residents
To improve the quality and safety of local services
To ensure good governance, financial stability of the local health economy, VfM and the delivery of statutory responsibilities
System Transformation To commission proactive care focused upon the prevention and the early detection of illness. Improve outcomes for Lambeth patients and achieve better value, integrated care through transformation programmes delivered in partnership with stakeholders and our residents. To ensure the CCG’s commissioning resource and organisational capability are effectively aligned to deliver its objectives
1
Involvement
To ensure patients and the public play a central role in the commissioning of the services they receive
To ensure effective involvement of member practices and other partners in commissioning decisions
Equality
Enact the Public Sector Equality and Diversity requirements
2 EXECUTIVE SUMMARIES 2.1 CCG ASSURANCE 2.1.1 National CCG Assurance Framework The Quarter 1 2015/16 Assurance Meeting took place on October 16th 2015. NHS Lambeth CCG is being assessed against the revised Assurance Framework for this financial year. The Quarter 2 2015/16 Assurance Meeting was cancelled to allow CCGs to focus on the 2016/17 Operational Plan requirements. However, regional teams continued to meet with CCGs throughout February and March to review and provide feedback submissions made during this time. NHS Lambeth CCG was due to participate in a Deep Dive Review on Continuing Care on the 9 th of March. This has been rescheduled for the 29th of April 2016. The findings of the review will be published in due course.
2.2 COMPONENTS OF THE CCG ASSURANCE FRAMEWORK 2.2.1
Well-led Organisation
The NHS Lambeth CCG Board Assurance Framework (BAF) is included in this report, along with a Heat Map showing the number of risks at each score for all risks recorded on Lambeth CCG’s Risk Register not just those scoring 12 or above. The BAF and supporting Risk Register are living documents, updated regularly.
Risk Matrix Likelihood
Impact 1 Negligible
Risks scoring 12 and above 2 Minor
3 Moderate
4 Major
5 Catastrophic
1 Rare
1x1=1
1x2=2
1x3=3
7
2 Unlikely
2x1=2
2x2=4
1
3 Possible
1
4 Likely
2x3=6
3x2=6
1x5=5
2
5
3x1=3
1x4=4
2x4=8
9 3x3=9
1
2x5=10
1 3x4=12
3x5=15
6
4x1=4
4x2=8
4x3=12
4x4=16
4x5=20
1x5=5
2x5=10
3x5=15
4x5=20
5x5=20
6 4x4=16 4x4=16 4x4=16 4x4=16 4x4=16 4x4=16
2C 2N 2K 2M 5N 5R
A&E Performance RTT Performance Cancer referral to treatment 62 days Community Nursing Vacancy Level SEL Strategy - inadequate workforce capacity SEL Strategy - integrated IT systems
1 3x5=15
1A
Safeguarding children
9 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12
2A 2B 3C 3M 3N 7A 7B 6K PMCF07
Community Nursing Service Improvement Plan Safeguarding Adults Risk to SLaM Contract IPSA Alliance LWN reduction in secondary care demand Financial Planning Risk QIPP delivery risk CSU procurement process risk Sustainability of Access Hubs
1 4x3=12
5S
PMS Contract Review
5 Almost Certain
2.2.2
Delegated Functions
NHS Lambeth CCG currently has no delegated functions. However, the general practice Out-ofHours service, for which the lead commissioner is NHS Southwark CCG, is a directed function. NHS Lambeth CCG is a co-commissioner for primary care with NHS England. The CCG Assurance Framework requires CCGs to return a quarterly self-assessment regarding delivery of these services. Quarters one to three have been submitted. Quarter four is due on the 25th of May 2016.
2
2.2.3
Financial Duties
Financial performance to Month 12 is summarised below.
Key Financial Performance Duties
Performance Area
Commentary
Revenue Surplus
Lambeth CCG is reporting a surplus of £7.753m for the year 2015/16. This is £140k above our target surplus of £7.612m and is in line with our target of delivering a 1% surplus
Cash Limit
Cash balances are planned to be maintained at low levels (less than 1.25% at 31st March 2016. Lambeth CCG's cash balance at bank at the end of March was. The CCG met its statutorycash limit target for the year 2015/16
QIPP
The CCG is forecasting full QIPP delivery of its annual QIPP target of £8.86m.
Public Sector Payment Policy
Public sector payment target is 95% on numbers. The CCG paid 99.09% of NHS invoives based on numbers and 99.88% by value. The CCG is not achieving its target for numbers for Non NHS invoices. Performance for the 12 months is 93.28% on numbers and 95.05% by value.
Running Cost
The CCGs running cost allowance is £7.8m. The CCG is reporting an underspend of £1.05m against its running cost budgets.
3
Final Year End Position
2.2.4 Performance Key performance measures rated as Red – based on latest reported data (please refer to section 4.4 for detailed updates on all targets)
18 weeks RTT – admitted and non-admitted treated Delivery of the admitted and non-admitted treated pathway remains a challenge across London. Kings College Hospital is currently not reporting activity. GSTFT has failed the admitted standard in every month since April 2015. The Trust recovered performance for the non-admitted standard in May and June, but performance has fallen below the 95% target in the other months. This has resulted in failure of the target overall during the first three quarters of 2015/16. Performance for the first two months in quarter four have also been below target. RTT – Incomplete Pathways Performance against this target remains high risk. The target of 92% was met for quarters one and two but not met in quarter 3. The target was missed in January achieving 91.8% and recovered in February 92.5%. 52 week waiters KCH have not been able to provide routine monitoring data for patients waiting longer than 52 weeks for most of 2015/16, however a recent validation process identified a number of long waiters as at the end of February 2016. The Trust wide figure is 182, 21 of these were Lambeth patients. Recovery plans have been put in place and KCH have produced an over 52 week trajectory. A&E Both GSTT and Denmark Hill continue to perform below the 95% standard and this has been the case since December 2015. Published figures for January and February show that achievement of the target is still challenging for both Trusts. February’s data has been published. GSST achieved 88.2% and 82.7% for KCH. Performance will continue to be a challenge and it is unlikely to improve until early April 2016. Cancer Cancer targets are measured on a quarterly basis. The 62 day target was not met in quarters one and two but achieved in quarter three. Improved performance has been noted for the start of quarter four, although performance dipped in February 2016. The Cancer two week wait (GP referral and breast symptoms) targets were also missed. Ambulance Response Times There has been no improvement in performance during 2015/16 to date. LAS continue to struggle to meet this target. Mixed Sex Accommodation Breaches have been reported throughout 2015/16 todate. Four breaches were reported in February 2016. The Trust is not required nationally to report these as mixed sex accommodation breaches however GSTT has chosen to do so for internal monitoring purposes.
4
5
2.3 STRATEGIC AND OPERATIONAL DELIVERY 2.3.1 Programme Assurance Statements Programme
Status/Risks
RAG Rating (Red/Amber/Green)
Integrated Children and Young People (Including Maternity) Integrated Adults (Elective, Long Conditions, Older Adults Urgent Care)
Term
Integrated Mental Health for Adults Staying Healthy Primary Care Development
2.4 QUALITY ASSURANCE The following parts of the CCG’s Quality Assurance Framework are available on a quarterly basis. Quarter 3 2015/16 data is available in this report, alongside the quarterly Provider Quality Report.
Provider Quality Reports Complaints and PALS enquiries Serious Incidents Quality Alerts
NHS England published a revised Serious Incident (SI) Framework in March 2015. All SI issues are monitored. Lambeth CCG was awarded a payment of £336k for the achievement of 2014/15 Quality Premiums. 2014/15 Quality Premiums achieved were Avoidable Emergency Admissions and Improving the reporting of medication related safety incidents.
6
3
CCG ASSURANCE
3.1 National CCG Assurance Framework 2015/16 The CCG Assurance Framework is designed to give assurance that CCGs are operating effectively to commission safe, high quality and sustainable services within their resources. The components of the 2015/16 assurance framework are as follows: Components of the NHS England CCG Assurance Framework 2015/16
In addition, the CCG Assurance Framework 2015/16 focuses on 6 CCG statutory functions which are considered to be ‘Areas requiring a more detailed focus’, as part of the Well Led Organisation component of the Framework. Whilst these areas will not themselves be assured, concerns around them will trigger a review of the Well Led Organisation component of the Framework.
3.2 NHS Lambeth CCG Assurance 2015/16 The Quarter 1 2015/16 Assurance Meeting took place on October 16th 2015. NHS Lambeth CCG is being assessed against the revised Assurance Framework for this financial year. The Quarter 2 2015/16 Assurance Meeting was cancelled to allow CCGs to focus on the 2016/17 Operational Plan requirements. However, regional teams continued to meet with CCGs throughout February and March to review and provide feedback submissions made during this time. NHS Lambeth CCG was due to participate in a Deep Dive Review on Continuing Care on the 9 th of March. This has been rescheduled for the 29th of April 2016. The findings of the review will be published in due course. CCGs are required to complete a quarterly self-assessment for Primary Care and the Out-of-Hours service. Quarter 4 is due on the 25th May 2016.
7
4 COMPONENTS OF THE CCG ASSURANCE FRAMEWORK 4.1 Well-led Organisation 4.1.1
Board Assurance Framework
The NHS Lambeth CCG Board Assurance Framework (BAF) is included along with a Heat Map showing the number of risks at each score for all risks recorded on Lambeth CCG’s Risk Register not just those scoring 12 or above. The BAF and supporting Risk Register are living documents, updated regularly. The BAF includes the key mitigating actions and tracks progress of risk scores over the previous 12 months. Risk Matrix Likelihood
Impact 1 Negligible
Risks scoring 12 and above 2 Minor
3 Moderate
4 Major
5 Catastrophic
1 Rare
1x1=1
1x2=2
1x3=3
7
2 Unlikely
2x1=2
2x2=4
1
3 Possible
1
4 Likely
2x3=6
3x2=6
1x5=5
2
5
3x1=3
1x4=4
2x4=8
9 3x3=9
1
2x5=10
1 3x4=12
3x5=15
6
4x1=4
4x2=8
4x3=12
4x4=16
4x5=20
1x5=5
2x5=10
3x5=15
4x5=20
5x5=20
5 Almost Certain
There are currently 17 risks rated 12 or above. 8
6 4x4=16 4x4=16 4x4=16 4x4=16 4x4=16 4x4=16
2C 2N 2K 2M 5N 5R
A&E Performance RTT Performance Cancer referral to treatment 62 days Community Nursing Vacancy Level SEL Strategy - inadequate workforce capacity SEL Strategy - integrated IT systems
1 3x5=15
1A
Safeguarding children
9 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12 3x4=12
2A 2B 3C 3M 3N 7A 7B 6K PMCF07
Community Nursing Service Improvement Plan Safeguarding Adults Risk to SLaM Contract IPSA Alliance LWN reduction in secondary care demand Financial Planning Risk QIPP delivery risk CSU procurement process risk Sustainability of Access Hubs
1 4x3=12
5S
PMS Contract Review
UPDATED April 2016
Denis O'Rourke
Corporate Objective 1.1: Quality, Safety & Effectiveness - To improve health outcomes, address inequalities and secure a parity of esteem
3C
Risk to SLaM Contract – possible risk that the delivery of AMH redesigns fails to reduce relapse rates and use of beds
3M
Possible risk that the IPSA Alliance contract fails to deliver service and financial outcomes resulting in poor outcomes for people and financial challenge
Director of Integrated Commissioning , Adults Denis O'Rourke
8
4
Mar
April
2016
Feb
Jan
Dec
Oct
Monthly Progress
Nov
2015
Aug
Target Risk Score and Direction of Travel
Sept
Principal Risk (Obstacle to achievement of Strategic Aim)
Jun
Risk Operation Register al Lead Ref
July
Strategic Aim
Executive Lead
May
ASSURANCE FRAMEWORK 2016/17 – PROGRESS SUMMARY
12 12 12 12 12 12 12 12 12 12 12 12
12 12 12 12 12 12 12 12 12 12 12 12
9
Risk Rated 12 or more
12+
12+
Key Actions
Working with Southwark on AMH re-design – ongoing Proposal to create provider/commissioner forum to monitor impact of SLaM re-design, LWN and IPSA agreed. First meeting of whole system forum met in November 2015. Meeting held in Dec 2015 - looking at impact of the various service transformation initiatives together. LWN 6 month report produced - going to the integrated commissioning committee for review. 6 monthly review being undertaken of AMH model. SLaM producing a progress report - completed. Subsequent report expected will show reduction in occupied bed days for those known to services; increase in admissions for those not previously known to services. Query regarding month 6 position suggesting substantial reduction in bed usage - Nov 2015.SLaM are undertaking a comprehensive review of data quality and accuracy and are feeding this through the contract negotiation process for 2016/17 - ongoing and to agree trajectory for 2016/17. 1. Supporting alliance in relation to housing supply – ongoing. Meetings with housing department and agreed actions in place to improve access to housing supply.Working to facilitate move on from supported housing working with providers. Met with director of Housing - agreed to work together to accelerate move on housing options for IPSA clients. 2. Developing peer support led evaluation of outcomes from Sept 2015. Recruiting peer supporters - completed; Outcomes reports expected Feb 2016 - draft published, end of year report March 2016. 3. Alliance members being interviewed by LH Alliances to support implementation of development plan agreed with existing partners at learning event. Report received and workshop to take place in April 2016 to agree next stage of the development plan. 4. To agree the service and financial plan for 2016/17 - April 2016.
