- NHS West Kent CCG
Transcription
- NHS West Kent CCG
Agenda and Papers for the NHS West Kent Clinical Commissioning Group Governing Body To be held on Tuesday 26 August 2014 At 1.30 pm In The River Centre, Medway Wharf Road, Tonbridge, TN9 1RE Page 1 of 163 Notice is hereby given of the meeting of the NHS West Kent CCG Governing Body meeting to be held on Tuesday 26 August 2014, at 1.30 pm – 3.00 pm, in The River Centre, Medway Wharf Road, Tonbridge TN9 1RE This meeting will be held in public. Questions from the public – The Chairman will take questions from the public relating to items on the agenda or other aspects of the CCG business. AGENDA Part 1 Chairman is Dr Bob Bowes *Papers for approval Time Agenda Agenda Item no. Lead Required Action 1.30 pm 113/14 Chair TO DISCUSS 1.45 pm 114/14 Welcomes and Introductions Chair TO NOTE 115/14 Apologies for Absence Chair TO NOTE 116/14 Quorum Chair TO NOTE 117/14 Declaration of Member’s Interests Chair TO NOTE *118/14 Minutes from the previous meeting held on 22.07.14 Chair FOR APPROVAL Page no’s 5-19 119/14 Actions arising from the previous meeting held on 22.07.14 Chair TO DISCUSS AND NOTE Page no’s 19 - 20 120/14 Matters Arising from the meeting held on 22.07.14 not covered elsewhere on the agenda. Chair TO DISCUSS AND NOTE Questions from the public Page 2 of 163 Chief Member Reports and Strategy Papers 2.00 pm 121/14 Chairman’s Report Chair ORAL REPORT 122/14 Chief Officer’s Report Ian Ayres ORAL REPORT Performance and Assurance Reports 2.20 pm 123/14 Quality Report Dr Meriel Wynter TO NOTE Page no’s 21 - 60 124/14 Safeguarding Annual Report Steve Beaumont FOR INFORMATION Page no’s 61 102 125/14 Integrated Performance Report Reg Middleton TO NOTE Page no’s 103 132 126/14 Chief GP Commissioner and Clinical Strategy Group (CSG) Report TO NOTE Page no’s 133 135 126.1/14 Integrated COPD Service for High Risk Patients Business Case 127/14 Practice Engagement Committee (PEC) Report Finish 3.00 pm Page 3 of 163 Dr Sanjay Singh Dr Sanjay Singh FOR APPROVAL Page no’s 136 160 Dr Garry Singh TO NOTE Page no’s 161 163 Resolution: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. Date of the next meeting: Tuesday 23 September 2014, 1.30 pm – 5.30 pm, The River Centre, Tonbridge Dates of Future Meetings Tuesday 28 October 2014, 1.30 pm – 3.30 pm, The Village Hotel, Maidstone Tuesday 25 November 2014, 1.30 pm – 5.30 pm, The Village Hotel, Maidstone Tuesday 16 December 2014, 1.30 pm – 3.30 pm, The River Centre, Tonbridge Tuesday 27 January 2015, 1.30 pm – 5.30 pm, The River Centre, Tonbridge Tuesday 24 February 2015, 1.30 pm – 3.30 pm, The Village Hotel, Maidstone Tuesday 24 March 2015, 1.30 pm – 5.30 pm, The Village Hotel, Maidstone Page 4 of 163 Draft MINUTES of the Governing Body meeting Held in Public Meeting held on 22 July 2014 at The Village Hotel, Castle View, Forstall Road, Sandling, Maidstone, ME14 3AQ Date of Approval: Present: Dr Bob Bowes Chair of the Governing Body Ian Ayres Chief Officer/Accountable Officer Dr David Chesover GP Governing Body Member Dr Mark Ironmonger GP Governing Body Member Reg Middleton Chief Finance Officer Sue Southon Lay Member for Patient and Public Engagement Malti Varshney Public Health Consultant and Governing Body Member Dr Mark Whistler Chair of the UCB and GP Governing Body Member James Hedges Lay Member for Governance Dr Garry Singh Chair of PEC and Finance and Performance Committee and GP Governing Body Member Dr Sanjay Singh Chief GP Commissioner and GP Governing Body Member Mr Nic Goodger Secondary Care Clinician Dr Meriel Wynter Chair of Quality Committee and GP Governing Body Member Dr Andrew Roxburgh GP Governing Body Member Page 5 of 163 Dr Tim Palmer GP Governing Body Member Dr Nick Cheales GP Governing Body Member Observing: Mr Tony Broadrick PPG Chair In attendance: Gail Arnold Chief Operating Officer/Deputy Chief Officer Richard Segall Jones Company Secretary Kofo Abayomi Interim Governance Support Manager Alison Brett Deputy Chief Nurse Louise Matthews Deputy Chief Operating Officer Apologies: Dr Bruno Capone GP Governing Body Member Dr Tony Jones GP Governing Body Member Dr Steve Beaumont Chief Nurse 97/14 Questions from the public There following questions were asked from members of the public: Cllr Richard Davison commented on facilities at Edenbridge Hospital and asked whether the facilities were fully utilised and if not were there thoughts/suggestions on how the facilities could be improved. Mr Ayres responded that whilst the hospital had very good facilities, it was not being utilised fully, he proposed more work to be done by the Community in the area to explore how it could be utilised more as a community wide resource rather than a purely NHS resource. Cllr Davison further commented that the League of Friends at a recent meeting discussed their concerns about this matter and the possibility of further use of the hospital. He stated that the League of Friends are seeking input in the process. Mr Ayres Page 6 of 163 confirmed that he met representatives of the League who had graciously showed him around the hospital premises during his last visit. Questions from Mr Jim Pragnell concerning Personal Health Budgets were sent ahead of the meeting. Dr Bowes acknowledged the questions and stated that these would be answered during the discussion on Personal Health Budgets and a communication would be sent to Mr Pragnell who was absent from the meeting. 98/14 Welcomes and Introductions Dr Bowes welcomed everyone to the meeting. No introductions were necessary. 99/14 Apologies for absence Apologies were received from Dr Bruno Capone, Dr Tony Jones and Dr Steve Beaumont. 100/14 Quorum The Governing Body agreed the meeting was quorate. 101/14 Declaration of Members Interests There were no changes to declaration of Members Interests at the meeting. 102/14 Minutes from the previous meeting held on 24 June 2014 The following amendments were requested to the Minutes of the meeting held on 24 June 2014 meeting: Page 7, line 7 to be redrafted to read Ms Varshney informed the Governing Body that the draft Health and Wellbeing Strategy was now published and a link to the draft strategy had been forwarded to members for feedback.” Page 8, 1st Paragraph “Abnormal scan results to be changed to abnormal haematology result”. The Governing Body confirmed that the Minutes of the previous meeting held on 24 June 2014 were an accurate record of the meeting subject to above amendments. 103/14 Actions arising from the previous meeting held on 24 June 2014 93/14 Integrated Performance Report Dr Bowes referred to the national and local quality measures on potential years of life lost for both male and female and he commented that the CCG was about 12% Page 7 of 163 off target and he asked what this meant for the CCG and what the CCG was going to do about this situation. He reminded the Governing Body that the target was reduction by 2% but the CCG was now 12% off the reduction target. He requested comments on this issue. Ms Varshney stated that she would look into this matter because it was important to understand where this was coming from and report back to the Governing Body. Action: Ms Varshney. 104/14 Matters Arising from the meeting held on 24 June 2014 not covered elsewhere on the agenda There were no matters arising from the meeting held on 24 June 2014 that were not covered elsewhere on the agenda. 105/14 Chairman’s Report Dr Bowes referred to the piece of work “Have your say” prioritisation. He commented that this had been partially successful last year because a lack of time and manpower had meant that each schemes description did not comply with a consistent standard so assessing which scheme to prioritise became difficult. This year the engagement process would be to ensure that the various schemes were in fact aligned with Mapping the future. In order to do this, commissioning plans need to be written in a way that is consistent and comprehensible. This will help members of the public understand what the CCG hopes to achieve but also will provide outcomes which are SMART for POGs to measure themselves against Dr Bowes highlighted how the aims would be achieved/delivered. He explained that this would make the CCG accountable and would be an opportunity to explain the strategic plans. Dr Bowes welcomed feedback from the Governing Body. Dr Garry Singh requested clarification of the use of 15% milestone from the presentation and Mr Broadrick commented that previously there was a pounds/pence denomination to explain value for money and he explained that the use of cost would be helpful. Dr Bowes responded that Ms Louise Matthews and her team were working on this and feedback would be welcomed before the end of August 2014. 106/14 Chief Officer’s Report Mr Ayres reported on the following key matters: NHS England - Understanding the new NHS Page 8 of 163 Mr Ayres informed the Governing Body that NHS England had published a short guide, written by 5 doctors in training, setting out how the NHS operates. The Governing Body noted the link provided to the guide. Commonwealth Fund Mr Ayres drew the attention of the Governing Body to the Commonwealth report which ranked the United Kingdom the best overall of 10 healthcare systems worldwide. Mr Ayres further stated that this had a political benefit as it helped the Secretary of State support the NHS. NHS Clinical Commissioners – Commissioning Show Mr Ayres commented that the term Accountable Care Organisations (ACO) is increasingly being used by politicians to describe what the CCG might become, he advised that this was important as we moved towards the year for election. Although it was still unclear what the term means, it was being mentioned frequently. He felt this concept was pushing the CCGs beyond integration to a place of taking responsibility for overseeing delivery of entire pathways. Dr Bowes enquired whether ACO in the context of CCGs would mean accountable commissioning. Mr Ayres responded that from the United States, Australian and Canadian perspective of ACO, these were organisations that commission as well as provide, i.e. responsibility of the totally of the pathways, provide some care and commission parts of it as well. He further stated that if the CCG was to move in this direction, it would require change in the primary legislation as presently CCGs have no entitlement to provide services. He did not think this was the intention but the rationale was that the CCG would own the end to end journey of patient care i.e. a wider reflection of the responsibility of CCGs. 105.1/14 CAMHS Progress Update Mr Ayres provided an update on CAMHS services. He stated that previously there were issues with the service, however work had been done which would boost improvement in performance e.g. Sussex Partnership waiting times were decreasing. Mr Ayres further explained that impact would begin to show in the near future and proposed that a written report would be presented to the Governing Body to highlight performance. This was already work in progress and the report would be presented to the September Governing Body meeting. Action: Mr Ayres. Ms Varshney recommended that quality markers should be taken into account in respect of the above. Mr Ayres agreed with this recommendation and commented that Public Health had also begun to look into it. Ms Southon commented that Health Watch have highlighted that they are getting considerable amount of feedback on the service and asked whether there was an Page 9 of 163 opportunity to triangulate what they were receiving with the data being made available to the CCG to ascertain accuracy. Mr Ayres agreed to look into this matter. Action: Mr Ayres. Dr Bowes commented that he was encouraged by the feedback that the service was getting better, however he had concerns about delaying a formal appraisal until September, and he felt that this could be missing relevancy to the commissioning cycle. Mr Ayres explained that this was not the case as the contract for tier 4 & 5 expires September 2016, it was not the usual April-April contract therefore it would not impact the commissioning cycle. 