UPDATED April 2016
Director of Avis Integrated WilliamsCommissioning McKoy , Children
Liz Clegg
1A
2A
Zero Tolerance Risk - Risk of failure to safeguard children and identify and 5 respond appropriately to abuse
Risk of failure to implement the Service Improvement Plan for Community Nursing
8
Mar
April
2016
Feb
Jan
Dec
Oct
Monthly Progress
Nov
2015
Aug
Target Risk Score and Direction of Travel
Sept
Principal Risk (Obstacle to achievement of Strategic Aim)
Jun
Risk Operation Register al Lead Ref
July
Strategic Aim
Executive Lead
May
ASSURANCE FRAMEWORK 2016/17 – PROGRESS SUMMARY
15 15 15 15 15 15 15 15 15 15 15 15
16 12 12 12 12 12 12 12 12 12 12 12
Risk Rated 12 or more
12+
12+
Director of Integrated Commissioning , Adults
Liz Clegg
Liz Clegg
2B
2M
On-going review of SCR in collaboration with Lambeth Safeguarding Childrens Board and NHS England - March 2016. Implement subsequent SCR recommendations as required LSCB Executive and Sub working groups now refreshed. Learning and Improvement Sub working group developing key performance indicators - draft indicators in progress. Review safeguarding arrangements with regards to health visiting and school nurses at SLAC - June 2016
Going forward GSTT plan to: Introduce mobile technology after the introduction of advanced care notes in September 2015 - The introduction of new reporting system Care Note has and continues to experience functional problems. Mitigation plan is set to achieve functioning system end of Q1 16/17 with the introduction of mobile technology in Q2. Review referral criteria - Community nurses are now clustered and working in defined geographical areas. Currently establishing referrals that should be declined and the reasons for decline. This will be tested with GPs during March 2016. Implement a geographical system Review community end of life roles within the district nursing with a view to creating dedicated roles. This will ensure that patients Priorities of Care are met so they receive individual care based on their needs which is delivered with compassion and sensitivity by our nurses - There are two dedicated roles for end of life care and the posts will be filled mid February 2016. Develop action plans by continuing to measure our services through our patients’ experience - Development of third party (e.g. Age UK Lambeth, Lambeth Healthwatch) review of patient centred outcomes Q4 15/16 and Q1 16/17, for roll out Q2 16/17. Continue to implement the recruitment strategy - 76 staff recruited in last year (to Dec 2015). Ongoing under 2M. Continue to work with health and social care partners and citizens to co-produce a model of care that supports and meet the needs of local people. Opportunities: Work better across the local hospitals, community and primary care to support patient pathways ensuring smooth transfers of care and to develop a transfer of care strategy - Community Matrons working with KCH and GSTT on in-reach to wards to support discharge of patients identified as frequent users of A&E. Considering test of similar in-reach for community nursing. Ensure that our clinical strategy is underpinned by working closely with social care and voluntary sector. Deliver 24/7 community nursing care - OOH service will be managed by GSTT from 07/12/15. PAL@home soft launch in December, managing End of Life and clinical emergency out-of-hours. Recruitment to PAL@home at 75%. Working with citizens, clinicians, key partners to develop a new model for community nursing, including learning from elsewhere i.e. Holland - new models of care are being tested in pilot form early 2016. Test and learn model of care using Buurtzorg methodology, to be launched Q2 16/17.
Corporate Objective 1.2: Quality, Safety & Effectiveness - To improve the quality and safety of local services
Zero Tolerance Risk - Risk of failure to safeguard adults and identify and respond appropriately to abuse
Key Actions
8
Likely risk to sustaining good quality community 16 nursing service due to high vacancy level
12 12 12 12 12 12 12 12 12 12 12 12
16 16 16 16 16 16 16 16 16 16 16
12+
CCG: To continue to monitor improvement via CQRG and contract monitoring meetings. This was most recently discussed at the August 2015 CQRG. Update provided at CQRG Dec 2015. Implement the accountability and assurance framework for safeguarding vulnerable people - implement recommendations from NHSE deep dive. Influence NHSE contracts to include safeguarding training requirements - ongoing; complete a training needs analysis Practices to nominate staff to attend 'Alerters' safeguarding training - as part of practice visits Recruit designated doctor for adult safeguarding Develop training strategy for primary care - March 2016 Stand alone Safeguarding Adults Policy (non-commissioning), including SC Supervision Policy - 31/05/16 Adopt London MCA Toolkit as part of CCG strategy Ratify CCG Prevent Policy Agree MCA audit tool with providers as part of MCA task and Finish group Mental Capacity Act Policy - 31/05/2016 Discussions with commissioners/providers to consider gaps around incomplete assurance processes with independent providers and formulate action plan - 30/04/16 GSTFT forward plan: Implement a geographical system Explore more flexible working for staff Prepare, continue to grow and support the workforce Continue to implement the recruitment strategy - 76 staff recruited in last 12 months. Continue to work with health and social care partners and citizens to co-produce a model of care that supports and meet the needs of local people - new models of care being tested in pilot form at beginning of 2016. CCG: To continue to monitor recruitment levels via CQRG, contract monitoring meetings. Updates at August and December 2015 CQRG meetings. Further update to be provided in March 2016.
10
UPDATED April 2016
Bisi Aiyeleso/ Sara White
Corporate Objective 2.1: Sustainable Delivery & Governance - To secure delivery of the NHS constitutional rights and pledges for all Lambeth residents
Director of Integrated Commissioning Harriet Agyepong , Adults
Harriet Agyepong
2C
2K
2N
Likely risk of not achieving the agreed access performance levels for A&E resulting in longer waits for patients 12 and failure of the CCG to meet the national target
Likely risk of not achieving the access performance levels for timely access to cancer treatment (as measured by the 12 standard for 62 days from GP referral to treatment) impacting on the CCG Quality Premium and Assurance Framework Ongoing risk of not achieving the agreed access initiative performance levels for RTT for 12 incomplete pathways impacting on the CCG Quality Premium and Assurance Framework
Mar
April
2016
Feb
Jan
Dec
Monthly Progress
Oct
2015
Nov
Target Risk Score and Direction of Travel
Aug
Principal Risk (Obstacle to achievement of Strategic Aim)
Sept
Risk Operation Register al Lead Ref
Jun
Executive Lead
July
Strategic Aim
May
ASSURANCE FRAMEWORK 2016/17 – PROGRESS SUMMARY
16 16 16 16 16 16 16 16 16 16 16 16
12+
Key Actions
12+
A repatriation project has commenced across SE and SW London. has delivered significant improvements; the numbers of patients awaiting repatriation to local hospitals from Kings, for example, was regularly reported in excess of 30 and this has now reduced to below 10 on a daily basis. Complete by end of March 2015. A&E performance remains challenging at both GSTT and Kings. The CCG is now represented at the weekly performance meeting at GSTT. Winter schemes agreed to support additional capacity. Tripartite visit made to GST ED including Lambeth CEO following significant drop in performance. Acknowledged that performance targets will be challenging during building works/moves and consequential loss of capacity. ECIP visit scheduled for November to assist with immediate improvements. Jan 16 – Improvement to performance in Dec 2015 but slight dip again in January. Platinum call established bi-weekly and chaired by the CCG to help unblock issues and facilitate faster discharge of patients (DTOCs). Urgent care dashboard developed and will be reviewed at the UCWG at every meeting to identify trends and work through with partners to unblock issues. Deep dive at GST did not reveal any key reasons for difference in performance between Lambeth and Southwark CCG. A watching brief will be kept on this. GSTT have revised trajectories for internal and external referrals. TCST action: Trusts being supported by TCST around patient choice and training of booking staff on PTL management.
16 16 16 16 16 16 16 16 16 16 16 16
12+
KCH outsourcing some elective activity to private providers to assist with the reduction of the backlog - ongoing Meetings between GSTT and commissioners to develop plans to manage referrals - GST and Commissioners agreeing referral guidelines for key specialties e.g. paediatric ENT. KCH and GSTT working with national PMO to identify and use and spare capacity - has not identified alternative providers which are geographically close. PMO providers are charging significantly above tariff and therefore not viable alternatives
16 16 16 16 16 16 16 16
11
12+
UPDATED April 2016
Christine Caton
7A
Risk that current planning and strategic approach is not sufficiently robust to manage pressures and deliver sustainable position in the context of potential reduction in growth resulting from the implementation of the CCG allocation formula
8
Mar
April
2016
Feb
Jan
Dec
Monthly Progress
Oct
2015
Nov
Target Risk Score and Direction of Travel
Aug
Principal Risk (Obstacle to achievement of Strategic Aim)
Sept
Risk Operation Register al Lead Ref
Jun
Executive Lead
July
Strategic Aim
May
ASSURANCE FRAMEWORK 2016/17 – PROGRESS SUMMARY
12 12 12 12 12 12 12 12 12 12 12 12
12+
12+
Chief Financial Officer
Corprate Objective 2.2: Sustainable Delivery & Governance - To ensure good governance, financial stability of the local health economy, VfM and the delivery of statutory responsibilities
Christine Caton
Director of Primary Care Development
Director of Primary Care Development
Corporate Objective 3.1: System Transformation - Commission Proactive care focused on prevention and early detection of illness; Improve outcomes for Lambeth patients, achieve better value, integreated care through transformation programmes in partnership
Andrew Parker
Andrew Parker
Director of Integrated Denis Commissioning O'Rourke , Adults
7B
Risk of failure to deliver QIPP and acute overperformance leading to CCG risk on financial sustainability
Prime Ministers Challenge Fund / Access Hubs - Risk that there will be insufficient PMCF07 resources to maintain the Access Hubs operational capacity beyond March 2016
5S
3N
Likely risk that the review of the PMS contract will result in changes to levels of funding to GP practices impacting on service delivery and service disruption Possible risk that the LWN does not reduce demand on secondary care resulting in the system becoming unsustainable and costs in relation to higher bed usage
8
4
6
8
12 12 12 12 12 12 12 12 12 12 12 12
12 12 16 16 16
4 12 12 12 12 12
12 12 12 12
12 12 12 12 12 12 12 12 12 12 12 12
12
12+
12+
12+
12+
Key Actions SE London CCGs are working as an SPG to deliver transformation across boroughs and providers. The CCG is represented on each Clinical Leadership Group and Enabler work stream. The Finance and QIPP Working Group and Governing Body have had oversight of the 2015/16 Operational Plan as it was developed and are responsible for in-year performance management of programme delivery - ongoing. The CCG delivers transformation through its programmes -ongoing. The CFO is a member of the Financial Provider, Commissioner and LA leadership group responsible for agreeing the financial and activity assumptions that underpin the SEL Strategic Plan and developing business cases for service change where appropriate. The CCG Five Year Strategy and SEL Five Year Sustainability and Transformation Plan (STP) are being produced for June 2016. Work is underway to assess in detail savings and investment required to delivery financial sustainability - Dec 2015. The CCG Governing Body signed off the Our Healthier South East London (OHSEL) strategic direction on 1st July 2015. Programme delivery plans are in place to achieve our 2015/16 commissioning intentions and these have been built into our signed contracts. Option appraisal and business case development is underway across SE London - June 2016. CCG programmes developed 2016-17 commissioning intentions including QIPP and investment. The 2016/17 financial framework and start budgets were approved by GB on 2 March. 2016/17 Operating Plan was submitted in draft 22 Feb 2016 2 Mar 2016 with final due on 11 April. CCGs required to hold 1% NR fund to mitigate health strategies. Existing CCG reserves are being used to fund NR investment including SELPMO and investment under review to mitigate risk because of reduced flexibility. SEL Five Year STP, base case to be submitted 11 April and final June 2016. We have developed plans that have impact going into 2016/17 to make sure we are in a position to meet the financial challenges that lay ahead - March 2016. The CCG continues to review its performance reporting to improve the way in which we manage delivery including reflecting the new CCG assurance framework- ongoing. The CCG undertakes in year risk assessments and develops contingency plans to deliver variances from plan - ongoing. Commissioning Intentions were reviewed and prioritised by programmes and GB during December 2015. The overall content and financial framework was approved by GB in January 2016 and start budgets on 2 March. Business cases for investment and project plans for programmes including QIPP are being produced to deliver 2016/17 Operating Plan. Contract negotiations are underway and due to be completed by 31 March 2016. Work on developing QIPP for Five Year Strategy underway April to June 2016 as £12m (3% of allocation) per annum, a significant challenge. 1. To be discussed and updated at regular contract meetings with CCG and Federations - ongoing 2. Monitoring of utilisation of Access Hubs from October 2015 - COMMENCED 3. Development of a plan for the use of the freed up capacity of General Practice, which improves care and reduces the use of other services - 30/11/15 (TF and JC) - Action never commenced 4. Plan the evaluation of effects on other services - results of the evaluation will inform the provision going forward - Action never commenced 5. Business Case to be developed for continuation of service after March 2016 - based on existing funding of £1.5million plus additional investment - there will be some provision of access hubs from April 2016. Exact configuration is to be decided from outcome of commissioning intentions - Ongoing, in discussion with the Federations
1. Project plan to be updated and contain actions 2-3 - COMPLETED 2. Develop a detailed communications plan, especially regarding communication sessions with practices and patient and public involvement groups - 31/01/16; in draft - ongoing. The last GP Bulletin (March 16) included information to practices about the halt in negotiations and will be reflected in a revised action plan. 3. Uncoupling of the PMS KPI and the GPDF services discussions, in light of the pause in the national PMS review. 4. GPDF services are being progressed outside of the PMS negotiations with providers in order to have 16/17 contracts in place by the end of Q1, enabling the CCG to deliver it’s commissioning intentions. Negotiating with GP Federation becoming part of the LWN Provider Alliance Group and future alliance agreement – Jan 2016 Single LWN performance management report including service and finance from Oct 2015 - initial report received and will be developed.6 monthly report published and reviewed at Provider Alliance group - to be discussed at Integrated Commissioning Committee and Governing Body. Meeting held with voluntary sector providers to signal where heading and how to best organise alliance - ongoing meetings. Working towards an alliance agreement to support the LWN – April 2016. To support this, a workshop scheduled for 10/10/15 - for whole market providers to outline plans. Project plan agreed to take this forward. Letter of Intent drafted with aim for full contract from Oct 2016. Commissioning intentions for 2016/17 include provision for CCG tapered pick up of LWN posts previously funded by GSTT. Complete application to GST Charity for further funding by 31/03/16. LWN - next phase of design work commenced. Identified two key prototypes - testing local area co-ordination and integration of LWN and CMHT.
UPDATED April 2016
Andrew Parker
5N
Director of Primary Care Development Corporate Objective 3.2 System Transformation - To ensure the CCG’s commissioning resource and organisational capability are effectively aligned to deliver its objectives
Andrew Parker
Chief Financial Officer/Director Christine of Governance Caton/Una and Dalton Development
5R
6K
Risk that inadequate workforce capacity/skills and a lack of integrated information systems will affect the delivery of the SEL Strategy in providing new models of integrated, high quality care
Risk that a lack of integrated information systems will affect the delivery of the SEL Strategy in providing new models of integrated, high quality care Risk that ineffective management of commissioning support service procurement process may lead to poor quality service procured.
Mar
April
Jan
2016
Feb
Dec
Oct
Monthly Progress
Nov
2015
Aug
Target Risk Score and Direction of Travel
Sept
Principal Risk (Obstacle to achievement of Strategic Aim)
Jun
Risk Operation Register al Lead Ref
July
Strategic Aim
Executive Lead
May
ASSURANCE FRAMEWORK 2016/17 – PROGRESS SUMMARY
12+
Key Actions
1. Workforce action plan to be developed from each CRG 2. Borough workforce plan to be reviewed (CEPN plan)
4
16 16 16 16 16 16 16 16 16 16 16
12+
Full alignment to CCG Programme Enablers
4
8
16 16 16 16 16 16 16
12+
1. Action plan in place for management of procurement process for each service line (GP IT and CCG IT) - June 2016. Two week deferment agreed to seek clarity on stranded costs from DH 2. Review of GP and CCG IT procurement process for lessons learned - June 2016 3. Begin procurement process for all other services - TBC
12 12 12
13
4.2 Delegated Functions NHS Lambeth CCG currently has no delegated functions. However, the CCG commissions General Practice services jointly with NHS England and commissions General Practice Out-ofHours services as a directed function. All CCGs are now required, as part of the CCG Assurance Framework, to provide NHS England with a self-certificate providing assurance around governance and management of potential conflicts of interest for these two services. Quarters 1, 2 and 3 have been submitted and quarter 4 is due on the 25th of May 2016.
4.3
Financial Management
4.3.1
Financial Position
To deliver financial control totals for resource and cash and support the delivery of statutory financial duties for 2015/16 The CCG is required by statute to meet certain financial duties to ensure that public funds are used appropriately. CCGs are required not to exceed the revenue (administration and programme) and capital resource limits in any one year and to have cash balances of no greater than 1.25% of the main monthly drawdown for March 2016.
At month 12, the CCG underspent by £7.752m against a planned surplus of £7.612m.
Running Costs budgets showed an underspend of £1,068k as at month 12. The main reason for this underspend is due to an allocation for quality premium received as admin and write back of 2014/15 accruals. The expenditure against this allocation is programme spend. The CCG is within the £22.50 per head Running Cost allowance.
The CCG drew down £407.904m and returned £2m against its maximum cash drawdown limit is £409.904m. The cash balance at bank as at 31 March 2016 was £87k.
Revenue Resource Limit
Summary of Budgets - March 2016
Issued Budgets - Programme
Month 11 March
Changes
Month 12 March
£'000
£'000
£'000
435,961
Issued Budgets - Admin (Running Cost)
7,825
Reserves
2,568
Planned Surplus
7,612
Total Allocation
453,966
14
1,535
437,496 7,825
(1,500)
1,068 7,612
35
454,001
Performance Summary
Key Financial Performance Duties
Performance Area
Commentary
Revenue Surplus
Lambeth CCG is reporting a surplus of £7.753m for the year 2015/16. This is £140k above our target surplus of £7.612m and is in line with our target of delivering a 1% surplus
Cash Limit
Cash balances are planned to be maintained at low levels (less than 1.25% at 31st March 2016. Lambeth CCG's cash balance at bank at the end of March was. The CCG met its statutorycash limit target for the year 2015/16
QIPP
The CCG is forecasting full QIPP delivery of its annual QIPP target of £8.86m.
Public Sector Payment Policy
Public sector payment target is 95% on numbers. The CCG paid 99.09% of NHS invoives based on numbers and 99.88% by value. The CCG is not achieving its target for numbers for Non NHS invoices. Performance for the 12 months is 93.28% on numbers and 95.05% by value.
Running Cost
The CCGs running cost allowance is £7.8m. The CCG is reporting an underspend of £1.05m against its running cost budgets.
15
Final Year End Position
Summary Budgets – Financial Position for March 2015/16 LAMBETH CCG EXECUTIVE SUMMARY - FOR THE YEAR ENDING 31st MARCH 2016 Annual Budget
Financial Position for the Year
Plan
Actual
Variance ((Adv)/Fav)
£'000
£'000
£'000
%
Month 11 Variance
Movement from Previous
£'000
£'000
Resource Allocation Programme Resource
7,825
7,825
0
0%
0
0 0 0
454,001
454,001
0
0%
0
0
280,073
280,987
(914)
(0%)
110
0 (1,024)
Mental Health
69,194
70,850
(1,656)
(2%)
(1,033)
(623)
Community Health
19,830
20,525
(695)
(4%)
(11)
(684)
Continuing Care/Free Nursing Care
14,721
15,858
(1,137)
(8%)
(1,976)
839
Primary Care
Running Cost Resource Total Resource Allocation
446,176
446,176
0
0%
0
Programme Expenditure Acute
44,299
43,296
1,003
2%
837
166
Other Programme Costs including Corporate
9,379
7,977
1,402
15%
522
880
Total Programme Costs
437,496
439,492
(1,997)
(0%)
(1,550)
(446)
3,709
4,034
(325)
(9%)
(331)
6
Running Cost Pay Non Pay
4,116
2,722
1,394
34%
1,381
13
Total Running Cost
7,825
6,757
1068
14%
1,049
19
-
1,068
Reserves including contingency Total CCG Expenditure Surplus
100%
511
558
446,389
1,068
446,249
140
0%
10
130
7,612
7,752
140
2%
10
130
It is essential that the CCG maintains strong internal financial controls to enable it to achieve its statutory duties, delivers value for money and have a clean bill of audit health. Actions being taken include:
Delivery of the 2015/16 Internal Audit Plan and making sure that recommendations are implemented promptly. This is closely monitored by the CCG’s Audit Committee.
Embed understanding across Governing Body Members/Head of Collaborative Forum of Internal and External Audit including the use of induction for new Governing Body Members.
Review Standing Orders, Prime Financial Policies and Scheme of Delegation under review to make sure that they best reflect the needs of CCG and to support accountability through programme boards.
16
The CCG is developing and implementing a training programme that along with the Budgetary Framework supports effective budget management and control.
Delivery of the action plan from the Financial Control Environment Assessment For finance risks, 7A and 7B, please see the Board Assurance Framework.
17
QIPP Lambeth CCG QIPP Delivery as at Month 12 (March 2016)
LAMBETH CCG QIPP DELIVERY FOR THE YEAR 2015/16 Final for the Year 2015/2016
PROJECT/SCHEME
Acute
QIPP Programme
Planned QIPP
QIPP Delivered
Variance Over/(Under)
£'000
£'000
£'000
£'000
% Delivery
5,264
5,264
5,264
0
100%
438
438
438
0
100%
Mental Health
2,425
2,425
1,933
(492)
80%
Prescribing
1,296
1,296
1,296
0
100%
Primary Care
208
208
208
0
100.0%
Non Acute & Other Schemes
180
180
180
0
100%
Total QIPP Savings
9,811
9,811
9,319
(492)
95%
Reprovision Costs
(950)
(950)
(458)
492
48%
Total Net QIPP Savings
8,861
8,861
8,861
0
100.0%
Community - Trust Led
QIPP Analysis By Delivery Area 2015/16 QIPP Delivery for the year 2015/16 is shown in the table below.
18
LAMBETH CCG QIPP DELIVERY FOR THE YEAR 2015/16
2015/16 QIPP
Annual Plan
Plan
Final for the Year Actual Variance % Variance
Underlying Position Actual Variance %
Acute Guys & St Thomas NHSFT Emergency Admissions Outpatient redesign - news and follow ups Local Integrated Adult Savings Inflammatory Bowel Disease (IBD) care pathway savings Patient Transport Services (PTS) Prescribing GSTT NHSFT - TOTAL QIPP
1,569 1,153 438 100 100 100 3,461
1,569 1,153 438 100 100 100 3,461
1,569 1,153 438 100 100 100 3,461
-
100% 100% 100% 100% 100% 100% 100%
1,177 461 1,638
(392) (692) (438) (100) (100) (100) (1,823)
75% 40% 0% 0% 0% 0% 47%
Kings Healthcare NHSFT Emergency Admissions Follow-up Outpatients Shift to Non-face to Face new Outpatients Prescribing KINGS NHSFT - TOTAL QIPP
1,449 472 249 71 2,241
1,449 472 249 71 2,241
1,449 472 249 71 2,241
-
100% 100% 100% 100% 100%
310 249 471 1,030
(1,139) (223) 222 (71) (1,211)
21% 53% 189% 0% 46%
TOTAL ACUTE QIPP
5,702
5,702
5,702
-
100%
2,668
(3,034)
47%
Mental Health AMH and EI inpatients beds IPSA EMI Beds Outpatients - Specialist Woodlands fixed costs Total
703 1,119 450 83 70 2,425
703 1,119 450 83 70 2,425
294 1,119 450
42% 100% 100% 0% 100% 80%
294 846 400 70 1,610
(409) (273) (50) (83) 0 (815)
42% 76% 89% 0% 100% 66%
Medicines Management Primary Care Savings Savings from Other Non Acute Property Services
1,296 208 80 100
1,296 208 80 100
1,296 208 80 100
100% 100% 100% 100%
1,296 208 80 100
0 0 0 0
100% 100% 100% 100%
Grand Total Gross QIPP
9,811
9,811
9,319
(492)
94.99%
5,962
(3,849)
61%
492.00
48%
0
100%
0
100.00%
(3,849)
56.57%
Investment Net QIPP
(950) 8,861
(950) 8,861
19
70 1,933
(458) 8,861
(409) (83) (492) -
(950) 5,012
4.3.2 QIPP Performance The table below provides a summary of the current performance of the ongoing QIPP schemes for 2015-16. All other areas of QIPP were secured at the beginning of the financial year through contractual negotiations with our main providers.
QIPP Scheme
Performance currently in line with target?
Highlights
Financial position Reduce variation in outpatient referrals
MECS (Minor Service)
Eye
Conditions
Diagnostics MSK workstream and Lambeth Integrated Musculoskeletal Service (LIMS) Redesign of GSTT UCC Paediatrics in ED GP Diversation to Waterloo Health Centre PALS Minor Ailments Scheme (GSTT Divert to GST Sainsbury’s or Lower Marsh Boots) Integrated Adults LTC/Medicines Optimisation QIPP Lambeth Alcohol Recovery Centre (LARC) Adults Mental Health Redesign EI Inpatient Beds
Whilst there has been an improvement in month 11, the cumulative performance of this project has still under-plan. The reduction up until month 11 is 209 and so the scheme is unlikely to deliver its full reduction target of 1203 by YE. The scheme is exceeding performing against expected activity targets. The scheme is performing within budget and against expected activity. This project is currently in a scoping phase This scheme is currently not performing in line with the target activity in terms cumulative YTD perfroamnce although M11 performance has improved. It is not expected that this scheme will meet activity reduction targets this year. This scheme did not perform to target in month 8. It is not expected to perform to target for the year due to the A&E rebuilding work. Reporting not currently available. This scheme is performing in line with target this month with 64% utilisation of slots. Agreement has been reached to decommission the service. This scheme is not performing in line with target this month or for the year so far. Agreement reached to decommission the service. Performance is significantly below target. Recommendation to made to the relevant decision making forum to decommission. Schemes in this area are performing well and delivering the required level of savings. This scheme is performing in line with target for the end of the financial year. Month 8 performance exceeded target for the month Savings associated with this scheme have been delivered in part. Risk to delivery is mitigated by contractually agreed risk share.
20
N/A No
N/A No
No
No
4.4 Performance 4.4.1 NHS England Top 8 Performance Measures and National Constitution Standards The performance dashboard covers the National Constitution Standards as set out in the national 2015/16 Assurance Framework and the Top 8 priorities as identified by NHS England are monitored through the assurance process. Lambeth CCG performance for each of these measures for the financial year 2015/16 is set out in the table on page 22. As part of the CCG Assurance Framework, NHS England has begun monitoring CCGs against a longstanding operational standard – Cancelled Operations Not Rescheduled Within 28 Days. NHS Lambeth CCG is monitored against performance at Guy’s and St. Thomas’s NHS Foundation Trust. This indicator has now been added to the performance dashboard. The data is reported on a quarterly basis with the table detailing latest performance for Quarter 3 and latest monthly data (within Q4) where available.