105.2/14 Personal Health Budgets The paper was presented by Mr Monie. He referred the Governing Body to the appendices contained in the report. The Governing Body noted that in addition to reviews by legal advisers, West Kent CCG was also taking advice from TIAA (Internal Audit) who advised that a manual should be provided, and KMCS would provide the relevant documentation. Mr Monie requested approval of the Governing Body in respect of Section 75 payment to be made. Mr Ayres added that the Personal Health Budget was a national initiative and he explained that there was now a right of those entitled to continuing health care to request a personal budget rather than a package of care, this requirement would become mandatory from October 2014 and the decision was how this would be done. The Governing Body noted that this did not change the definition of need and entitlement but how care is delivered. Mr Ayres highlighted and provided answers to Mr Pragnell’s question on Personal Health Budgets (PHBs) as follows: 1) Are PHBs a national requirement or could WKCCG decide not to offer PHBs if it wanted to? Mr Ayres responded that PHB is a national requirement and WKCCG is mandated to abide by the requirement. 2) Has WKCCG undertaken a study of how many patients will receive PHBs in West Kent and whether the scheme is affordable in West Kent? Mr Ayres responded that this information would not be available for a few years. He further explained that individuals had to be entitled to continuing care to be eligible for PHB. This provides a sense of the maximum number of patients that would be eligible to receive PHB. With regards to whether the scheme is affordable in West Kent, Mr Ayres stated that the scheme would be affordable with necessary controls put in place. 3) A support plan will include the amount of money available to meet the patient’s needs. Bearing in mind the cost of running PHBs, does WKCCG envisage that the amount of money available under PHBs will be more or less than currently available to patients under traditional care pathways? Mr Ayres responded that if the CCG gets the processes right, it should be comparable. He further drew the Page 10 of 163 attention of the Governing Body to the limited amount of research available on informed patient choice. He explained that patients when informed tend to be more conservative in choices than otherwise, this was demonstrated a few years ago during the introduction of beta interferon which identified that the more you informed patients, the more conservative they tend to be in the management of their illness. 4) Will the PHB brokerage service mentioned in the draft PHB policy be manned directly by staff from WKCCG? Mr Ayres responded that the policy would not be manned directly by WKCCG staff, but would be commissioned by WKCG through the Kent and Medway Commissioning Support Unit with performance measures in place. 5) Will patients with PHBs be allowed to top up their budgets from their own resources or by private health companies? Will private PHB management companies be allowed to manage patients’ PHBs? Mr Ayres responded that PHBs were an NHS obligation where it has been identified that patients have continuing health care needs as part of their support plan. However patients are able to buy additional services that have not been assessed as a need of their support plan e.g. they might choose to purchase additional carer hours, beyond the level specified in their plan, from their own private funds. With regards to whether private PHB management companies are allowed to manage patients PHBs, Mr Ayres responded that this was possible if the patients choose for it to be privately managed on their behalf. 6) The draft policy states that PHBs are voluntary and a patient “can consider ceasing the budget and returning to a traditional care pathway should issues arise “. Will such a return always be accepted no matter what the issues are? Is this a national right or something WKCCG has decided it wants? Mr Ayres responded that currently this was a national right i.e. the patients can choose to have a PHB or return to the traditional care pathway. Ms Southon referred to Section 75 agreement and asked why local authorities were included. She further commented that the agreement was only valid till 2015 and enquired whether it was still being tested. Mr Monie responded that Local Authorities were included due to their vast experience and with regards to duration of the contract this was because the care packages were done by brokerage companies and it would give the CCG time to test out whether it would continue in that line. Mr Broadrick commented on topping up of budgets and issues of preferential rates and enquired whether this could be controlled. Mr Ayres responded that it would not be externally controlled as the aim was to give patients control by creating a personal budget. Mr Monie added that although this aspect would not be controlled, areas of bringing the cost down had been identified. Mr Middleton stated that with regards to Section 75 agreement, there were policies and procedures in development with KMCS not referred to in the report. He explained that these were operational procedures to underpin individual care plan, decision making and financial transactions. He explained that these were in the process of being reviewed. Mr Page 11 of 163 Middleton highlighted that the most important of these was the nature of the support plan, and West Kent CCG was seeking advice from Internal Audit to get the process right from the start. Mr Middleton assured the Governing Body that governance and decision making was being looked at and would be tightly managed by the CCG. The Governing Body approved the Section 75 Agreement between Kent County Council and NHS West Kent CCG (and including East Kent CCGs), for Personal Health Budgets in Continuing Healthcare. The Governing Body further approved the associated agreement between Kent and Medway Commissioning Support Unit (KMCS) and NHS West Kent CCG to manage and provide brokerage service for Personal Health Budgets. 106/14 Quality Report The Quality Report was presented by Dr Wynter. She noted the numerical discrepancies as highlighted by Governing Body colleagues, she was happy to take feedback from members to originators of the report. The following highlights were noted by the Governing Body: SI Incidents Dr Wynter commented that it would be helpful to have Kent Community Health Trust (KCHT) present during SI closures and also to enable the CCG to provide observations regarding some of the length of their reports. The CCG would be working closely with KCHT in this area to streamline the reports and review causes. Looked After Children Dr Wynter confirmed to the Governing Body that the CQC report was now available and feedback would be given to Quality Committee in 6 weeks. Home Care Dr Wynter highlighted that home care has now been included on the risk register. The Governing Body noted the overall downwards trend in in-hours and out-of-hours care. Discharge Summaries Dr Wynter highlighted that GP complaints regarding discharge summaries and different prescribing summaries, the general complaint was the amount of time GPs are spending double checking the summaries. She commented that this was still happening despite Dr Bowes letter to the providers. Page 12 of 163 Dr Bowes enquired what action was being taken to address this issue and Dr Wynter commented that further to Dr Bowes letter, individual feedback was also being collected and would be dealt with as they become available. Ms Varshney commented on LAC services and stated that if there was a named lead, she was happy to work with the individual. She further commented that the safety thermometer needed more clarification. Ms Southon referred to the dermatology procurement in the report and pointed out that the use of surveys affected response rate. She further requested an explanation of the safety thermometer. Ms Brett explained that the thermometer concerned what MTW was doing regarding harm free care. Members of the Governing Body highlighted that this was still below the national average. Ms Brett agreed to feedback to MTW. The Governing Body received the Quality Report. 107/14 Placement Transformation Project The report was presented by Ms Brett. She provided a summary and the Governing Body was asked to note the work of Kent & Medway Commissioning Support Unit (KMCS) in partnership with the CCGs, Kent County Council, other health and social care agencies / professionals and patients representatives. Ms Brett informed the Governing Body that two phases of the project had been finalised and were now going to transformation phase and the project was scheduled to go live on 16 September, 2014. Mr Ayres added that benefits were now being evaluated as they go through the systems. The Governing Body noted that the system was now IT based and education would be provided to support the project. Mr Ayres explained that there would be review dates built into the system to ensure oversight by the Commissioners. The Governing Body noted the Placement Transformation Project report 108/14 Integrated Performance Report The report was presented by Mr Middleton. He highlighted the following key areas: Waiting Times Page 13 of 163 The Governing Body was reminded of funds allocated towards performance on waiting times and Mr Middleton explained how trajectories on waiting times would be achieved. Resilience Funding Mr Middleton informed the Governing Body that the funds (£6m) would be released based on CCG QIPP plans. He referred the Governing Body to page 8 of the report and explained that work taking place at MTW i.e. initial decline in 18 week standard on all specialities; this would begin to improve by the end of September 2014. The Governing Body noted continued breaches of 52 weeks waiters within London providers. Areas of concern Mr Middleton highlighted that an area of concern was levels of activities at MTW. He referred the Governing Body to the graphs on pages 11-13 of the report and highlighted that these illustrated increased activities. He explained that this would drive up cost. Finance – Key Developments Activity Performance Mr Middleton commented that issues arising from activity performance, he explained that the indicative figures and activities posed questions to the CCG i.e. these have not been validated by KMCS and the CCG needs to work with KMCS in this area. This would also include review of QIPP schemes to determine whether they are having the contemplated impact. Specialist Commissioning Mr Middleton commented that the Governing Body would recall that in the last financial year, there was a staged approach to finalising the transfer of resources from the CCGs to NHS England (NHSE), who had assumed responsibility for specialist commissioning. NHSE ended last year with significant financial issues in terms of excess spend, as a result NHSE intended to revisit this area with CCGs i.e. there was an opinion that CCGs had not transferred sufficient resources to NHSE. The Governing Body noted that NHSE would be reviewing allocation from the CCGs and are proposing a significant amount of money to be transferred from CCGs (£50m) and West Kent CCG would be paying out around £900k. West Kent CCG was currently