21
22
4.4.2
RTT (Referral to Treatment Times for Lambeth Patients)
Note: From 01/01/2015 NHS England ceased to monitor the RTT 18 weeks admitted and non-admitted pathways as performance measures. NHS Lambeth CCG continues to monitor them as local Trusts have struggled to deliver this standard guaranteed in the NHS Constitution.
18 weeks RTT – admitted and non-admitted treated Delivery of the admitted and non-admitted treated pathway remains a challenge across London. Kings College Hospital is currently not reporting activity. GSTFT has failed the admitted standard in every month since April 2015. The Trust recovered performance for the non-admitted standard in May and June, but performance has fallen below the 95% target in the other months. This has resulted in failure of the target overall during the first three quarters of 2015/16. Performance for the first two months in quarter four have also been below target.
Incomplete Pathways GSTT - The CCG met the national target of 92% for incomplete pathways on February, this followed two months of being below standard. The backlog of patients waiting beyond 18 weeks continues to be an issue at the and will continue into 2016/17. Trust wide GSTT were at 92.2% in February leaving litte room for in month performance issues which may cause capacity to dip such as the junior doctors strikes. Referrals into the Trust continue to be high and there are some services with limited alternative provision. Performance and delivery against this target remains high risk.
KCH - had been implementing a RTT recovery plan over quarters one and two of 15/16 with a planned return to compliance against RTT standards from October 15/16. This included a backlog reduction plan, alongside a waiting list validation programme. The Intensive Support Team reviewed the position prior to reporting in October and advised against a November return to reporting, recommending a further period of suspended national reporting whilst continued validation takes place. The IST have reviewed the KCH validation programme and confirmed that KCH Patient Tracking List is now in a position to return to national reporting for the March submission. This will be reported to the Integrated Governance Committee in June and the Governing Body in July. Based on draft reports for the February submission the Trust has submitted an over 18 week backlog reduction trajectory to get to 88% by the end of March 2017. Based on the current performance trajectory KCH will put the CCG into an underperformance position for each month of 2016/17.
RTT– waiting more than 52 weeks, and still waiting (incompletes) KCH have not been able to provide routine monitoring data for patients waiting longer than 52 weeks for most of 2015/16, however a recent validation process identified a number of long waiters as at the end of February 2016. The Trust wide figure is 182, 21 of these were Lambeth patients. Recovery plans have been put in place and KCH have produced an over 52 week 23
trajectory. This is being reviewed at a tripartite level, the current trajectory shows all non Neuro long waiters reduced to zero by October 2016. However, Neurosurgery breaches show an increase over the year to 198 by March 2017. This is being discussed at tripartite level with all options for reducing Neurosurgery long waiters being assessed.
4.4.3 Diagnostics (Lambeth Patients)
Diagnostic performance at the CCG deteriorated in December driven by a dip in performance at both GSTT and KCH, the position improved in January and February but remains above 1%. KCH - represents the biggest proportion of the decline, Trust wide performance was at 4.1% in February, with the Denmark hill site the largest driver of this deterioration at 5.4%. The two biggest issues are with Neuro MRI and Ultrasound. Neuro MRI was driven by staff vacancies reducing capacity, Inhealth has also been unable to provide additional days on site. However, since April Inhealth capacity has been available. Ultrasound has had a Sonographer vacancy and the Trust was unable to source an agency member of staff to cover. The Trust is now extending bank shifts on Saturday from 8 – 1 to 8-2 pm, resulting in 38 additional appointments each Saturday. An agency Sonographer began work on 14/1/16, the backlog has reduced significantly over February. There are other areas that have smaller amounts of breaches contributing to the overall performance. The Trust has produced an improvement trajectory to get to 2.6% for the end of March Trust wide and then to improve to 1% from June 2016. GSTT - represents a much smaller portion of the decline being at 1.8% Trust wide in February. The Trust has agreed an improvement trajectory to get to 1% from June 2016.
24
4.4.4 A & E Waiting Times
Both GSTT and Denmark Hill continue to perform below the 95% standard. Performance at GSTT is driven by: higher levels of acuity; impact of the A&E re-building programme; and overall capacity constraints. The Trust has produced an updated ED action plan, key actions within the plan include: Review of options to increase Emergency Department capacity - considering use of the Plastics Department; Internal ED ‘Back to Basics’ action log to maximise efficiency of the four-hour timeframe; 'Ace-Team’ project with three work streams to improve efficiency of the Emergency Pathway outside of the Emergency Department 1.Maximise efficiency and increase use of Evan Jones. 2.Admissions Wards and Hot Clinics. 3.Reduce delays to discharge and increase morning discharge. The “Northern Line Project” ; Live bed state to be implemented to increase efficiency in the admission pathway; Trust ‘Star Chamber’ with the Executive Team to review all actions against the Emergency Pathway. All these actions are expected to support performance improvement over Q4 with an expected return to compliance in April 16.. The Trust has established an internal winter planning group to have oversight of this work. For 2016/17 the Trust expects to meet performance for Q1 and Q2. and has planned deterioration in Q3 and Q4 following necessary reconfiguration at that point in the year. Performance at Denmark Hill has been below target throughout 2015/16. The Denmark Hill site is now working to improve to 92% by the end of Q4, a revised trajectory which has been agreed by CCGs, NHSE and Monitor. There are four key areas where work is currently underway to mitigate current challenges.1. The ED recovery plan (work streams cover in hospital and out of hospital) 2. Out of hospital care services, this has a focus on minimising repatriation and rehabilitation delays, maximising the utilisation of OOH care services and improving mental health pathways). 3. Demand and capacity plan implementation (actions to reduce the bed gap). 4. Winter planning and funding (Southwark CCG has funded schemes along with the Trust's in contract winter funding to support resilience and performance over winter).The Acute care hub opened on the 5th of January to aid patient flow. KCH has now agreed a trust wide trajectory to return to 95% from November 2016.
4.4.5 Cancer Waiting Times OP std 15/16
National Priorities including Top 8 Performance Measures
Cancer 2 weeks (GP referral) Cancer 2 weeks (breast symptoms) Cancer 31 days (first definitive) Cancer 31 days (subsequent - surgery) Cancer 31 days (subsequent - drug) Cancer 31 days (subsequent - radiotherapy) Cancer 62 days (GP referrral) Cancer 62 days (referral NHS screening) Cancer 62 days (first definitive - Consultant)
25
Q1 15/16 Q2 15/16
Q3 15/16
Jan-16
Feb-16
86.8% 93.8% 96.9% 100.0% 100.0% 95.2% 90.3% 83.3% 100.0%
91.1% 91.5% 96.6% 97.1% 100.0% 91.3% 72.3% 100.0%
93% 93% 96%
93.1% 96.2% 96.8%
93.9% 94.8% 99.0%
93.3% 92.9% 97.2%
94% 98% 94% 85% 90% No std
98.0% 99.1% 100.0% 78.8% 100.0% 85.7%
95.2% 99.2% 97.7% 83.5% 100.0% 100.0%
98.0% 99.0% 94.9% 87.7% 100.0% 100.0%
Lambeth CCG missed three of the nine targets in February 2016. Cancer 2 weeks (GP referral) Performance on 2 week wait is driven by underperformance at GSTT and KCH. A telephone triage clinic has been set up at GSFT which allows patients to be directly booked into Endoscopy diagnostics. Whilst this change in pathway speeds up the process of attending the diagnostic appointment it means that the previous outpatient appointment does not occur to stop the 2ww clock resulting in breaches. The clock now stops when the diagnostic takes place. On occasion this is after 2 weeks. The Trust is working to improve it’s booking processes direct from the telephone triage to ensure that the endoscopy can happen sooner. 42 of the 74 breaches were at GSFT. KCH have seen a 25% increase in referrals for dermatology which has caused a capacity offset within this tumour type for 2ww referrals. The Trust is in the process of producing a breakdown to highlight where the additional referrals are being sent from,. This will allow the system to understand where to target any actions. 28 of the 74 breachces were are KCH. Cancer 62 days February’s performance relates to 13 breaches. 9 breaches treated at St Georges, 1 KCH, 1 Royal Marsden, 2 breaches were transferred from KCH to GSTT. 8 patients waited over 100 days and 3 patients were catagorised as avoidable breaches (administrative delays). GSTT’s performance against this target remains challenging. National data is available up to February. This was a particularly challenging month as GSTT treated many patients that were transferred to clear backlogs. Performance in February was then expected to be worse in order for performance in March to improve. March data has not yet been published, however local data shows that GSTT was above 85% for internal performance for March which met the Trusts agreed trajectory. Overall trust-wide performance improvement is linked to reducing late referrals. Actions to reduce late referrals will support a trust wide improvement for GSTT, but are considered high risk. KCH continue to have strong internal performance but will need to work to the agreed inter trust transfer trajectory in order for performance across the SEL system to improve. The CCG operating plan trajectory for 2016/17 shows the target being met for all months.
4.4.6 Ambulance Response OP std 15/16
National Priorities including Top 8 Performance Measures
Ambulance response times (South East London)
Q1 15/16 Q2 15/16 Q3 15/16
Cat A (Red 1) calls response within 8 mins
75%
67.7%
65.1%
71.0%
Cat A (Red 2) calls response within 8 mins Cat A response within 19 mins
75% 95%
65.5% 94.0%
64.4% 93.0%
65.3% 93.3%
Jan-16
66.8% 64.7% 60.4% 56.3% 91.7% 91.4%
The London Ambulance Service continues to struggle to meet the national standard response times. NHS Lambeth CCG is currently reviewing the CQC findings published in November 2015. LAS received a rating of Inadequate. 26
Feb-16
4.4.7 Health Visitors From October 2015, responsibility for commissioning the Health Visitor service transferred to local authorities from NHS England.
4.4.8 Improved Access to Psychological Therapies (IAPT) OP std 15/16
Q1 15/16
Q2 15/16
Q3 15/16
Jan-16
Feb-16
As reported in Contract Monitoring Reports
15% (Annual) 3.75% (Qtrly)
3.8%
5.0%
3.9%
4.3%
4.5%
As reported in Contract Monitoring Reports
50%
49.2%
46.3%
49.8%
57.3%
55.2%
Proportion of patients that finished a course of treatment who received their first treatment appointment within 6 weeks of referral
75%
93.14%
94.32%
95%
94.0%
96.0%
Proportion of patients that finished a course of treatment who received their first treatment appointment within 18 weeks of referral
95%
97.29%
99.04%
99.5%
97.0%
100.0%
National Priorities including Top 8 Performance Measures
Proportion of people with depression receving for psychological therapy Proportion who complete therapy who are moving to Improved Access to Psychological Therapies recovery
The service continues to over-perform on the access target achieving 4.5% as at February 2016. Work has started on waiting list validation which and has highlighted approximately 100 clients who had completed treatment but were not properly discharged from the clinical records system. They were all discharged in September. These un-discharged clients skewed the recovery rate. The service has been awarded non-recurrent funding to validate waiting lists and ensure waiting list data accuracy, and also to clear the backlog of appointments. This is in preparation for the consistent achievement of waiting targets due to be formally initiated in April 2016. The service is working with NHSE and commissioners on data sets by which to monitor the new targets.
4.4.9 New Early Intervention In Psychosis 2 Week Standard NHS Lambeth CCG is working closely with South London and Maudsley NHS Foundation Trust (SLaM) to deliver the Early Intervention in Psychosis (EIP) 2 Week standard from 01/04/2016. SLaM will be running the standard in shadow form from 01/11/2015. SLaM has carried out significant pieces of work to enable collection of data to support the standard, including: •
A psychosis gap analysis to identify requirements to deliver the standard
•
Review of the patient data collection system to confirm that it can capture appropriate clock start and stop dates
•
Development of new processes to identify ‘Suspected First Episode of Psychosis’ in all internal and external referral forms
•
Appointment of a Better Access Programme Manager
•
Development and roll-out of a programme of training for staff to support delivery of the standard
SLaM report on progress in delivery of the standard to NHS Lambeth CCG at monthly commissioning meetings. The Trust is committed to delivery of the EIP standard from 1st April 2016. 27
A joint work shop between commissioners, practitioners and managers within secondary care and the Living Well Network (LWN) took place on the 25th November 2015. It was recognised at that workshop that a whole system response was required in order to effectively meet the target. It was also recognised that the interface between the LWN and the Early Intervention Psychosis Team needs to be enhanced, as the LWN sees people in the first instance they experience mental distress, either via GPs or through self-referrals (SLaM) to deliver the Early Intervention in Psychosis (EIP) 2 Week standard from 1st April 2016. SLaM and the CCG completed a NHSE self-assessment which rated Trust’s readiness in terms of meeting the two waiting time target, IT development and the recruitment and training of staff. SLaM has a task group which meets on a monthly basis and is in a position to report the first extract of data in January.
In January and February a total of 47 referrals were received by the EI Psychosis Team in Lambeth. Of these 47 referrals 16 were rejected because they were not appropriate referrals while the remaining 31 referrals were assessed as appropriate for EIP intervention. A total of 21 were successfully seen within the 2 week period, with 10 referrals not meeting the target. So overall this year to date Lambeth has achieved 41.67% against 50% waiting time standard.
4.4.10
Dementia Diagnosis Rate
% of Expected Prevalence with Recorded Diagnosis
% Recording by GP Practice of Dementia Diagnoses against Expected Prevalence 2015/16 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
The Health and Social Care Centre (HSCIC) has now published data for Dementia Diagnosis Rate for the year to February 2016. A new methodology is being used for 2015/16 to calculate estimated dementia prevalence. NHS Lambeth CCG continues to rank 2nd in London for recording dementia diagnoses in primary care. NHS Lambeth CCG achieved a rate for recording dementia diagnoses in primary care of 85.3% in February 2016 and 85.1% overall for quarter 3.
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The graph shows published data for NHS Lambeth CCG’s GP practices, for the percentage of patients for the CCG with a dementia diagnosis recorded against estimated prevalence. The rate would be expected to fluctuate slightly month on month as patients join and leave GP practices. The CCG’s Older People team have been working consistently over 2 years to achieve this success. Some of the things that the team did included: • The GP with a special interest in dementia reviewed GP practice data and referrals to the Memory Service. The GP did awareness raising and education with practices which did not refer, or had a low rate of referral. • Regular communications to practices about the importance of registering diagnoses for patients with dementia. • The Memory Service wrote to GP practices reminding them to register diagnoses for patients they were seeing. • All people in Lambeth care homes who are receiving nursing are given a memory assessment as part of their regular reviews with the GP practice assigned to their home. • Protected Learning Time has been used to educate GPs about dementia and how to refer.
4.4.11
Transforming Care
Since January 2015 NHS England has directed CCGs to increase the level of scrutiny to ensure that the people placed locally in hospital settings are receiving the right care that meets their individual needs, with discharge plans in place for those that are able to move to a community setting. The people with learning disabilities who are the responsibility of NHS Lambeth CCG are placed in assessment and treatment units when there is an escalation in their need for support in relation to their condition and/or behaviour that challenges. The CCG is then made aware of the placement and the Transforming Care Leads and the Commissioners for Mental Health becomes involved in the monitoring of the placement and the commencement of discharge planning. The Transforming Care Lead organise the CTR for the patient and reports every 2 weeks to NHSE on the progress for each individual patient. Since that time NHS Lambeth CCG has worked to progress the discharge of the people originally identified by the CCG and has maintained a register of all existing and new people who are in assessment and treatment units. At the time of writing this report the CCG has 10 people in assessment and treatment settings who are at varying stages of their care, treatment and discharge. Of the 10 people admitted: Lambeth’s current list of Transforming Care patients and estimated discharge dates NHS Providers
Location
SLAM
National Autism Unit
Number of patients 1
29
Discharge Date TBC (all likely to be short term admissions)
SLAM
Bethlem Royal Hospital Atlas House
1
Independent Providers Cygnet Sequence Care Sequence Care Cambian
Location
Danshell Danshell
Bostall House Yewtrees
Number of patients 1 1 1 1 1 1 1
Oxleas
Becton Hospital Bloomfield Court Olive Eden Fairview
TBC (both likely to be short term admissions) July 2016
1
Discharge Date October 2016 April 2016 September 2016 October 2016 March 2017 30 March 2016 October 2016
Future Service Model A national service model, developed with the help of people with lived experience, clinicians, providers and commissioners, sets out the range of support that should be in place no later than March 2019. Implementing this model, and giving people greater power over the services they use, will result in a significantly reduced need for inpatient care. NHSE expect that as a minimum, in three years’ time no area will need capacity for more than 10-15 inpatients per million population in clinical commissioning group (CCG) commissioned beds (such as assessment and treatment units), and 20-25 inpatients per million population in NHS England-commissioned beds (such as low-, medium- or high-secure services). These planning assumptions will mean that, at a minimum, 45 – 65% of CCG commissioned inpatient capacity will be closed, and 25 – 40% of NHS Englandcommissioned capacity will close, with the bulk of change in secure care expected to occur in low-secure provision. As requested by NHS England, a South East London Transforming Care Programme (TCP) Board has also been set up, with representation from each statutory sector organisation. The TCP Board will also have individuals with lived experience. Who they are and how they represent a wider group will be determined during the planning phase of the programme. The Board has met once and a planning workshop, with all TCP Board members and others, took place on 4 March. The Senior Responsible Officer for the Programme is Annabel Burn, Chief Officer at NHS Greenwich, and the Deputy is Gwen Kennedy, Director of Quality and Safety at NHS Southwark. There is also a programme manager, Smriti Singh, working across all six areas. Subject to approval from CCG Chief Officers, the South East London TCP Board will oversee the Transforming Care programme while accountability for delivery of the Transforming Care Programme rests with the Governing Bodies of each of the CCGs. 30
Since this is a shared South East London programme it can be approved through the South East London (CCGs’) Committee in Common. NHS England process Whilst the TCP is a joint initiative across health and social care, CCGs are accountable for delivery of their local Transforming Care programmes (as set out in ‘Building the Right Support’ Oct15). As part of the national Transforming Care Programme, NHS England requires that local Transforming Care Partnerships follow its programme plan and monitoring process. TCPs have to complete a number of NHS England programme documents, which include information about our TCP programme plan and population and cost data. An initial submission was made on 8 February and a final set of documents must be submitted by 11 April 2016. The TCP’s submissions to NHS England also included a bid for programme funding.
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5 STRATEGIC AND OPERATIONAL DELIVERY – OUR PROGRAMMES 5.1 Integrated Children and Young People (including Maternity) Programme Responsible Director
Maria Millwood, Director of Integrated Commissioning (Children & Young People, Adult Disabilities)
Clinical Lead
Dr Nandini Mukhopadhyay
Programme Lead
Emma Stevenson, Assistant Director Children & Maternity
Scope of business area
The purpose of this business area is to lead the redesign of children’s and maternity services and disability services to achieve quality, and value for money services. This business area has strong links with the business areas on integrated mental health for adults, a model of integrated care and citizen participation and empowerment.
Objectives of business area
The objectives of this business area are to:
Redesign the child and adolescent mental health services
Implement the recommended London standards across child health services
Develop and implement integrated child health pathways
Implement Maternity standards and effective local pathways
Develop an integrated commissioning strategy for a whole life disability pathway
5.1.1 Programme Assurance Statement Assurance
Status/Risks
RAG Rating (Red/Amber/Green)
Is your programme delivering as planned – is it Many objectives on target but some risks on target? identified. 32
5.1.2 Integrated Children and Young People (including maternity) Programme Risk Register Please see Board Assurance Framework for risks 1A rated 12 and above.
Risk Title
Risk Current Register Risk Approach where Risk Score is managed
Unlikely risk that the Children’s and Maternity Programme will not achieve its objectives due to the dependency on the delivery of other programmes (Leap, CYPHP)
Programme Board / Directorate Risk Register
6
Mitigate
To review and implement clear thresholds to specialist and acute services - completed To review the universal service reviews - completed To restructure targeted workforce to develop an integrated team by June 2016 To complete service re-design process for remaining LEAP interventions - completed Governance structure for Childrens Transformation Programme to be submitted to a workshop of the CFSP for discussion on 16/07/15 - completed. Corporate review in Council re key boards will determine how this is taken forward - ongoing To mitigate against delayed delivery of CYPHP: - Implement GP Delivery Scheme for Paediatric Asthma implemented and being monitored. Worked up 2016/17 Commissioning Intentions including QIPP awaiting approval by CCG Governing Body March 2016
Unlikely risk of failure to reduce waiting time from referral to first treatment for the CAMHS Early Intervention Team resulting in poorer outcomes and increased escalation to Tier 3-4 services.
Programme Board / Directorate Risk Register
6
Mitigate
Complete recruitment to posts - SLAM, Oct 2015 - Completed Set up and run agreed new group work - SLAM, Oct 2015 Completed.
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Action Plan Summary
Risk Title Unlikely risk that babies under one year not vaccinated with the BCG vaccine during a period of non-supply will not be robustly identified and vaccinated in a timely way by the commissioned provider once supply is restored, resulting in increased risk of exposure to infection.
Risk Current Register Risk Approach where Risk Score is managed
Action Plan Summary
Programme Board / Directorate Risk Register
6
Mitigate
Monitor implementation of provider action plan - progressing against plan.
Risk of failure to improve rate of health Programme reviews to meet local and new Board / nationally mandated targets, resulting Directorate health issues in children potentially Risk missed. Register
6
Mitigate
Action plan to improve performance against targets – being implemented.
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Children and Maternity Dashboard – items to note The RAG rating of the 29 indicators on the dashboard: 8 rated red 8 rated amber 13 rated green This is four more green and five less amber but one more red than in the previous month, which overall represents an improvement. 14 indicators have had data updates since the previous programme board. Updates are pending for:
Quarter 4 data for the mental health indicators will not be available until May. Data is still delayed in respect of “enhanced healthy child programme” indicators due to the migration of community data over to the new Care Notes system. This is being chased with GSTT.
It has previously been agreed that EHC1 data (percentage of maternal booking made within less than 12 weeks 6 days gestation) should be presented monthly byTrust as a proxy for Lambeth population specific data. Latest data for this indicator is on page 2 below. Indicators where there is currently a query: SAF1 – admission of full-term babies to neonatal care unit (without congenital abnormalities): the data on this indicator has been sunject to revision and this matter will be raised at the next CQRG meeting. MAT1 – Friends and family (ante-natal recommend) test score for GSTT and St Georges. An unusually low number of responses were recorded at both Trusts in January. This matter will be raised at the monthly maternity meeting.
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5.1.3 Children and Maternity Programme Board Dashboard
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5.1.4 Key Deliverables Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
Paediatric A&E Reduction, Admission Avoidance and Early Discharge 5.1.1
Commission a 7 day a week pilot Quarter 2-4 ambulatory care service across LSL for general paediatrics, including those with respiratory and sickle cell conditions to manage winter pressure from Oct 2015
The service went live across all 3 Trusts from February 2016 at a reduced service (8-6pm) until April when it will deliver at full capacity (8-10pm).
5.1.2
Ensure effective interface and joint Quarter 2 working with the CCNT
This is being taken forward via the above Commissioner/Provider meetings. Assurance of effective interface and joint working across the 3 Providers and with the pilot Paed H@H (Hospital at Home) service is being reviewed as part of the evaluation and on going monitoring.
5.1.4
Improve communication and Quarter 2-4 information sharing with parents and carers of young children through dissemination of the ‘Common Childhood Illnesses’ Booklet
The Common Childhood Illnesses booklets have been ordered by GSTFT community health and are being distributed by Health Visitors and are part of the GST Transformation Programme. Quarterly reporting on number of books ordered, number delivered to parents and parent satisfaction is being monitored via the GST contract monitoring meetings. Initial findings show that parents find the books helpful and options to explore online version are being explored
Dr Emma Sherwood, PH Consultant is leading the evaluation which will inform the Children’s community Nursing service model going
Lambeth Early Action Partnership (LEAP) 5.1.6
Work with GP clinical network leads Quarter 2-4
Two GP clinical network leads have been appointed. As part of their
37
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
for LEAP to ensure primary care are fully engaged with the programme and there is effective linking with LCN
ongoing work they are meeting with the Practices that fall within the 4 LEAP wards and working up the detail of the GP LEAP Programme. A dedicated PH consultant has been appointed (to start in April 16) to work with the GP’s to further develop the GP Failsafe Programme
5.1.7
Continue to work up the local Quarter 2 -3 evaluation framework for LEAP and each intervention through a consortium of academic stakeholders
This is on-going. An Evaluation Lead has been appointed as part of the core LEAP team and they continue to liaise with stakeholders including KHP.
5.1.8
Work with London School of Quarter 3 economics to develop the LEAP cost benefit analysis tool
This is in progress. There has been some delay across the a Better Start Big Lottery sites due to getting the correct data etc
Children’s Transformation Programme 5.1.10
Ensure children’s agenda embedded into LCN development
is Quarters 2-4
Children’s issues have been discussed at the SEL LCN and plans are being developed to ensure priorities link with and are informed by LEAP, CYPHP, Wells Centre and Children’s GP Delivery Scheme. SW LCN has recently prioritised Children & YP, with a focus on supporting schools with effective emotional resilience, aligned with the CAMHS Strategy and CYPHP.
5.1.11
Continue to roll out and monitor Quarters 1-4 enhanced vitamin D programme
The 25% target was exceeded in Q3 with 36.9% take up by eligible population in Q3. The Children & Maternity Programme Board continues to monitor take up on a monthly basis. The evaluation of the programme hs been completed and next steps are to ensure equitable availability and to ensure children are actually taking the vitamin, not just registering to 38
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update receive it
5.1.12
Scope and consult on the delivery Quarter 3 service model for integrated targeted family support, incorporating social care, early help, health visiting, voluntary sector etc.
The focus on has been on integrating family support services and work is currently being developed around improved integration of HVs with Children Centre and early years model. Proposed models will be consulted on through out early 16/17
5.1.13
Ensure the healthy child programme Quarters 1-4 is effectively delivered, focusing on improving Child Health reviews
The Health Reviews are below the agreed target of 85%, however improvement has been made in HR1 increasing from 78.9% in Q1 and 79.2% in Q2. HR2 remains below target at 70.1% in Q2. Work is on-going with GST and the Health Visiting service, with an improvement plan in place. The main issue was newly qualified HVs not booking children in early enough, this is being addressed and monitored via the CMB.
5.1.14
Ensure service improvement in line Quarter 3 with Ofsted Inspection: Initial Health assessments of LAC (Loooked After Children) completed in timely manner and care leavers receive and talk through their health passports
Work is ongoing to improve Health of LAC. The focus is on improving the interface and joint working between the designated LAC health team and spocial workers to ensure information and processes are effective.