in discussion with NHSE regarding the figures. Mr Middleton explained that this posed a financial risk to the CCG, which is currently uncovered as plans have not been devised to deviate from the planned surplus. Based on the above, Mr Middleton highlighted the way forward and explained that work was required from the finance team to understand activities impacting MTW performance. He further stated that the CCG needed to maintain the position held previously, i.e. hold headroom funds to mitigate financial pressures crystallising and additional resources Page 14 of 163 available to the CCG had to be deployed carefully and West Kent CCG would continue to work with NHSE regarding specialist commissioning. Mr Middleton assured the Governing Body that by September, West Kent CCG would be in a position to assimilate the emerging pressures and it would be clearer whether the risks can be managed with further actions. RTT Issues Ms Arnold reported that based on feedback received from Providers, there was a suggestion that this matter was now on target. The only issue related to patients declining treatment during the holiday period (July/August), she explained that this could impact target performance in September. Dr Garry Singh commented that performance was improving in areas of infection i.e. MRSA, C.Dif and there was also improvement in Friends and Family Test. He stated that the CCG was now managing long term issues with the effort of the GPs. Ms Southon commented on the issue of patients waiting more than 52 weeks and asked whether there was anything to do to put pressure on Kings College Hospital. Ms Arnold responded the Trust would be directly contacted although services were not directly commissioned by West Kent CCG. Dr Sanjay Singh commented on data reported on page 12 & 13 i.e. upward trend in elective & non-elective and enquired whether this should be reviewed. Mr Middleton responded that there was a spike but when reviewed from June 2013 to date, it had stabilised. He further stated that it was identified that short stay was still unstable and it was agreed that work in this area would focus on GP aspect. Dr Palmer referred to the breast cancer referral data and stated that the delay was due to process i.e. GPs putting the referrals through the wrong channel. Dr Bowes suggested that this should be reviewed for evidence of it happening and a communication would be issued to GPs reminding them of the appropriate pathway. Mr Goodger commented that services for acute conditions not requiring hospital admission was getting worse, he enquired what work had been carried out to analyse what the conditions were and what patients were using the services. Ms Arnold responded that a significant amount of work has been carried out, however the major issue was that the definition was compiled from a national level which therefore included a number of things under a broad umbrella, this made it difficult to analyse. She further explained that the Urgent Care team were working on this and it should be acknowledged that some of the reason why patients end up in hospital was not because they necessarily needed to be there but because there were no right alternatives in the system. Ms Arnold commented that this issue was being considered pathway by pathway to put in a system wide provision to ensure Page 15 of 163 that patients can be treated outside of hospital. The Urgent Care Team would continue to work to refine the pathways. Mr Goodger further enquired whether this had to do with the 4 hour rule in A&E. Ms Arnold was not in a position to provide an answer and Dr Bowes suggested that a clinical audit would be considered in the near future. Dr Sanjay Singh recommended that definition of admission within 4 hours should be shifted to 12 hours as pathways are usually determined within 12 hours. The Governing Body received the Integrated Performance Report. 108.1/14 NHS 111 Report Dr Bowes enquired whether NHS 111 report should continue to come to the Governing Body monthly. Dr Whistler recommended reporting on a quarterly basis. Dr Whistler highlighted key areas of the performance report as follows: 1) Focus on mental health patients calling NHS111, the Governing Body noted ongoing work to streamline this area. 2) Various strategies being implemented to reduce urgent demand for prescriptions. Mr Hedges commented on staffing concerns and enquired whether the service lacked sufficient resources. Dr Whistler responded that this issue had to do with rostering of staff to deal with peak periods and identified difficulty in getting the rostering right. He explained that the focus was to ensure safety of patients during waiting times. Dr Chesover commented on the mental aspect and enquired whether the mental health street triage could be modelled into NHS 111. Dr Whistler stated that there was currently a workstream to deal with mental health cases. Dr Cheales mentioned that feedback from the practices was that the service was improving. The Governing Body noted the NHS 111 Report. 109/14 Board Assurance & Risk Management Page 16 of 163 Mr Segall Jones reported that significant amount of work was ongoing to develop the Board Assurance Framework (BAF) and the Corporate Risk Register in line with the CCG’s revised strategic goals. Mr Segall Jones informed the Governing Body that Internal Audit had flagged some concerns about the BAF. It was agreed that Mr Segall Jones and Mr Ayres would continue to work with Internal Audit to gain a better understanding of their requiremements and report back to the Audit Committee and a further report to the Governing Body in September. The Governing Body noted the Board Assurance & Risk Management Report. 110/14 Audit Committee Report Mr Hedges highlighted the following items discussed at the Audit Committee meeting held on 8 July 2014: Quarter 4 CCG Assurance Annual Report & Accounts 2013/14 Board Assurance Framework Operational Risk Register Dr Bowes commented that the Board Assurance Framework in development would be linked to Governing Body appraisal and achievement of the CCGs strategic aims. 111/14 Chief GP Commissioner and Clinical Strategy Group (CSG) Report A summary report highlighting items discussed at the last CSG meeting held on 8 July 2014, had been previously circulated. Dr Sanjay Singh drew the attention of the Governing Body to the following items discussed: Resilience Funding Quality Care Homes Roving GP Pilot Autism/ADHD The Governing Body noted the CSG Summary Report. 112/14 Practice Engagement Committee (PEC) Report Page 17 of 163 A summary report highlighting items discussed at the last Practice Engagement Committee meeting held on 1 July 2014, had been previously circulated. Dr Garry Singh updated on key matters discussed at the meeting as follows: Local Incentive Scheme Health & Social Care Coordination The Governing Body noted the Practice Engagement Committee Report. Dr Bowes thanked everyone for their attendance and closed the meeting at 3.30pm. Date of next meeting The next meeting is on Tuesday 26 August at 1.30pm at the River Centre, Tonbridge. Page 18 of 163 Action Points of West Kent CCG Governing Body (WK CCG GB) Meeting was held on 22 July 2014, commence time was 1.30 pm, in The Village Hotel, Castle View, Forstal Road, Sandling, Maidstone, Kent, ME14 3AQ. Action No (in accordance with agenda no) 105.1/14 CAMHS Progress Update Action Points Officer Mr Ayres provided an update on CAMHS services. He stated that previously there were issues with the service, however work had been done which would boost improvement in performance e.g. Sussex Partnership waiting times were decreasing. Mr Ayres further explained that impact would begin to show in the near future and proposed that a written report would be presented to the Governing Body to highlight performance. This was already work in progress and the report would be presented to the September Governing Body meeting. Mr Ian Ayres Action: Mr Ayres. Ms Southon commented that Health Watch have highlighted that they are getting considerable Page 19 of 163 Status Action No (in accordance with agenda no) Action Points Officer amount of feedback on the service and asked whether there was an opportunity to triangulate what they were receiving with the data being made available to the CCG to ascertain accuracy. Mr Ayres agreed to look into this matter. Action: Mr Ayres. 109/14 Board Assurance & Risk Management Mr Segall Jones informed the Governing Body that Internal Audit had flagged some concerns about the BAF. It was agreed that Mr Segall Jones and Mr Ayres would continue to work with Internal Audit to gain a better understanding of their requirements and report back to the Audit Committee and a further report to the Governing Body in September. Mr Ian Ayres / Mr Segall Jones Action: Mr Ayres/Mr Segall Jones Page 20 of 163 Status Quality Report This paper is for: Information Recommendation: For the Governing Body to Note For further information or for any enquiries relating to this report please contact: Dr Meriel Wynter/Dr Steve Beaumont Reporting Officer: Dr Meriel Wynter Lead Director: Dr Steve Beaumont Report Summary: (A précis of the contents of the report) Date: Aug 14 Agenda Item: Version: This report gives an update on quality for the Governing Body. FOI status: State either: This paper is disclosable under the FOI Act Strategic objectives links: C. Improved health outcomes and reduced health inequalities. D. Service quality and patient safety. Board Assurance Framework links: Identified risks & risk management actions: N/A Resource implications: Legal implications including equality and diversity assessment N/A This document has taken into account Equality and Diversity best practice. Report history: N/A Appendices N/A Next steps: N/A N/A Page 21 of 163 West Kent CCG Quality Report End of Month 4 – 07/14 Page 22 of 163 Index Item 1 2 3 4 5 6 7 Subject West Kent CCG Key Highlights National Updates West Kent CCG MTW KCHT KMPT SPFT (ChYPS) SECAmb NSL (PTS) Page 3 4 5 - 11 12 - 21 22 - 28 29 - 32 33 34 - 38 39 - 40 Page 23 of 163 WEST KENT CCG HIGHLIGHTS Maidstone & Tunbridge Wells Hospital Following a CQC inspection of Tunbridge Wells Hospital in November 2013 and the CQC Safeguarding review of West Kent and North Kent CCGs in May 2014 the CCG is working with MTW on a CQUIN around the national recommendations for paediatric pathways in A/E to ensure standards are being met. Stroke service provision at MT continues to be reviewed and the Trust is currently exploring the best method to engage patients and public views about any proposed service reconfiguration. Nursing staffing numbers are now publically available. The Trust in line with current guidance for all in patient areas and will be regularly reviewed Kent Community Health Trust The report on the CQC inspection carried out in June 2014 is expected in August 2014 Patient satisfaction surveys completed in the Minor Injury Units and Walk in Centres during May achieved a combined satisfaction score of 95.6% Kent and Medway Partnership Trust Unannounced visits by Mental Health Act Commissioners have taken place at several sites and KMPT were compliant in all reviews. A CQUIN is in progress. with the transition joint working group There were no reported cases of MRSA bacteraemia or Clostridium Difficile infections during the months of May and June 2 NHS111 NSL After initial problems in 2013 the service is now improving A CQC inspection in March 2014 has shown improvements since 2013 although three standards need further action. Joint working is ongoing between the CCG and NSL to review the action plans. Page 24 of 163 National Updates In July 2014, CQC announced changes to the indicators for intelligent