Children & Young People’s Health Partnership (CYPHP) 5.1.15
Develop comprehensive Child health Quarter 3 pathway,, specifically for asthma, diabetes and sickle cell
There is a range of work in development around asthma pathway. A dedicated asthma post is in place at GST through the Transformation fund, ensuring the quality standards are effectively implemented. The Children’s GP Delivery scheme is operational with good take up by 39
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update Lambeth Practices to improve paediatric asthma diagnostic and care management. Work is being developed to include an asthma KPI in 16/17
5.1.16
Review adolescent health Quarter 3 commissioning and delivery model, in line with learning from the Wells Centre model
This is being developed through CYPHP. Considerable co-production work has taken place with a range of young people, identifying what works well, gaps in service and accessibility and ideas for improvement. This work will feed into local strategies across social care, CAMHS and youth violence
Emotional Health & Wellbeing 5.1.17
Sign off of the Emotional Health & wellbeing Strategy
Quarter 2
The CAMHS Transformation Plan has been approved by NHSE and £684k has been allocated to the CCG. The detailed Transformation plan is being implemented. Plans for regular reporting to NHSE, CMB and H&WB are in place. In addition the CCG invested £182k recurrent funding in 15/16 to address the long waiting times into the early intervention CAMHS team. A detailed improvement plan is in place monitored by the CAMHS JCG. The target is to reduce to 10% wks waiting by Q4 16/17. Good progress is being made with waiting times reduced from 45 weeks at the end of 14/15 to 15.4 weeks in Q3 15/16
5.1.18
Continue to co-produce the Quarters 1-4 A part time post has been recruited, funded via the CAMHS implementation plan to ensure & 2016/17 Transformation budget to co-produce and consult on the implementation stakeholders are fully engaged in of the Transformation Plan. Events , focus groups etc have been held delivery of the Strategy (3 year plan) with key groups of C&YP, including those known to the YOS, LAC, CWD and certain BME groups. Findings from the work will be summarised in a report by end of April and will inform on going service review and 40
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update development
5.1.20
Improve service in line with Ofsted Quarter 3 Inspection: Timely access to CAMHS for LAC, post adoption support
As part of the CAMHS Transformation Plan all teams are being reviewed to ensure the right pathway, capacity, outcomes are being met. The CLAMHS team for LAC has been prioritised as one of the first services to be reviewed, which will take place in April /May
Perinatal Mental Health 5.1.21
Take forward the recommendations Quarters 2-4 from the Perinatal MH pilot
The part time perinatal MH worker has started in post and is leading on the following specific work: scope the training needs across the children’s workforce, review training programmes and evidence of impact, work with service users and professionals to further develop the perinatal MH pathway and align it with current acute model, carry out research into cost benefit analysis of implementing an effective pathway and input into the development of a Perinatal MH Commissioning strategy. Lambeth was shortlisted for the RCM 2016 Awards for our perinatal MH pathway work and the pilot we ran earlier in the year. Results were announced on March 8th. Lambeth didn’t win, but were praised for our work and for being shortlisted to just 3 services nationally.
Ensure LEAP peri-natal MH Quarters 2-4 interventions is effectively developed and informed by learning from the pilot
Service design phase of the LEAP peri-natal MH intervention began in January 2016, following a logic model approach. The focus is on rolling out the recommendations form the pilot initially and testing them before scaling up borough-wide
Maternity & New Born Screening
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Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref: 5.1.24
Objective Maternity standards:
Delivery Period Quarters 1-4
Working with GSTFT to ensure workforce requirement are met (Increasing consultancy hours cover, supervisor ratio etc.) 5.1.25
Continue to reduce C-Section rates – Quarter 1-4 focus on vulnerable groups, prepregnancy support and antenatal management (i.e. through Centring pregnancy, increasing caseload midwifery etc.)
Progress update This is being looked at via the CQRG meetings for both Kings and GST and more widely as part Our Healthier SEL work. The SEL Maternity Network ToR has been reviewed to ensure effective membership with both commissioning and clinical involvment
GSTFT has appointed a Consultant Midwife for Antenatal Care who started in May 2015. The remit of this person is to identify and support women and pathways of care where women may be at increased risk of delivering by C-section. The Trust is liaising with those organisations with lower C-section rates to determine any learning. They have also commenced a small pilot testing the use of acupuncture to stimulate the start of labour in post term pregnancies. KCH has established a working group to review the C-section rates and investigate possible opportunities for reducing it. A joint GST/KCH Maternity Group with commissioners has been set up to review a number of maternity issues.
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Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref: 5.1.26
Objective
Delivery Period
Working across primary care and Quarter 1-4 maternity services to increase early booking down to 10wks gestation (supports better management of sickle Cell) (on-going and reviewed each quarter)
Progress update Both GSTFT and KCH are committed to increasing early bookings down to 10 weeks gestation. KCH established a new centralised antenatal booking system at the PRUH at the start of May. This has a dedicated phone line for easy access for women who choose to self-refer over the phone or a simple on-line form located on the website. GSTFT is looking at modifying the maternity website to improve access for women wishing to self-refer. The London Maternity Specification includes booking at 10+6 weeks, we have agreed to include it as an aspirational KPI in 16/17 to work up fully from 17/18
5.1.27
Supporting the local management of Quarter 1-4 new born screening programme commissioned by NHSE
GSTFT are implementing the agreed action plan, following recommendations from the EQA (Equality Analysis) of new-born screening. NHSE are the lead commissioners
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5.2 Integrated Adults Programme (Elective, Long Term Conditions, Older People, Urgent Care) Responsible Director
Moira McGrath, Director of Integrated Commissioning (Older Adults)
Clinical Lead
Drs. Lisa Le Roux, John Balazs, Martin Godfrey & Paul Heenan
Programme Lead
Various – please see work streams
Scope of business area
The purpose of this business area is to lead the redesign of adult’s health and social care services to achieve quality, and value for money services, promote independence and self-care. This business area has strong links with the business areas on integrated mental health for adults, a modern model of integrated care, primary care and citizen participation and empowerment.
Objectives of business area
The objectives of this business area are to:
To improve integrated services to provide better health and wellbeing outcomes for patients
High quality and cost effective health and care system
Delivery of financially sustainable health care system for Lambeth
5.2.1 Programme Assurance Statement Assurance
Status/Risks
RAG Rating (Red/Amber/Green)
Is your programme delivering as planned – is it on target?
Many objectives on target but some risks identified.
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5.2.2 Integrated Adults (Elective, Long Term Conditions, Older People, Urgent Care) Programme Risk Register For risks scoring 12 and above, 2A, 2B, 2M, 2C, 2K and 2N, please see the Board Assurance Framework.
Risk Title Likely risk of E-referral service not being implemented fully leading to issues for GP practices and providers around outpatient referrals
Risk Current Register Risk Approach where Risk Score is managed Programme Board / Directorate Risk Register
9
Mitigate
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Action Plan Summary IT training plan for practices in progress. Priorities for 16/17 to be agreed with providers in Q4 2015/16 - A working group with the Trusts, Lambeth CCG and including Southwark CCG has been established and a draft work plan for 2016/17. The working group has established links with the Lambeth and Southwark ICT group and will provide updates to the group and receive support to resolve issues.
Integrated Adults Dashboard – items to note The Programme Board is asked to note the following in the dashboard: Plan 2015/16 The plan for 2015/16 used in this report is the one used by the Contracting Team to monitor activity by provider Trusts. This may be the driver for the apparent large variances between activity and plan year to date (YTD). The report is for Pbr and Non Pbr, to negate the Shift from Pbr to non Pbr in certain trust. Generally elective inpatients and emergency are underperforming in local hospitals, against plan. Outpatient is also overperforming against plan. GP First Outpatients is underperforming when compared with last year’s activity, there are no plan figures at GP practice level. Elective Activity Elective activity is underperforming against plan. This is the case for all 3 main Trusts, with other marginally over plan. Emergency Activity Non-elective activity is underperforming against plan. This is the case for all 3 main Trusts, although other Trusts are 14% over plan. The overall position is showing an under performance of 4%. Non-elective Other Activity The Non Electives are showing over performance in all Trusts with the exception of Kings, which is under performing by 6%. The percentage variances appear high because of the small numbers involved. Across all Trusts there is a variance of 175% over plan. Outpatients First Outpatient First activity is overperforming by 28% overall, when compared to plan. Overperformance against plan varies at local Trusts from 11% at GSTT to 28% at St Georges. Cardiology, Gastroenterology, Nephrology, Rheumatology, Ophthalmology and non QIPP Specialities all show over performance, other specialties are mostly underperforming.
46
Outpatients GP First The activity is slightly down overall when compared to the previous year. GSTT is 8% higher but Kings and ST Georges are 12% and 2% down respectively. Cardiology, diabetic medicine and gastroenterology have increased since last year. Outpatients Follow-up Outpatient follow-up activity is overperforming against plan. The three main local Trusts are between 5% and 38% over plan. First Outpatient attendance activity impacts on follow up activity. Outpatients Procedures Outpatient procedures are overperforming across the board. Accident & Emergency Accident & Emergency activity overall is overperforming against plan by 11%. The GSTT and St Georges Trusts are underperforming by up to 4% whilst Kings is 5% over. Chelsea and Westminster Foundation Trust is overperforming when compared to the previous year. Most of the headline over-performance is attributable to the 79% over-performance at other Trusts. Emergency Admissions for Long Term Conditions Overall, emergency admissions for patients with long term conditions have risen by 3%. Diabetes admission in Kings increased by 28% since last year. Overall Heart failure admissions shows a 13% increase when compared to 2014/15, GSTT shows an increase of 46%.
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5.2.3 Integrated Adults Dashboard
48
49
5.2.4 Elective Responsible Director
Moira McGrath, Director of Integrated Commissioning (Older Adults)
Clinical Lead
Dr Martin Godfrey
Programme Lead
Bisi Aiyeleso / Sara White, Assistant Director Service Redesign
Scope of business area
The Elective Care project has historically focussed on GP referred activity in outpatients, both first and follow up. The elective programme in 2015/16 aims to reflect the changing nature of the work required to deliver improvements across the elective pathway as a whole. Whilst there is still a focus on reduction of activity in outpatients via appropriate referral to specialist services, the Programme also focuses on associated activity along the elective pathway including diagnostics and pre/post-surgical elements of elective pathways. The elective care project links into work being implemented to support the delivery of 18 week referral to treatment targets. It cross references work to the Long Term Conditions project, the Primary Care Development Programme including the GP delivery framework within this, Children’s Services and work undertaken by Southwark and Lambeth Integrated Care (SLIC).
Objectives of business area
The objectives of this business area are to:
To strive to achieve an approach to create solutions for service redesign and delivery with consistency across providers that are accessed by patients living in Lambeth
To create an outcome based approach to agreeing changes to the way in which services are delivered across primary, social, community and secondary care
To manage and mitigate in-year risk, whilst recognising minimal material impact
To reduce the number of people inappropriately seen in outpatients
To reduce inappropriate specialty specific follow up
To agree a consistent approach across Lambeth and Southwark where possible
To reduce variation in the GP referral patterns to outpatients
50
To agree contractual levers to treating patients referred correctly within a pathway
To agree whole pathway approaches within defined areas, including outcome based approaches to pathway management
To reduce expenditure by making people responsible for their own health
To address some of the Information Technology challenges to allow primary care clinicians to feel
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
Reducing Variation In Referral Practices 6.1.1
Complete pilot phase of an Quarter 1 information workflow process (DXS)
Complete. The DXS system has been implemented across all practices. Monitoring of practice usage of the system is occurring and the use of the system has been included as an indicator within the GP federation contract.
6.1.2
Implement DXS across all practices
See section 6.1.1
Quarter 2
A new online training package is being explored as part of the drive to increase utilisation in practices. Review currently being conducted of DXS to provide recommendations on the future of the service and evaluation of its use in Lambeth. This will include a visit to Camden to look at how they use DXS. 6.1.3
Development of checklists in key Quarter 3 areas and implement onto DXS
There are two areas where checklists are still being finalised. The completion of these is due in Q4. Diabetes checklists for DXS have been finalised. Checklists require completion in CVD.
Ophthalmology 6.1.4
Agree and sign new contracts with all Quarter 2
MECS contracts and service specifications have been signed by all 9 MECS 51
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective MECS providers, providers to 10
Delivery Period increasing
Progress update providers that are currently operating. Work has progressed with recruiting an optometrist Provider in the Streatham and Clapham area. Optometrists in Specsavers Clapham will start to provide a MECS service from 1st April 2016.
Reduction In Trust Led Referrals 6.1.5
Acute contracts agreed reductions in trust led activity
with Quarter 1
Agreed acute contracts included reductions in trusts led activity including the areas of Follow up appointments and consultant to consultant appointments
Diagnostics 6.1.6
Implement process to identify Quarter 2 potential areas for improvement that could deliver efficiencies within 2015/16
Work plan identified in pathology. Workplan to be agreed for imaging, meeting in December to agree. Priority areas address quality issues and are unlikely to deliver financial efficiencies during this financial year.
Implementation of e-Referrals 6.1.7
Improve functionality of e-referral Quarter 4 advice and guidance function
6.1.8
To understand and monopolise on Quarters 2- Action plans to increase utilisation, which were delayed due to system the improvements that e-referral 4 instability, are now being reinstated. Provider/CCG interface meeting on offers and aim to increase utilisation ERS now established bi-monthly. Training plan agreed for ERS and of e-referral in primary care implementation commenced. Low utilisation practices identified and
ERS meeting with Providers and Southwark planned for end January. Advice and guidance plan to be discussed but unlikely to make any impact until 16/17. ERS will now be regularly discussed within the agenda of the Lambeth and Southwark ICT group.