monitoring which is used to determine when, where and what inspections are undertaken. A summary of the indicator update can be found at: http://www.cqc.org.uk/public/hospital-intelligent-monitoring End of Life Care NHS England, as part of the Leadership Alliance for the Care of Dying People has developed a new approach to caring for people in the last few days and hours of life. One Chance to Get it Right, focuses on the needs and wishes of those dying and the people closest to them, and is based on five new Priorities for Care, and follows the recommendations of the independent Neuberger Report that included the phasing out of the Liverpool Care Pathway by 14 July 2014. Learning Disabilities NHS England has asked Sir Stephen Bubb, the Chief Executive of charity leaders network ACEVO, to head a new multi-agency group of experts, advisors, patients and their families to develop a national guide for how to provide health and care for those with learning disabilities. It aims to design a more innovative and integrated local commissioning of healthcare and housing to best support the often complex needs of people with learning disabilities at home and in their communities to reduce reliance on hospital care. Too often we see people being admitted to an inpatient setting and staying for long periods of time purely because this support is lacking. This is not good for patients and through the Winterbourne Joint Improvement Programme, this is being addressed by ensuring local areas improve their discharge and care planning arrangements. Patient safety In July 2014 NHS England produced a new series of patient safety indicators which allow the public to see how hospitals are performing on key safety measures which have been welcomed by Jane Cummings, Chief Nursing Officer for England. The information, published on a new safety section of NHS Choices alongside hospital performance on infection control, blood clots and patient and staff feedback, allows the public to examine the staffing history of wards and will act as a barometer for local health services. Page 25 of 163 Integrated Personal Commissioning Simon Stevens has set out plans for a new Integrated Personal Commissioning programme, which will for the first time blend comprehensive health and social care funding for individuals, and allow them to direct how it is used. The programme will work with the voluntary sector to commission support locally for personal care planning, advocacy and service brokerage. The first wave of the programme is likely to include those with long term conditions, learning disabilities, severe mental health problems and children with complex needs. WEST KENT CCG Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm CCG Highlight report for the Practice Nurse Adviser (PNA) team - July 2014 The team is composed of 4 experienced practice nurses and one assistant practitioner (AP) who also current hold posts in general practice. The existing team has been in place since May this year and we have aligned a PNA to each CCG in order to facilitate a good knowledge of the local provider landscape and quality issues arising as well as developing good working relationships with the local stakeholders. Each member of the team also leads in specific clinical areas (respiratory, diabetes, non-medical prescribing, cervical cytology, immunisations, wound care and health care assistant issues) and we share this expertise collaboratively across Kent and Medway. Caroline Flasse leads the team, See Skoda is the lead for DGS, Medway and Swale CCGs, Sue Gassor for SKC, Thanet, Ashford and Canterbury CCGs and Hilary Loft for West Kent CCG. Lorraine Hicking-Woodison, our AP leads on HCA issues across the whole of Kent and Medway. The team is fully funded by NHS England area team until the end of March 2015. Discussions will take place during this year to ensure continuity of the funding for the PNA team in the future. The team will provide a short highlight monthly report to keep the CCG informed on our work. For further information, please contact Caroline Flasse [email protected] Health Care Associated Infections West Kent CCG - MRSA These figures are those that are attributable to WK CCG. This means any resident registered with a GP in the West Kent CCG area, receiving care from any provider, other than the acute Trust. Page 26 of 163 West Kent CCG had a total of 11 MRSA bacteraemias during 2013/14. To the end of July 2014 WK CCG, have not reported any. Data taken from National HCAI Data Capture System on 01/08/14 MRSA WK CCG 13/14 Total Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 June 14 July 14 YTD Actual 14/15 Limit 11 1 1 1 1 2 0 1 0 0 1 2 1 0 0 0 0 0 0 WK CCG – C.difficile West Kent CCG had a total of 91 cases of C.difficile during 2013/14. The 2014/15 limit has been set at 98 and to date they have reported 39. Based on their current reporting trajectory, which has seen a doubling of the figures for July up to 15, against 8 in June, they will exceed their limit for the year, having reached almost half of their numbers in the first 4 months of the year. Data taken from National HCAI Data Capture System on 01/08/14 C DIFF West Kent CCG 13/14 Total Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 June 14 July 14 YTD Actual 91 10 10 10 6 8 9 6 6 6 3 10 8 7 9 8 15 39 Page 27 of 163 West Kent CCG HCAI 12mths to July 2014 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 MRSA July 14 June 14 May 14 Apr 14 Mar 14 Feb 14 Jan 14 Dec 13 Nov 13 Oct 13 Sep 13 Aug 13 Jul 13 C DIFF Kent and Medway CQC Reports A total of 53 CQC reports were published for Kent & Medway during July 2014, with 19 not meeting all expected standards. Of the 19 not meeting all expected standards, 1 received enforcement actions. The following table illustrates those reports published for Providers in West Kent CCG that failed to meet expected standards: Key: X Enforcement action X Failed outcome area Page 28 of 163 CCG Location Org Type Standards of quality and suitability of management Mrs Jasiree The Oast and Mr Maidstone Balkissoon Nemchand NSL Limited NSL Kent Aylesford Weblinks Standards of staffing Provider Name Location Name Publication week Location Postal Code Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm NHS Trusts are highlighted in red 14/07/201 ME15 4 7AT West Kent Social Care Org X X X X X 28/07/201 ME20 4 6SE West Kent Independ ent Ambulan ce √ X √ X √ http://www.cqc.org.uk/ directory/1-121903434 http://www.cqc.org.uk/ directory/1-793656098 Serious Incidents for West Kent CCG Total Serious Incidents Ongoing July 2014 – West Kent CCG patients only Page 29 of 163 Total Ongoing July 2014 - 89 Total Closed July 2014 - 6 KEY Green 0-2 days Yellow 3-4 days Amber 5-10 days Red 11 days and over Breakdown of Incidents for West Kent CCG Patients Logged in July 2014 STEIS Ref 2014/21218 2014/21417 2014/21424 2014/21683 Date Logged 01/07/14 02/07/14 02/07/14 03/07/14 Time to Report 11 3 17 27 Incident Date 16/06/14 27/06/14 09/06/14 27/05/14 Provide r KCHT GP KMPT MTW Hospital Name/State if Care Home/Independe nt Provider/Patient' s Home Ward Specialty Name of Care Home etc. Patients Home Patients Home Sundridge Medical Centre Not applicable Patient's home Not applicable Maidstone Hospital Page 30 of 163 Ward area Geriatric Medicine Category Allegation Against HC nonProfessional Unexpected Death (general) Unexpected Death of Community Patient (in receipt) C.Diff & Health Care Acquired Infections Never Event Grade 1 2 1 1 2014/23216 2014/23197 2014/23638 2014/23678 2014/23713 2014/23807 2014/24201 16/07/14 16/07/14 21/07/14 21/07/14 22/07/14 22/07/14 25/07/14 2 35 5 2 60 8 34 12/07/14 28/05/14 13/07/14 17/07/14 25/04/14 10/07/14 07/06/14 MTW Tunbridge Wells Hospital Ward 31 SECAm b Care Home Tonbridge MTW Tunbridge Wells Hospital Labour ward and delivery Maternity service Tunbridge Wells Hospital Accident and emergency Delayed diagnosis Tunbridge Wells Hospital Accident and emergency Delayed diagnosis Tunbridge Wells Hospital Accident and emergency Delayed diagnosis Tunbridge Wells Hospital Ward 22 Elderly Care Adverse media coverage or public concern about the organisation or the wider NHS MTW MTW MTW MTW Page 31 of 163 Slips/Trips/Falls 1 Ambulance (general) 1 1 1 1 1 2 2014/24764 30/07/14 21 01/07/14 KMPT Maidstone Hospital John Day Ward Unexpected Death of Outpatient (in receipt) 1 There are currently 89 SIs ongoing for West Kent CCG patients including 15 SIs under consideration through the Child Death Review Service. Of the 89 ongoing SIs, 13 have been submitted to the Area Team for closure, including 8 Child Death Reviews and 1 request to down grade an incident from a Level 2, Never Event. Page 32 of 163 Provider Trust Level information 1 Maidstone and Tunbridge Wells NHS Trust (MTW) CQC As part of the response to the points raised by the CQC visit to Tunbridge wells hospital in November 2013 and Maidstone Hospital in February 2014, an action plan has been put in place. Although identified primarily during the visit to Tunbridge Wells Hospital the medicines management plan is being implemented Trust wide, and the outstanding risk which still needs to be addressed is the issue of locking drug fridges. Self-locking fridges have been identified, and these are now being assessed as to their suitability for use in a ward environment. Another key issue identified at both hospitals, was the staffing in A&E. The Accident and Emergency plan is addressing the points raised around the care of children attending A&E. A Paediatric Emergency Care Pathway Review Group has been established, and they will be carrying out a review, and recommending system changes to ensure that the standards set out in the Royal College of for Children Paediatrics and Child Health ‘Standards and Young People in emergency Care Settings’ are met. A CQUIN is in progress for improving paediatric A/E pathways. Outcomes Framework Domain 4 – Ensuring that people have a positive experience of care Patient Experience Complaints During the month of May 2014, the Trust received 30 new complaints, 13 relating to Maidstone hospital, and 17 relating to Tunbridge Wells. Of these 7 were complaints about nursing issues, and 26 were medical complaints. All complaints and significant incidents are discussed at Directorate level. Information folders incorporating incident feedback, feedback from complaints and serious incidents relating to both the Directorate and individual wards are being developed for the wards and medical staff. The communication and sharing of this learning has been highlighted as a key area to be addressed, and this is being done through the development of an Intranet page, which includes a suggestion box to enable staff to communicate their concerns either openly or anonymously. The learning from complaints is key to the implementation of service improvements and is reported to the Clinical Governance and Patient Experience Page 33 of 163 Committees. Organisational learning will be the subject of the next Quality & Safety Committee “deep dive‟ meeting in August. Specialist nurses are also invited to spend time on the wards and question staff regarding incidents relevant to their area of expertise in order to test staff knowledge and identify gaps whilst also working with staff and ward managers to address learning relating to their area. It has been identified that there has also been an increased number of informal contacts made with PALS, and there are plans to make the service more accessible across both sites with the use of open days and ward visits. The main themes that are raised with PALS are communication, and the information given to patients. Friends and Family Test During May the Trust reported an Inpatient response rate of 47%, which is an increase from 42.6% in April, achieving a score of 78. This is a net promoter score. The calculation is the proportion of patients who would strongly recommend minus those who would not recommend, or who are indifferent. The best score is100, where 100% of respondents are 'extremely likely' to recommend The worst score is -100, where 100% of people are 'not likely' to recommend. The A&E response rate has increased slightly from 18.4% in April to 19.3% in May, achieving a score of 61, which is a decrease from 69 in April. The combined Maternity response rate 15.9%, an increase from 11.7% in April, but has shown a decrease in the combined score, falling from 87 in April to 81 in May. As demonstrated by the breakdown in the table below, this is explained by the low score of 57 for Question 4 about Postnatal care, which fell from 71 in April. The individual response rates and scores for the Maternity questions are shown below. NHS England has produced new comprehensive guidelines on the Friends and Family Test to make the process easier to understand and to gain more personal comments to inform patient decision making and choice. Please follow the link to access this new guidance: http://www.england.nhs.uk/wpcontent/uploads/2014/07/fft-imp-guid-14.pdf The response for friends and family test is improving, and is being sustained. For inpatients the response is now being sustained above the national average. The key actions being taken at present are: Continued focus especially in A&E and maternity to further improve response rates including daily monitoring Page 34 of 163 Each ward / department receives a monthly report detailing their achievement, performance and comments received Publication of performance and comments in all wards and departments Exploring options for implementation in outpatients with a plan to commence trail in September 2014. The aggregated scores for the local patient survey give a 91.6% satisfaction score 60 2.6 0 0 100 n/a n/a n/a n/a n/a Local response trend this month 2.8 Local score trend this month 65 Mth National response rate 1.8 Mth National score 52 % response 1.6 Score 66 % response 2.8 Score 60 % response Maidstone and Tonbridge Wells NHS Trust - A&E Score 79 % response 19.1 Score 76 % response 15.3 Score 75 % response 11.8 Score Score 77 % response % response 16.1 Score score 77 20.55 75 21.3 78 19.9 77 16.2 79 17.1 77 18.4 78 47.04 77 46.42 74 38 q q 82 1.9 71 7.7 70 13.1 68 10.8 67 7 69 18.4 61 19.3 63 15.5 53 20.8 p q 100 83 86 n/a n/a 2.3 n/a n/a 46 80 81 n/a n/a 5 n/a n/a 71 98 96 80 n/a 26.6 n/a n/a 67 96 89 56 n/a 13.7 n/a n/a 76 86 85 71 n/a 9.7 n/a n/a 70 94 89 71 n/a 18.5 n/a n/a 69 94 89 57 n/a 19.3 n/a n/a 66 93 92 87 n/a 21.1 n/a n/a 67 77 67 77 n/a 23,1 n/a n/a q q p p NOV 13 Score % response Maidstone and Tonbridge Wells NHS Trust - Inpatient Maternity 1 - Antenatal Care* Maternity 2 - Birth* Maternity 3 - Postnatal Ward* Maternity 4 - Postnatal Com* % response score OCT 13 % response SEP 13 score AUG 13 % response JUL 13 score JUN 13 % response MTW 17.03 74 DEC 13 JAN 14 FEB 14 MAR 14 April 14 May 14 June14 n/a p n/a n/a *Organisations were asked to provide eligible populations for each of the four questions. Some organisations will be unable to calculate exact populations for all four questions. As the number of women giving birth is a clearly identified and counted population, a response rate will be published for Question 2 (birth), but not for the other three questions Maidstone District - Inpatient Maidstone District - A&E Tunbridge Wells - Inpatient Tunbridge Wells - A&E Tonbridge Cottage 78 62 79 50 13.98 4.1 19.47 1 70 84 77 75 21.82 2.7 19.66 1 74 69 76 73 18.96 6.7 23.41 8.7 77 17.27 68 13.2 79 21.73 72 13 67 65 82 71 11.3 10.2 21 11.3 79 68 79 65 10.81 7.7 23.67 6.3 73 74 79 65 31.71 14.1 49.61 23.1 75 66 80 58 100 43.7 13.2 49.69 25.8 50 72 66 82 62 83 46.16 8.2 46.44 23.1 85.7 74 53 74 53 74 38 20.8 38 20.8 38 q tu p p q p q q q p Data taken from NHS England on 01 August 2014 Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm Upper GI Surgery Following the upper GI surgery report of the Royal college of Surgeons December 2013MTW are continuing to work with NHS England and other partners on Page 35 of 163 plans for future commissioning of this service Stroke Stroke service provision across the Trust continues to be a concern as demonstrated by both the Trust’s performance on key indicators, and the Sentinel Stroke National Audit Programme (SSNAP). A Quality & Safety Committee ‘Deep Dive’ was undertaken on 18th June. It was agreed by the Board, that the options paper would be progressed to support a possible service reconfiguration; however action is needed in the short term for an immediate improvement in the service currently being delivered. The main considerations for the future service were the skills and staffing required the affordability of the service and how the cover arrangements for the Trust’s two hospital sites would be managed. The Trust is currently exploring the best method to engage patients and public views about any proposed service reconfiguration. A & E Waits During the Month of May 2014, the Trust achieved a 95.2% rate for seeing patients and carrying out the initial assessment within 15 minutes; however they only achieved a 40.5% rate of treating patients within 60 minutes. It is highlighted that the attendances in A&E for May 2014 is 9% higher than the same period last year, but the conversion rate remains similar to previous months, and the same period last year at 26.7%. Year to date, emergency admissions are up by 2.6% on the same period last year. To the end of June 2014, the Trust achieved a 95% compliance rate against the 4 hour wait, with 1 breach of the 12 hours to admission being noted. Mixed Sex Breaches During the month of May 2014, the Trust did not report any mixed sex accommodation breaches. Workforce Maidstone & Tunbridge Wells NHS Trust now publishes nursing staffing numbers publically via UNIFY to NHS England, NHS Choices and its own website. Staffing levels for all in-patient areas are in line with current guidance and are under regular review. There does remain a reliance on temporary staffing solutions to meet the changing demands in acuity and dependency and to manage short notice absence. A staffing review is in the process of being carried Page 36 of 163 out, and the results will be available in September. There are robust recruitment plans in place, as well as clear processes for monitoring staffing levels and standards of care. Overall the Trust feels it is able to meet the nursing care time demands, and has systems in place to allow for a flexible, responsive provision of care. Evidence from complaints and patient feedback further supports this, suggesting that the standards of care generally meet expectation. Safer Staffing figures 8/08/14 national data for June not available yet. Infection Control During May 2014, non-elective screening for MRSA was 97%. Both ITUs and Lord North have consistently achieved 100% for an entire year. It is worth noting that non elective MRSA screening is more difficult to achieve, but is an area that has consistently performed above over the 95% compliance target. During May 2014, elective MRSA screening was 97%, with the surgical directorate achieving 100% compliance across all sub specialities. It was noted that Cancer services and Urgent Medical Assessment Unit were areas of concern when it came to screening patients. It remains a challenge to achieve the 98% compliance, and the following actions actions are on-going in an effort to improve the picture around MRSA screening: Performance discussed at the Infection Prevention and Control business meeting with Matrons Matrons clearly sighted on the areas that are underperforming Specific plans for oncology and Urgent Medical Assessment Unit have been put in place and being closely monitored MRSA During the month of July 2014, MTW reported no MRSA bacteraemias. Data taken from National HCAI Data Capture System on 01/08/14 MRSA 13/14 Total Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 June 14 July 14 YTD Actual 14/15 Limit MTW 3 0 0 0 1 1 0 0 0 0 0 1 0 0 1 0 0 1 0 Page 37 of 163 C.difficile During the month of June 2014, MTW have reported 5 cases of C.difficile, bringing their year to date total for the year to 15 cases, and if this trajectory continues they will exceed the year end limit of 40. Data taken from National HCAI Data Capture System on 01/08/14 C DIFF MTW 13/14 Total Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 June 14 July 14 YTD Actual 14/15 Limit 36 6 4 4 4 2 4 1 2 2 1 2 3 4 3 3 5 15 40 Serious Incidents 8 new SIs have been reported during July, a decrease from 14 reported in June and 11 reported in May. The highest number of incidents reported within MTW in July occurred at Tunbridge Wells hospital. Of these 4 related to delayed diagnosis following X-ray in A & E at Tunbridge Wells hospital. There are currently 51 ongoing serious incidents with 33 (65%) having occurred at Tunbridge Wells Hospital. Slips/Trips/Falls continue to be the highest category of ongoing SIs, with 13 (37%) of the total being attributed to this category. Delayed Diagnosis is the second highest category with 11 (32%) ongoing SIs. There are currently 21 ongoing SIs breaching the 45/60 day deadline for submission, 10 are with the provider and 11 have been submitted to the CCG for closure. The resulting changes to practice from SIs agreed for closure include Obstetrics and Haematology to ensure robust communication and inter-play in the event of a Code Red. Additional Consultant support should be considered in high risk cases. There has been significant work undertaken both by MTW and the CCG to complete SI investigations within the stipulated timeframes; however there has been a slight increase in the number open with MTW due to the increase over the last few months in the number reported. Additional SI panels have taken place to address this issue. Page 38 of 163 Page 39 of 163 Never Events No new Never Events were reported during July 2014. There are 2 ongoing Never Events for MTW. Safety Thermometer – Harm Free Care The NHS Safety Thermometer records the presence of absence of four harms: Pressure Ulcers Falls Urinary Tract Infections (UTIs) in patients with a catheter (CAUTIs) New Venous Thromboembolisms (VTEs) Harm Free Care is the absence of all four of these harms. These four harms were selected as the focus by the Department of Health’s Safe Care programme because they are common, and because there is a clinical consensus that they are largely preventable through appropriate patient care. During May 2014, 645 patients were surveyed for the Safety Thermometer, which was 94% of all patients in hospital on the day the snapshot was carried out. The score for patients who had Harm free care was 97.7%, which is above the national benchmark of 93.5%. Page 40 of 163 Data captured from National Safety Thermometer 1/8/14 The median line is the median figure for the hospital, and the proportion of patients is the % of those who received harm free care on the day of the snapshot The blue values line is MTW joint hospitals reporting and the red is national reporting. Page 41 of 163 Pressure Ulcers MTW are currently working with the CCG to review pressure ulcer data. Falls The severity of any fall that the patient has experienced within the previous 72 hours should be recorded. A fall is defined as an unplanned or unintentional descent to the floor, with or without injury, regardless of the cause, (slip, trip, fall from bed or chair, whether assisted or unassisted). Patients ‘found on the floor’ should be assumed as having fallen, unless confirmed as an