52
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update targeted for training. ‘How to….’ guide distributed to all practices. ERS-only access pilot for LIMS service being planned for Q3 2016/17.
6.1.9
To devise a work plan that aims to Quarter 1 encourage local Trusts to further improve their ‘Directly Bookable Services’, ‘Named Clinician in Service Name’ and increase their specialty clinics
See 6.1.8. Draft workplan produced has been disseminated to Southwark CCG and acute trust ERS leads for comment. Workplan to be agreed by April 2016.
5.2.5 Long Term Conditions/Medicines Optimisation Responsible Director
Moira McGrath, Director of Integrated Commissioning (Older Adults)
Clinical Lead
Dr. John Balazs (Long term conditions), Dr Di Aitken and Dr Sadru Kheraj (Medicines Optimisation)
Programme Lead
Vanessa Burgess, Assistant Director & Chief Pharmacist.
Scope of business area
The purpose of this business area is to improve the quality and length of life of people with one or more long term conditions, to promote the clinical and population behaviours, which allow the right care to be delivered in the right setting. We aim to do this by commissioning high value, patient-orientated outcome clinical interventions which aim to support self-management though joint decision making with patients and importantly address parity of esteem for mental health.
Objectives of business area
The objectives of this business area are to:
Improve quality and length of life for people with long term conditions by commissioning high value, 53
accessible patient-orientated outcome clinical interventions for people living with long term conditions. Empower patients with long-term conditions through enriched clinical consultations – development of coordinated care, shared decision-making, prevention, emotional support and self-management. Focus on prevention and improve the recognition, diagnosis and interventions for improving care specifically in respiratory and cardiovascular disease including diabetes. Reducing the need for unscheduled care and unnecessary out-patient activity for people with long term conditions by education and improving focus on prevention and self-management. Work closely with clinicians and the mental health programme to ensure that mental health needs of patients with long term conditions are incorporated into pathways.
54
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
Commissioning Integrated Services 6.2.1
Benchmarking population needs – assessment Quarter of data for long term conditions outcomes. 1
Complete Data analysis with Public Health on evaluating mental health needs of people with Long Terms conditions is underway as part of the evaluation and mainstreaming of the 3DFD service (3 dimensions of care for Diabetes). A draft Long term conditions pathway for including support for people with depression and anxity is to be discussed at the IAPB in March. Data on multimorbidity is being shared with Local Care Network leads and plans to pilot multimorbidity virtual clinics in some practices have been included in plans for 16/17.
6.2.2i
Community management of Diabetes Diabetes intermediate care team) commissioned for 15/16.
(via Quarter re- 1
Complete, Diabetes Intermediate Care Team (DICT) service recommissioned until 31.3.16.. Scoping of commissioning model for the DICT service for 2016/17 is undergoing evaluation of evidence base on outcomes based diabetes contracting and understanding models used in other areas – meetings with Camden CCG and Islington CCG have been completed. Darzi fellow: a workplan has been agreed covering severe mental illness (SMI) and structured education programmes; increasing the number of people with severe mental illness who attend structured education, completing service evaluations of currently commissioned structured education programmes and designing
55
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update modified-structured education for people with SMI with a view to rolling this out across Lambeth practices. Complete, National Diabetes Audit (NDA) 2014-15 - 100% of practices participated. Update: The NDA report for 2014-15 was published at the end of January. Initial review suggests Lambeth practices are performing as follows Care process completion for people with Type 1 diabetes as expected. Care process completion for people with Type 2 or other diabetes – lower than expected. Percentage of newly diagnosed people with Type 1 diabetes recorded as being 'offered' or 'offered or attended' a structured education program – higher than the England Average. Percentage of newly diagnosed people with Type 2 or other diabetes recorded as being 'offered' or 'offered or attended' a structured education program – similar to the England average. Treatment target (HbA1c, BP & total cholesterol) achievement for people with Type 1 diabetes - similar to the England average. Treatment target (HbA1c, BP & total cholesterol) achievement for people with Type 2 diabetes - similar to the England average. Further analysis is required.
56
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update Education for practices – peer support and learning: DICT have been commissioned to provide 2 practice events. Update: 60 clinicians attended the second learning event in March 2016. Ensure cost effective prescribing in diabetes via active promotion of QIPP projects and audit against NICE guidelines. The Lambeth Diabetes Intermediate Care Team have moved into the third phase of implementation of reviewing Blood Glucose Monitoring in people with uncomplicated type 2 diabetes. The CCG are developing plans to commission community pharmacists to co-deliver this initiative with Lambeth GP practices and Lambeth DICT. Scoping potential for a combined CVD and diabetes network to embed learning into other LTCs. Update: The first focus group for leads from each LTC area, LCN leads, Federation chairs, Acute Trusts and Healthwatch took place in February, facilitated by South London HIN .The session scoped ideas of what an LTC network would look like, the aims for the next focus group and the broader group of stakeholders that need to be involved. A further meeting to plan next steps is scheduled in March. Optimising type 2 diabetes care via search and virtual clinic. Target: patients with uncontrolled HbA1c - 64 mmol/mol or greater (QOF) and sub-optimal medicines. Included in LTC scheme, GP Delivery framework. Update: 42 out of 47 practices have completed their first virtual
57
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update clinic to date. Ten practices have been offered additional support by the DICT to improve clinical outcomes for patients. The practices were selected based on Quality and Outcomes Framework (QOF) clinical domain data relating to HbA1c, blood pressure and total cholesterol as well as expected prevalence data. 8 out the 10 practices have accepted the offer. The Diabetes Specialist Nurse linked to each practice has made contact and intial visits are underway to meet and discuss the best way to support each practice. Lambeth CCG and Local Authority submitted a joint expression of interest with CCGs/LAs in South London in October 2015 to be part of the first wave of the National Diabetes Prevention Programme (NDPP). Lambeth, along with all 12 South London CCGs and Local Authorities were successful in this bid. Planning work with NHS England, Lambeth LA and the other CCGs is underway with a view to starting referrals to the NDPP from May 2016. A paper to discuss future integrated services for diabetes for 17/18 and onwards is to be discussed at the IAPB in March
6.2.2ii
Performance indicators agreed and reports Quarter monitored for 15/16. 1
Complete.
6.2.3i
Hypertension service re-commissioned for 15/16 Quarter
Community hypertension service – GSTT outreach and virtual clinic service recommissioned for 15/16.
58
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective with updated reports.
performance
Delivery Period indicators
Progress update
and 1 Ambulatory Blood Pressure Monitoring (ABPM) - Aim to obtain further information regarding the service and the different models across the borough to allow evaluation of the service and design of the future delivery model. Practice survey is complete and results are being collated for presentation at the next CVD steering group. Secondary care activity data has been requested in order to review all ABPM activity since the introduction of the practice based service. A service evaluation report was presented at the last Integrated Adults Programme Board and arrangements for future commissioning were agreed. This will be taken forward by the Medicines Optimisation Team. Hypertension – optimising management. Over 15/16, identify a target cohort of uncontrolled HT patients - BP systolic >160 or diastolic >100mmHg for optimisation. Each practice holds a minimum one annual CVD virtual clinic plus HT clinic referral where needed for complex patients. Implementation plan for practice to include learning from previous work, and action planning to optimise patients identified. Offer lifestyle advice & stop smoking. Included in LTC scheme, GP Delivery framework. An update from the hypertension team was received mid March and 45 out of 47 practices have had their virtual clinic and over 800 patients have been reviewed. Only one practice will not have had a hypertension virtual clinic within the financial year. 59
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update Baseline data for our hypertension equalities objective has been obtained and will be included in an encompassing hypertension report to be presented at the IAB in the first quarter of 2016-17
6.2.3ii
Equality objective for Hypertension delivered.
Quarter 4
6.2.3iii
Performance indicators for 15/16 for the Quarters community heart failure service and reports 1-4 monitored.
6.2.3iv
Ambulatory Blood pressure monitoring service Quarter reviewed and re-commissioned by April 2016. 4 60
The service specification and KPIs for 16/17 were ratified at the January Integrated Adults Programme Board. Providers have shared data relating to delivery of the currently commissioned service. This data consists mainly of activity data rather than outcome data due to data collection problems which have now been resolved. Meetings are in place to plan the implementation of the successful heart failure charity bid for 7 day working, moving care into the community and aligning with Federations and locality care networks. A key focus of this work will be to look at how to integrate across other long term conditions and how to deliver improved outcomes for our patients and reduced heart failure admissions across the system. Providers have agreed to provide both activity and outcome data for the end of the financial year for the current commissioned service. This data will also act as a baseline for the heart failure charity programme which will start in April.
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective Indicators
Delivery Period
6.2.3v
Performance monitored.
developed
and Quarters 1-4
6.2.4
Integrated respiratory team (based @KCH) recommissioned for 15/16.
Quarter 1
Pharmacist support to enable medicines optimisation in respiratory disease.
Quarter 1-4
Progress update As 6.2.3i. Complete for 15/16.
Complete Optimise care of asthma patients via virtual clinic. Discuss information from the Quality Asthma Review Pyramid to; 1. develop a practice specific action plan to improve asthma care 2. Implement the action plan with a progress report by March 2016 and Identify patients on high dose Inhaled corticosteroids and step down as clinically appropriate Included in LTC scheme, GP Delivery framework. Optimise care of Chronic Obstructive Pulmonary Disease (COPD) patients – in 15/16 each practice identifies cohort of patients to discuss during IRT VC; 1. Patients on high dose inhaled corticosteroids with mild/mod COPD. 2. COPD patients with any recent urgent care episode (A&E, hospital admission). Complete a review with IRT Support using the COPD review template and CCG prescribing guidelines. Increase referrals of people with COPD and tobacco dependency to specialist stop smoking services via singlepoint of referral.
61
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update All clinicians to strongly consider completion of NCSCT Included in LTC scheme, GP Delivery framework. 100% of practices have booked a virtual clinic. Education for practices – (1) PLT event with 80 in attendance, focussing on cough, breathlessness and asthma to support delivery of LTC scheme. (2) IRT to provide additional afternoon training sessions, on spirometry, asthma and COPD in Q3 and Q4 – all events have booked attendance at 80 – 100%. Patient support – pilot project involving Self-Management UK is being streamlined with the established Breatheasy group as an alternative mechanism to support reluctant patients into Pulmonary Rehab service. BA training and if already completed then Level 1 quit smoking training. Lambeth patients participating in Singing for Better Breathing study. Establish a SEL Responsible Respiratory Prescribing group to report to the SEL Area Prescribing Committee. Terms of reference have been agreed with the APC and the group is meeting in November 2015. The SEL Responsible Respiratory Prescribing group has devekped a respiratory management guideline and pathway for asthma and COPD across SEL. The guideline is undergoing approval via the Area Prescribing Committee and will be implemented locally in partnership with the Integrated Respiratory Team and practices via inclusion in the medicines plan.
62
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
6.2.5i
Performance indicators for the IRT service for 2015/16 developed and monitored.
Quarter 1
Review underway. Final indicators to be agreed at November Core Group meeting. Focus on holistic patient outcomes. Range of metrics are being discussed, for example: the “Asthma pyramid”, and a similar pyramid for COPD for accessible data from EMIS. Also patient-reported outcome measures to ensure the patient experience is captured.
6.2.5ii
Community Spirometry service to be commissioned for 2015/16 in line with approved business case.
Quarter 1
The service specification is complete and has been sent to localities for expressions of interest. Alternative models of provision including via IRT are being explored and a paper will be taken to the Integrated Adults Programme Board in December/January. Implementation during Q4, anticipated start date no later than April 16. Update to the spirometry business case: The IRT are progressing the spirometry service via their business planning process, and are expecting final sign off from KCH at the end of January. Federations have been updated.
6.2.5iii
Performance indicators to be developed and monitored.
Quarters 1-4
6.2.7i
Commission mental health support for people with LTCs for 2016/17.
Quarter 4
6.2.7ii
Embed and mainstream the learning from the 3DFD pilot
Quarters 1-4
63
As 6.2.5i.
Mainstream the service over the next 12 months. Interim funding for 15/16 agreed. The first review meeting with KCH has taken place in June and it was agreed to pursue 2 routes
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update concurrently ; 1. Contribute to the Trust led amended bid to the Health Foundation to continue the service and roll out to CVD patients (Hypertension) – the “3DLC” proposed model. A second stage application for funding for 3DLC has been supported by CCGs in October on the basis that agreement on alignment with currently commissioned pathways is agreed over the next few weeks. 2. Lambeth CCG has met with the IAPTs provider (SLAM) in July to discuss meeting needs of patients with LTCs. To identify the small cohort of complex patients who will need more intensive support and how that can be provided for all patients with LTCs using the learning from 3DFD. This will be further progressed over Autumn.
Commissioning For Outcomes 6.2.8
Establish a steering group to scope a model of care for enabling quality care and selfmanagement for patients with LTCs, possibly via an outcomes based/year of care approach to commissioning long term conditions services.
Quarter 2
Initial scoping underway internally.
Quarter 1
Promote care planning and shared decision making via personalisation in patients with long term conditions through incentivising enriched clinical consultations – development of
GP Delivery Scheme 2015/16 6.2.9
Consult and agree on a scheme with General Practice and federations to improve selfmanagement and optimisation for people with
64
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
LTCs and obtain best value from medicines.
Progress update coordinated care, shared decision making, prevention, emotional support and self-management. CVD and diabetes virtual clinics and medicines reconciliation ensure adoption of care plans into practice in primary care. Included in Long Term Conditions Scheme 15-16 which has been launched via 3 launch events with 100% attendance from practices. The scheme has been designed to build on proven successful interventions by the virtual clinic model of care in key elements of CVD, Respiratory Disease and Diabetes plus Medicines Reconciliation in primary care. Phase 2 of the LTC scheme scoping is delayed due to lack of system capacity. This will now be incorporated into commissioning intentions and plans for 16/17.
6.2.10
Deliver medicines QIPP plan and financial balance on prescribing budget.
Quarters 1-4
The Medicines Optimisation Scheme 2015-16 has successfully been developed and fully consulted with stakeholders. The key areas are: Cost Prescribing Efficiencies; Repeat Prescribing Systems and Waste Reduction; Patient Safety on Antibiotics. The scheme has been designed to progress on foundations laid from the 2014-15 scheme for example practices will be asked to minimise the risks identified within the Repeat Prescribing Support Day visits. ScriptSwitch continues to be actively managed to raise potential savings within all practices and the profile review and rationalisation is 80% complete
65
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update CCG commissioned high cost drugs spend is monitored and inappropriate charges are challenged monthly. The GSTfT and KCH High Cost Drugs Policy for 15/16 has been agreed. Key Performance Indicators have been agreed for KHP. Regular medicines contracting meetings are held quarterly with Trusts and medicines/CSU teams. Collaboration on cost effective use of high cost drugs is via pathway development as part of SEL APC. Lambeth CCG continues to have representation on the GSTfT Medicines Safety Forum and the SLAM Medicines Safety Committee to facilitate learning across organisations on medicines errors. The three Electronic Prescribing System (EPS) workshops for practices took place in September and were well subscribed with representatives from 41 practices and 9 community pharmacies attending. Feedback from attendees was positive, with the opportunity to obtain peer support and address questions directly to EMIS Web/HSCIC/CSU representatives cited as particularly helpful. Medicines Waste Campaign materials have been agreed and circulated, commissioned alongside other SEL CCGs via the CSU. A draft Medicines optimisation scheme for 16/17 has been developed by the Borough Prescribing Committee to ensure cost effective prescribing and delivery of QIPP . This is under consultation with federation leads and the LMC.
66
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
6.2.11
Deliver effective implementation of the LTCs and Quarters Medicines schemes – communications, 1-4 specialist support, resources and monitoring.
Ongoing.
6.2.12
Scope phase 2 of the LTCs plan – mental health inclusion in LTCs, shared care for medicines, osteoarthritis.
Included in the scoping and development of 2016/17 commissioning intentions
Quarter 3
Enabling Self-management And Resilience: Allied Health Professionals 6.2.13
6.2.14
Support GP federation/local care network to promote extended consultation times in primary care for complex younger people with long term conditions not currently included in the holistic assessment process.
Quarters 1-4
Holistic Assessments now available for over 65 years.
Commission a scheme to deliver routine pharmacist support to the frail elderly taking complex medication regimens in the community.
Quarter 1
Complete – service business case for an Integrated Pharmacy Service for Older People was approved by the Committee in Common in October 2015.
Care planning for younger people via LTC virtual clinics.
A Community Pharmacy Older Peoples Support service for ongoing medicines and support in the community is being scoped and a business case will be submitted to the Committee in Common in early 2016.
67
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
6.2.15
Commission a domiciliary specialist clinical pharmacy medicines assessment service for complex frail elderly to enable local authority social services and primary care to support people in their own homes.
Quarter 3
Complete
6.2.16
Scope a scheme with the older people’s team for incentivising waste management and increasing quality of prescribing for community pharmacies with a care home supply contract.
Quarters 1-2
Scoping
Enabling Self-management And Well-being: Community Access to Effective Medicines 6.2.17
Review of community pharmacy common ailments scheme – list of products available
Quarter 1
The common ailments scheme has been reviewed and approved by the Lambeth Borough Prescribing Committee - complete
6.2.18
Integrated working with local authority commissioners to support development and approval of patient group directions in local authority commissioned services, and access to medicines to support prevention and well-being e.g. stop smoking, contraception.
Quarters 1-4
Work has been undertaken to support the local authority to develop and approve a range of PGDs for use by Community Pharmacists and Brook Sexual Health Clinic nurses.
Quarters 1-4
Year 2 CQUIN on medicines review and communication from acute trusts with GSTfT and KCH – agreed to include learning from year1.
Safe Transfer of Information Between Care Settings 6.2.19
GSTFT and KCH Medicines CQUIN – develop, monitor and embed into routine practice. CQUIN is delivery of a robust medicines review in high
68
Key Deliverables For Quarters 1 - 4 2015/16 Business Plan Ref:
Objective
Delivery Period
Progress update
risk polypharmacy patients admitted to hospital which is well communicated to primary care on discharge 6.2.20
LTCs scheme (GP Delivery Framework) incentivised medicines reconciliation in primary care in line with NICE NG5, March 2015.
Quarter 4
Medicines Reconciliation in primary care included in the LTC scheme, GP Delivery Framework.
Collaboration Across South East London 6.2.21
Active engagement and leadership (hosting function) from Lambeth CCG for the SEL Area Prescribing Committee and work streams.
Quarters 1-4
Shared care guidelines for rheumatology have been approved via the Area Prescribing Committee. The associated DMARDs primary care scheme has been updated in consultation with the Borough Prescribing Committee and LMC and will be discussed by the IAPB in March 16, ready for launch on 1.4.16.
6.2.22
Ensure that medicines related IFRs are progressed in a timely manner in line with current policy.
6 monthly report
Ongoing
Attendance at IFR panel meetings. IFR policy in place.
69
Medicines Optimisation & LTC – data element A. Overall Performance 2015/16 (Month 10) Overall the prescribing budget underspend at Month 10 is £449,174 (1.5%, see finance report). The North is underspent by 3.5%, the South East by 0.8 % and the South West by 0.9 % Spend per ASTRO-PU (data available quarterly) No of practices Achievement CCG achieving Threshold average threshold (out of 47) =1% from the 2013/14 position b) Reduction in the proportion of broad spectrum antibiotics prescribed in primary care – threshold either >= 10% from the 2013/14 position or below the 2013/14 median English CCG position of 11.3%. The table below shows that this was being achieved from June 2015 for antibacterial items but not for Co-amoxiclav, Cephalosporins and Quinolones.
130
NHS England Antibiotic Quality Premium monitoring dashboard (12 months rolling data) Green = target met Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Antibacterial items/STAR PU13
Co-amoxiclav, Cephalosporins & Quinolones
Target Value by end of 2015/16 to be equal to or less than 0.825:
Target Value by end of 2015/16 less than 11.3%
0.835
0.828
0.825
0.820
0.817
0.806
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
0.801
0.801
0.777
TBC
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
11.9%
11.8%
11.7%
11.5%
11.3%
11.2%
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
11.0%
10.8%
10.7%
TBC
c) Secondary care providers have validate their total antibiotic prescribing data as certified by PHE This measure will be worth 10% of this year’s Quality Premium. This measure is reported as part of the Medicine’s Management Report earlier in this report under Long Term Conditions.
Maternal smoking at delivery This is a long-standing measure. This measure will be worth 10% of this year’s Quality Premium. Performance against the standard itself is achieving the target. However, there is a risk that the standard will not be achieved because the data validation measure - 97
Monthly
97
95
95.9
95.4
95.2
85.5
95
96
96
96
FFT- A&E (Response Rate)
NHS England website
Percentage
>20%
Monthly
22.6
22.7
18
12.8
16.2
13.1
17.8
15.3
12.7
14.2
FFT - A&E(% Recommended)
NHS England website
Percentage
>88
Monthly
85
85
85.3
85.8
85.4
86.1
84
85
85
87
Complaints opened in Month (number)
Integrated Quality & Performance Report
Number
not spec
Monthly
67
95
85
73
104
91
114
91
97
Time taken to respond to complaints (median wait in days)
Integrated Quality & Performance Report
Number
not spec
Monthly
38
64
52
58
56
46
49
38
54
Maternity: % women booked 12 weeks 6 days
Trust Obstetric dashboard
Percentage
>90%
Monthly
83
82
81.1
83.4
88.4
84.9
84.5
85.5
84.5
86.7
Maternity: % C- Section total rate
Trust Obstetric dashboard
Percentage
88% during Q3 15/16. In December, 87% of patients recommended A&E, which is in line with the London average. The response rate has dropped slightly in Q3 15/16 and is below internal target of >20%, however above the London average of 12.7%, with 14.2% reported in December. The percentage of patients recommending the Trust Maternity care, as measured by FFT, shows an improvement. In Q3 100% of patients recommended antenatal care, 94% of patients recommended care received during birth and 87% of patients recommended postnatal care and 100% of patients recommended care received in the community wards. There is an increase in percentage of patients that would not recommend birth care at the end of Q3 15/16 (2% in December), which is higher than the England average (1%). An improvement can be seen in the Maternity FFT response rate in birth settings with 26.7% reported at the end of Q3 compared to Q2 15/16 (in September 19.8% reported). A slight increase was noted in the percentage of patients recommending the Trust in postnatal ward in Q3 (December 87%) compared to Q2 15/16 (September 82%). Please note that there is no data for Q3 Staff FFT as this is replaced this Quarter with the existing NHS Staff Survey (data will be released on 23rd February). Safety There have been 16 Never Events reported at GSTT this year to date (Feb 2016). This issue was discussed the last GSTT Clinical Quality Review Group Meeting (CQRG) in February. A detailed Action Plan was submitted by the Trust to CCGs. This will be monitored by the CQRG, with the objective of securing improved assurance in relation to reducing the number of Never Events. The Trust continues to achieve the appropriate levels of safeguarding training in adults and children - both areas are consistently above 80% during Q1,Q2 and Q3 15/16. There has been a slight increase in Safeguarding Adults training level at the end of December this year (91.12%) compared to December 2014 (90.7%). Effective and Well-led 139
There has been a similar performance in the percentage of women booked within 12 weeks and 6 days in Q3 when compared to Q2 15/16 but this still below the internal target of 90%, with 86.7% reported in December. In Q3 15/16 there has been a sharp increase in the Caesarean section rate from 30.6% reported at the end of Q2 to 37.8% reported at the end of Q3. The percentage of Caesarean section rates remains well above the 27% target year to date. There has been a slight decrease in the number of births per midwife in Q3 compared to Q2 this year.
The information provided in this section is a summary of discussion from the monthly CQRG meeting. This meeting is attended by senior Trust representatives, including the Medical and Nursing Directors, Clinical Commissioners and Directors of Quality and colleagues from Lambeth and Southwark Clinical Commissioning Groups (CCGs). The Trust provided an update on the 15/16 Winter Flu vaccination. The programme began in October and will run for 10 weeks with 65 drop in clinics scheduled. The programme is builds on the successful 14/15 strategy. Given the negative national press this year regarding the efficacy of last year’s vaccination, the Trust reported that internal communications are on track to promote the vaccine – with the programme being advertised via media such as You Tube, and posters/banners and with the Chief Nurse actively promoting the vaccination programme. Current performance figures are as follows: 46.5% of all staff has been vaccinated year to date compared to 49.5% last year. In regards to front line workers, 53.5% have been vaccinated up to date compared to 53% last year at this time. IA noted that figures will go up as Trust still have 2 more sessions before completing the programme, so these do not represent the definitive figures. It was also noted that some staff will have been vaccinated by other means (e.g. at their GP surgeries) and these will not have been captured by the Trust figures.
There was a main agenda item discussion on Patient Experience. In response to the 14/15 CQC national inpatient survey the Trust presented comprehensively on the main areas of the action plan which they noted was near to completion; Enhance the visibility of staff/ the member of staff’s name so that patients know who they are speaking to and who they should approach if they have a concern about their care or need emotional support. Improve the support provided to patients who need assistance at mealtimes. Improve the quality of information about medication side effects at discharge. Involve patients and families more in the discharge planning process keep patients informed of delays on the day and improve the quality of information provided to support self-care and management of their medicines. Improve information provided about complaints and the process by which patients can make a complaint. The slight performance decline in Friends and Family A&E scores in September was noted. September was a very challenging month in meeting the 4 hour target and the unit was extremely busy. The Trust focused on a number of improvement initiatives, one of which related to the ‘’Hello my name is …’’ campaign which seeks to ensure that staff wear their badges and introduce themselves to patient friends and family. This was developed in response to patient feedback. 140
An update was provided on Community Nursing. The Trust reported that the majority of the Transformation Plan had been achieved and new models of care are being piloted, e.g. the Buurtzhog model. In terms of recruitment, 76 staff have been recruited within the last 12 months and the single point of access for the service has been implemented.
141
4.0 King’s College Hospital NHS Foundation Trust – Quality Dashboard Source
Units
Target Reporting Dec-14
Apr
May
June
Q1
Jul
Aug
Sep
Q2
Oct
Nov
Dec
1. Denmark Hill site QUALITY INDICATORS - ALL TRUSTS Red Adverse Incidents (inc medication errors) number
KCH Scorecard
Number
0
Monthly
14
15
9
13
12
16
9
14
12
15
Falls (moderate)
KCH Regulatory team
Number
25 working days
KCH Performance Report
Number
0
Monthly
35
25
31
39
42
23
39
34
24
21
Maternity: % women booked 12 weeks 6 days (CCG adj. figure)
Obstetrics Scorecard
Percentage
90%
Monthly
84.3
78.3
81.5
82.3
79.3
78
71.5
79.2
76.6
81.1
Maternity: % caesarean section rate
Obstetrics Scorecard
Percentage