intentional act. During May 2014, the Trust reported a rate of 7 falls per 1000 occupied bed days. Of the 134 falls reported during the month, 96 were classed as no harm, 31 were low harm, 2 moderate harm, 5 severe harm, and 0 in death. Ward audits have been carried out, and have identified the continued need for consistency in identifying those patients who are at risk of falls, as well as the full completion of Falls Prevention care plan assessment, with all the elements of the documentation completed and signed. Additionally, Doctors should undertake a medication review of all patients identified at risk of falls, and sign to indicate that the review has been carried out. The falls prevention team at MTW is working closely with other Trusts to learn and implement strategies for falls prevention. There has been significant investment over the last two years in equipment from low rise beds, alarm mats to non-slip socks, which has resulted in a reduction in the overall rate of falls. However, although the numbers of falls has dropped, the severity of the level of harm by the falls has increase There are falls CQUINS currently under discussion. Safety Thermometer – Venous Thromboembolism (VTE) Assessment All surveyed patients should have it reported whether a documented risk assessment has been carried out. The VTE nurse facilitator carries out a root causes analysis on all known cases of hospital acquired VTEs in the Trust and all and this information is forwarded to the CCG. For 2014-2015 the VTE CQUIN reverts to the safety thermometer MTW will still have to achieve the national standard of 95% for VTE risk assessments and will provide the CCG with a yearly hospital acquired thrombosis report. Page 42 of 163 2 Kent Community Health Trust (KCHT) CQC The Care Quality Commission (CQC) carried out an inspection of the Trust in June 2014. The report from CQC is expected in July, and will be presented to all stakeholders at a Quality Summit, and subsequently published on the Trust’s website. Outcomes Framework Domain 4 – Ensuring that people have a positive experience of care Complaints KCHT received 50 complaints in May. This is an increase compared to the 17 received in April and 38 received in March. Of these, 45 complaints were graded as low risk, 4 as medium risk (Dental, Lymphoedema, Children’s Speech and Language Therapy, and Deal MIU), one as high risk (Wheelchair Service). 11 of these complaints related to staff attitude, with 9 about communication and a further 9 about the treatment received. There has been a significant rise in complaints about Community Paediatrics and Audiology (7), whose complaints had previously been going down. The reasons for this vary and include access to appointments to the level and nature of treatment. The Wheelchair Service (6) saw a big increase in complaints in May compared to April, however this service’s complaints figures usually vary month to month Of the 11 complaints relating to staff attitude, 4 were about services in West Kent CCG. The first was about the attitude of a Community Nurse in the Maidstone and Malling area, and the second is about the attitude of a clinician in the Maidstone and Malling Community Paediatrics and Audiology service. The remaining 2 related to the Musculoskeletal Physiotherapy Services in the Sevenoaks, Tonbridge and Tunbridge Wells Area. Out of the total of 50 complaints received 11 came under the West Kent CCG area. The Trust has ten cases being reviewed by the Ombudsman, with five of these at the formal investigation stage. A report on two upheld cases and lessons learnt from them went to the Adult Quality Group in June 2014. One of these two cases is still ‘open’ with the Ombudsman until the joint action plan with KCC has been agreed. Page 43 of 163 PALS have also noticed an increase in the number of calls received compared to April, both in raising concerns or complaints, but also in giving compliments. A total of 186 compliments both verbal and written have been received in May. Patient Satisfaction KCHT carried out 2 patient satisfaction surveys during May. 2,958 patients carried out the KCHT satisfaction survey and an additional 2,424 patients across Kent completed an NHS Friends and Family Test short paper survey based on the National FFT questions. These were completed in Minor Injury Units and Walk in Centres during May. The combined satisfaction score was 95.6% based on both surveys. A summary score is calculated for each CCG based on the amount of responses received and the score achieved. It is felt that this is more accurate than working out an average. For West Kent CCG this score is +75 based on 1,122 surveys completed. Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable Infection Control Between April 1st and June 30th 2014, Trust Compliance with hand hygiene training averaged 84%, and mandatory training averaged 74% however compliance amongst clinical staff was 83% for hand hygiene, and 66% for mandatory training. The Infection Prevention and Control team have contacted the areas with poorest compliance, to offer local bespoke training, and reviewed all training packages in order to reduce the time taken to complete training. The IPC team are currently liaising with learning and development to include the new presentation at induction, so all new starters are compliant from their first week in the Trust. It is envisaged these changes will be implemented during August 2014 MRSA There have been no MRSA bacteraemias in the previous Quarter although 1 MRSA is subject to review at NHS England. KCHT set the standard of screening 100% of patients admitted for Podiatric surgery, and all patients admitted from home to the community hospitals within 24 hours of admission (unless there is a known result within the last 2 weeks). Any patients transferred from A&E or CDU’s will also be screened, if they have been admitted for less than 24 hours. Page 44 of 163 MRSA screening for patients in community hospitals is currently 99% during June 2014, which equates to 4 patients not being screened. C.difficile The national target for the Trust is 7 cases for the year. Year to date there has been 1 attributable case of C.difficile, which means the Trust is on trajectory to remain within their annual target. The C.difficile action plans remain in use and is updated regularly, and presented to the Infection Control Group for assurance. Urinary Tract Infections Urinary Tract Infections (UTIs), and Catheter Acquired Urinary Tract Infections (CAUTIs) are monitored monthly in Community Hospitals. The CAUTI/UTI working group has revised and updated the action plan. During the month of July, KCHT reported 13 UTIs and 4 CAUTIs. Additional information is being requested from KCHT to identify whether this is an increase or decrease from the previous month. Workforce The vacancy rate across Kent for June 2014 is 7.49%, which are 359 vacancies out of an establishment of 4,788.6 staff. The vacancy rate has remained stable since April 2014, remaining around the 7.5% mark. The West Kent Locality remains the area with the highest vacancy rate of 18.18% for June 2014. During July 2014, KCHT carried out an overseas recruitment project targeting nurses in Spain. This was successful, with 25 of the 56 candidates who attended for interview being offered a role. During April and May 2014, all staff working in KCHT was given the opportunity to complete and anonymous Staff, Friends and Family test. The survey was designed to find out how staff feel about the services that KCHT provide, and about working for KCHT. 888 members completed the survey, with 83.7% giving a positive response about recommending KCHT to friends and family if they needed treatment, with 6.2% responding negatively, and the rest answering in a neutral manner. In response to the question about recommending KCHT to friends and family as a place to work, 62.2% responded positively, with 20.5% responding negatively and the rest answering in a neutral manner. Page 45 of 163 Safer Staffing In June 2014 5.8% of all shifts across KCHT were uncovered, which is an increase of 1% from the previous month. Across the 12 hospitals, the Escalation Process was activated 181 times. This is an increase of 37% on May, and of these 180 were amber alerts raised by the Heads of Service in relation to staffing levels. 67% of these alerts were about staff shortages but where the shifts were covered by temporary staff. The remaining 33% were incorrect skill mixes on the shift. 8/8/14 National safer staffing data for June not available yet Serious Incidents Serious Incidents 9 new Serious Incidents (SIs) have been reported during July 2014 including 7 Pressure Ulcers Grade 3 and 4. Pressure Ulcers remain the highest reported categories, reporting of these has been encouraged within all teams across KCHT. Currently there are 44 ongoing SIs under investigation including 25 Grade 3 and 4 Pressure Ulcers, 7 Confidential Information Leaks and 5 Slips/Trips/Falls. The highest number of ongoing SIs for KCHT are in the Swale area with 13. West Kent have 10 and South Kent Coast 8. The lowest number of ongoing SIs is in Ashford with 1 open. Kent Community Health Trust has 2 serious incidents breaching the closure deadline. 1 was due to a police investigation taking place, a further extension has been agreed. The second SI breaching is due to delays in obtaining medical notes and these have now been received. For July 2014 11% of SIs were reported in 0-2 days and 89% reported 11+ days, this has increased from last month when 69% of SIs were reported in 11+ days. KCHT review internally all incidents before reporting as an SI, this can cause a delay in reporting Serious Incidents. 10 SIs were submitted and 6 agreed for closure during July 2014, 1 was reviewed and required evidence of audit, this is awaited. The resulting changes to practice include staff have developed and implemented their own process for monitoring and evidencing chasing of equipment from ordering to delivery. All staff must have a glucometer when they visit diabetic patients. Initial assessments must be comprehensive to identify the correct and most appropriate management of patients care Page 46 of 163 Page 47 of 163 Never Events No new Never Events were reported during July 2014. There are no ongoing Never Events for KCHT. Safety Thermometer – Harm Free Care The NHS Safety Thermometer records the presence of absence of four harms: Pressure Ulcers Falls Urinary Tract Infections (UTIs) in patients with a catheter (CAUTIs) New Venous Thromboembolisms (VTEs) Harm Free Care is the absence of all four of these harms. These four harms were selected as the focus by the Department of Health’s Safe Care programme because they are common, and because there is a clinical consensus that they are largely preventable through appropriate patient care. The Harm Free Care for all harms for June 2014 is 94.5%, with the percentage of patients who did not obtain any new harm 98.7%. The Trust is currently reporting 98.8% Harm Free Care in the Community Hospitals. Safety Thermometer - Pressure Ulcers KCHT have set themselves a target of reducing Grade 3 & 4 pressure ulcers to zero. Currently 81% of Community Teams are reporting zero Grade 3 and 4 pressure ulcers. For the month of June there were a total of 28 attributable, avoidable and unavoidable grade 3 and 4 pressure ulcers reported. Safety Thermometer - Falls The severity of any fall that the patient has experienced within the previous 72 hours should be recorded. A fall is defined as an unplanned or unintentional descent to the floor, with or without injury, regardless of the cause, (slip, trip, fall from bed or chair, whether assisted or unassisted). Patients ‘found on the floor’ should be assumed as having fallen, unless confirmed as an intentional act. There have been a total of 54 falls reported for June 2014, with 5 being recorded as moderate harm. 44 of the 54 falls occurred within community hospitals, Page 48 of 163 where 2 of the 5 moderate harm falls were reported. The remaining 10 falls occurred in the patient’s home, with 2 of the moderate harms being reported from here. Safety Thermometer – Venous Thromboembolism (VTE) Assessment All surveyed patients should have it reported whether a documented risk assessment has been carried out. The Trust report that for April they achieved a compliance rate of 95%. WK KCHT Learning Disabilities A service review document has been produced detailing the integrated, partnership provision for people with learning disabilities across Kent to meet their needs for timely assessments and support and breaking down barriers to improve access to main stream services. In West Kent, a project at Kingswood surgery has successfully involved learning disabilities nurses working with GPs in developing clinics to desensitise people to their concerns in seeking health provision which have increased rates of access to care. There is a need to determine potential gaps in identifying all people with learning disabilities in West Kent to ensure equality of service provision. It is envisaged that the Kingswood surgery model can be shared to promote this example of good practice and that further discussions with link practitioners can determine current service provision and highlight any issues specifically in West Kent. Community Beds Building work is still ongoing at Sevenoaks hospital which has resulted in 7 beds being temporarily closed. WK CCG will review how to take this forward with Propco to resolve this The quality team have undertaken a visit to Tunbridge hospital and there is a planned review of admission criteria to resolve the bed blocking issues. Page 49 of 163 3 Kent & Medway Partnership Trust CQC At the July 2014 board meeting the quality committee reported that KMPT has received unannounced visits by Mental Health Act Commissioners at the following sites, Groombridge Ward, Sevenscore Ward, Willow Suite, Cramner Ward, Amherst Ward, Amberwood Ward, Emerald Ward and The Red House. Provider action statements have been completed (or are currently being compiled for the most recent visits) and have been returned to the CQC. It was noted that KMPT has been compliant in all reviews The transition CQUIN working group has identified link workers within KMPT to support the referral process between CAMHS and Adult Mental Health Services. A draft joint transition pathway protocol and good practice guidance has been produced and is being worked on further. An engagement day for service users, parents and carers is being planned for September. Outcomes Framework Domain 4 – Ensuring that people have a positive experience of care Patient Experience Complaints During May and June, KMPT received 77 new reportable level 2-4 complaints. The themes of these reports include all aspects of clinical treatment, attitude of staff, and admissions, discharge and transfer arrangement. These are the same 3 categories which recorded the highest number of complaints in April. The Acute Service Line Received 20, with Amhurst Ward receiving 2. The Community Recovery Service Line received 42, of which 20 were relating to Maidstone. Carers Survey KMPT carried out a carer’s survey during 2014, with more than 500 responses received. The results and recommendations are being shared with carers across the county. Page 50 of 163 The key results include: Information, Advice and Involvement: improvements could be made around information sharing, and engaging with carers around discharges and transfers, as carer’s felt their views were not always considered Carer’s needs assessment – it was felt that awareness of carers’ needs is fairly high, but additional explanation of what it is needed. Carer experience – whilst it was felt there was a high level of satisfaction with the support KMPT offers carers, the impact of caring and the expectations of the services was not always clear. Friends and Family. In July, NHS England has produced new comprehensive guidelines on FFT to make the process easier to understand and to gain more personal comments to inform patient decision making and choice. It is anticipated that KMPT will have to start reporting FFT results in October 2014. The Friends and Family Test is gradually being embedded into frontline services, although the process is slower than expected. The Patient Experience team are taking action by reminding the wards and teams on a fortnightly basis, through informing them how many responses have been received, and by providing a monthly report of the F&F score and comments made by patients. Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm Infection Control There were no reported cases of MRSA bacteraemia or Clostridium Difficile infections during the months of May and June 2014. The Trusts compliance with mandatory training for infection control has increased and is above the 85% Trust target. 2 yearly compliance stands at 90%, 3 yearly compliance is 92%, and once only training is at 96%. The monthly observational hand hygiene audit in in patient areas was 100% in February. Serious Incidents Page 51 of 163 There were 8 new Serious Incidents (SIs) reported by KMPT in July compared to 10 in June and 7 in May. 6 SIs were reported under the category ‘unexpected death of community patient (in receipt)’. Suicide by outpatients continues to be the highest category of ongoing SIs for KMPT, with 15 falling into this category and a further 4 SIs relating to suspected suicide. The second highest category is unexpected death of community patient (in receipt), with a total of 8 SIs. There has been a gradual decrease in the number of SIs reported within the 0-2 day timeframe. The delay in reporting may be due to KMPT being informed of incidents retrospectively, by other services. There are currently no SIs breaching the 45/60 deadline submission for closure. There are 9 KMPT closure requests awaiting CCG review and 3 closure submissions awaiting review by the Area Team, none of which are breaching. Closure was agreed on 4 SIs during July. Changes to practice include risk assessments to be updated when a client’s mental state starts to deteriorate in order to reflect the concerns about behaviour and the associated risks. Page 52 of 163 Never Events No new Never Events were reported during July 2014. There are no ongoing Never Events for KMPT. Page 53 of 163 4 Children and Young People’s Mental Health (ChYPS) Provided by Sussex Partnership Foundation Trust Serious Incidents (ChYPS) There was one new SI reported by ChYPS in July relating to Unexpected Death of Community Patient (in receipt). As at 31 July 2014 there are 13 ongoing SIs of which 11 were breaching the 45/60 day deadline for submission for closure. KMCS have continued to request updates from Sussex Partnership Trust and are waiting for information to be submitted. Of the 13 ongoing SIs 6 involve patients from East Kent, 5 involve patients from North Kent, 1 involves a patient from West Kent and 1 is a security threat involving a member of staff. 5 South East Coast Ambulance Service (SECAmb) Outcomes Framework Domain 4 – Ensuring that people have a positive experience of care Complaints During the period April-May 2014, the Trust received 123 formal complaints, compared to 154 for the same period last year, which coincided with the launch of the NHS111 service. May 2014 received 65 complaints, the highest level recorded since May 2013 which received 77. Of the formal complaints received 1 has been identified as a Serious Incident Requiring Investigation (SIRI). Since April 2013, the four areas of Accident & Emergency (A&E), Emergency Operations Centre (EOC), Patient Transport Services (PTS) and NHS111 have consistently received the highest number of complaints. The complaints relating to patient care have decreased over the year, there is a 25% increase in the complaints logged about the attitude and conduct of staff. The main issues raised around EOC were around the timelines of response or backup. The A&E themes were 72 % about staff attitude, with 21% about patient care. Although Of the complaints raised about NHS 111, the majority of concerns were about triage, the Directory of Services, communication issues and delayed referrals. Although Page 54 of 163 Additional to the formal complaints received, PALS received 534 contacts for the period of April-May 2014, compared to the same period last year when 907 were received. Of the 534 contacts made with PALS, 193 of these were received from Health Care Professionals. The remainder were requests for information, advice and assistance. For the months of April-May 2014, the Trust received one request from the Parliamentary and Health Service Ombudsmen (PHSO). Since October 2013, the PHSO has reviewed nine cases, of which 1 was partially upheld, and 2 are awaiting conclusion. Actions identified through complaints and concerns raised, are logged on the Datix database, and identified as individual actions, or those which need to be shared Trust wide. Friends and Family As part of the national CQUIN for this year, the Friends and Family test question must be asked. The staff question must be asked at least once a year and the first quarterly survey is being carried out. Guidance on the Patient Friends and Family Test question is still awaited, but it is anticipated that the ambulance services will implement it in October. Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm Performance During June 2014, both the Red 1 and Red 2 calls performed to expected standards, achieving 75% for Red 1 and 75.4% for Red 2. For Quarter 1, both of these targets were met in Kent & Medway. Cat A19 Calls continue to do well and consistently remained above the 95% target with a performance percentage of 96.3% for June. Serious Incidents There were 5 SIs reported in July by SECAmb, an increase from 2 in June and 3 in May. It was reported last month that North Kent CCG was aware of a call where the patient was given poor advice and later died and two others where the patients have suffered cardiac arrests and none of these have been raised as SIs. SECAmb were asked to investigate and raise as serious incidents. These have now been reported and are included in this month’s figures. There were no SIs breaching the 45/60 day deadline for submission for closure. There are currently 9 ongoing serious incidents, all are still within submission deadlines. Ambulance (general) remains the highest category of on-going SIs, with 4 of the total being attributed to this Page 55 of 163 category, which incorporates complaints, pathway problems, training issues and call handling issues. A comparison of reporting on a month-on-month basis illustrates that reporting has decreased compared to each comparative month in 2013. 33 SIs were reported during January – July 2013, compared to 21 SIs for the same period in 2014. This is an indication that the learning from serious incidents is being shared across SECAMB via various media and is now becoming embedded within the organisation and robust processes and procedures are being implemented. At the July closure meeting, North Kent SI Group agreed closure on 6 SIs, the Area Team agreed formal closure on 1 SI. The resulting changes to practice include that all EOC Clinicians clearly and concisely document their involvement in any call whereby they have instructed the EMA to pursue a particular pathway, or deviate away from the pathway/advice as directed by NHSP. All Clinicians to allocate their call sign to any call that they are involved in. The Clinician Procedure document has been updated to reflect the changes. Page 56 of 163 Never Events No new Never Events were reported during July 2014. There are no ongoing Never Events for SECAmb. Infection, Prevention and Control Based on the standards identified in the Health and Social Care Act, SECAmb have developed an Infection Prevention and Control Assurance Framework (IPCAF). This defines the standards the Trust is required to maintain as registered providers of healthcare to ensure compliance with CQC requirements. Self-assessment against the CQC Provider Compliance Assessment for Infection Prevention Control continues, with no actions or gaps identified at this time. Safeguarding SECAmb report an increase of 204% in the vulnerable person referrals dealt with, 6941 from April 2013-March 2014, compared to 3402 the previous Page 57 of 163 financial year. Additional resources have been brought in to process the backlog caused by this increase, and work is underway to update the DATIX module to allow the capture of the required information relating to these referrals. To support the completion of this information, the Trust website has been updated with additional information and guidance for staff. As part of the work to provide assurance on the Safeguarding process within SECAmb, a meeting will take place during July/August 2014, between the Trust and the newly appointed safeguarding commissioner, which will identify gaps and provide support to enhance the Safeguarding Assurance Framework, and agree actions to manage any identified gaps. NHS 111 NHS England have produced a quality and safety report to provide assurance on the quality (safety effectiveness, equity and patient experience) of NHS 111 services to support effective decision-making and to reflect on the learning outcomes. The service originally experienced many problems in 2013 with the main areas of concerns being around operational and staffing challenges causing overall delays in the system including response times and ‘Incorrect call centre outcome’. Many of the initial problems have been addressed and following this, the relevant performance indicators appear to have improved across most sites as reflected by the Minimum data set information. This suggests that generally, people are receiving positive care from the NHS 111 service. Although it is providing a good quality safe service overall, there is room for improvement, with some variation in the quality of services being delivered across the country. The findings of the review will inform a programme of work to deliver safe sustainable services in the future and a sub-group of clinical leads has been established to take forward its recommendations Key findings from the review are : Key roles in NHS111 need a clear remit of role and responsibility to ensure governance assurance There is an issue with availability and access to data and information to enable providers and commissioners to assess the quality of their services, although this improving, most notably through the development of the Intelligent Data Tool (IDT) which is in progress. There are Information governance issues for sharing and tracking patient information. Shared patient notes have been used in some areas. There is a need to develop secure and lawful data linkages across care boundaries. Page 58 of 163 There is no national process for recording and monitoring and Sis and complaints The delivery and accreditation of training should be reviewed to ensure that standards are well-defined and are upheld to provide assurance of its quality 6 NSL Transport Services In July 2014 CQC published the results of the inspection of NSL Kent in March 2014. Since the last inspection in November 2013 CQC reported that the service has generally improved but there needs to be further improvements to ensure provision of a consistently reliable service to meet people’s needs. NSL met the standards for assessing and monitoring the quality of service provision and complaints. However, there were three areas that did not meet the required standards and need further action. The key issues are highlighted below: Care and welfare of people who use services: Since the last inspection, there has been an increase in staffing, the number of vehicles and floorwalkers, employed to coordinate peoples journeys, there remain issues with service planning and delivery. However, specific issues remain which relate to the timely arrivals for appointments as well as transport delays later in the day, particularly after 6 pm. Concerns were raised about the impact delays have on patients with specific healthcare needs, ie diabetics. Requirements for workers Since the November inspection, a retrospective review of all staff in post has been undertaken to ensure Disclosure and Barring (DBS) checks have been completed and all new staff have a DBS check. However, some of the documentation of employment history and references are not meeting the expected standard for recruitment processes and procedures. Supporting workers All new staff undertake an induction training programme, but it was identified that not all staff are up to date with required mandatory training and records for mandatory training were not always completed. CQC have requested a report from NSL by 16 August 2014, detailing their action plan to meet these standards. This will be followed up by CQC to ensure Page 59 of 163 this action is taken. The CCG have received the action plans from NSL and are reviewing the documentation. Outcomes Framework Domain 4 – Ensuring that people have a positive experience of care Complaints During May and June 2014, NSL as a service received 58 complaints, 45 during May and 13 in June. The main source of these complaints were hospital staff, relative and patients in that order. The main reason for complaints during these two month were the delay in provision of transport, 88.89% in May and 92.31% in June. Quality data has been received by the CCG from NSL and this will be reviewed at the Quality and Performance meeting on August 28th 2014. The CCG is asking for explanatory narrative to support the complaints data and a more streamlined report to define West Kent specific data. Compliments During May, June and July, the service received 9 compliments which were recorded. 5 were via the phone, 3 were letters or email, and one was in response to a survey. Outcomes Framework Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm Serious Incidents No SIs were reported by NSL report during July 2014. There are currently 5 on-going serious incidents including 3 relating to injuries sustained by patients during transportation. All 5 cases are now breaching the 45/60 deadline for submission for closure. Requests for the completed investigation reports are being followed up with the provider and submissions are awaited. Never Events No new Never Events were reported during July 2014. There are no ongoing Never Events for NSL. Page 60 of 163 Safeguarding Children & Adults in Kent and Medway Annual Report 2013/2014 This paper is for: Information Recommendation: For the Governing Body to Note For further information or for any enquiries relating to this report please contact: Dr Meriel Wynter/Dr Steve Beaumont Reporting Officer: Dr Steve Beaumont Lead Director: Dr Steve Beaumont Report Summary: (A précis of the contents of the report) Date: Aug 14 Agenda Item: Version: The Safeguarding Children & Adults in Kent and Medway Annual Report 2013/2014 gives the Governing Body information and update reading safeguarding. FOI status: State either: This paper is disclosable under the FOI Act Strategic objectives links: C. Improved health outcomes and reduced health inequalities. D. Service quality and patient safety. Board Assurance Framework links: Identified risks & risk management actions: N/A Resource implications: Legal implications including equality and diversity assessment N/A This document has taken into account Equality and Diversity best practice. Report history: N/A Appendices N/A Next steps: N/A N/A Page 61 of 163 Safeguarding Children and Adults across Kent and Medway Compassion Courage Respect Safeguarding Children & Adults in Kent and Medway Annual Report 2013/2014 July 2014 Page 62 of 163 Contents Page 1 Purpose of the Report 3 2 The NHS Reforms and Kent and Medway strategic approach to safeguarding 3 2.1 National context 4 3 Safeguarding Children 5 3.1 Multi-agency safeguarding arrangements 5 3.1.1 KSCB/MSCB sub-groups 10 3.2 Serious case reviews – Children and Young People 15 3.3 Looked After Children (LAC) 16 4 Safeguarding Adults 18 4.1 National context 18 4.2 Multi-agency safeguarding arrangements 18 4.2.1 Kent and Medway Safeguarding Vulnerable Adult Board (K&MSVAB) 18 4.2.2 Multi-agency safeguarding assurance 19 4.3 Care Homes and Safeguarding 20 5 Domestic abuse 20 5.1 Domestic Homicide Review (DHRs) 21 6 Deprivation of Liberty Safeguards 22 7 Safeguarding achievements and areas for Development in 2014/15 23 7.1 Safeguarding Children 23 7.2 Looked After Children 25 7.3 Safeguarding Adults 26 8 Health Providers across Kent and Medway CCGs 27 8.1 Quality Assurance 33 8.1.1 Other multi-agency quality assurance mechanisms 39 Page 63 of 163 1. Purpose of the Report This report provides West Kent CCG Governing Body with an overview of safeguarding across health services in Kent/Medway during 2013/14. The report reviews the work across the year, giving assurance that the CCG has discharged its statutory responsibility to safeguard the welfare of children and adults across the health services it commissions. 2. The NHS Reforms and Kent and Medway strategic approach to safeguarding The Health and Social Care Act 2012 has radically transformed how health services are now delivered. Since April 2013, Clinical Commissioning Groups (CCGs) have been responsible for the majority of health service commissioning. CCGs are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and adults at risk of abuse or neglect. This includes specific responsibilities for looked after children and for supporting the Child Death Overview process, to include sudden unexpected death in childhood. Local authorities have the same responsibilities in relation to the public health services that they commission. In August 2013 an independent report was commissioned by Medway Clinical Commissioning Group (CCG) on behalf of all the eight Kent and Medway CCGs. The current resources within the Safeguarding team were historically ‘lifted and shifted’ from the PCT Cluster arrangement pre April 2103, and managed within the hosted arrangements agreed by CCGs through the collaborative shared services agreement. The independent safeguarding review “Report on the Health Safeguarding Needs Assessment across NHS Kent and Medway Clinical Commissioning Groups” was completed in early October 2013. The review identified 16 recommendations covering child safeguarding; child death overview process; adult safeguarding issues relating to care homes and continuing healthcare; the named GP function and capacity; retention of the hosted safeguarding model; the development of a safeguarding business plan; and assurance that safeguarding aspects are included in contracts. Page 64 of 163 Implementation of the recommendations is being monitored by the Safeguarding Partnership Board and taken forward by CCG Chief Nurses and the safeguarding team. The recommendations from this review continue to be progressed meanwhile across Kent and Medway a hosted safeguarding team continues which provides a central point of contact for the health economy and cover for absences and peer support. 2.1 National context In March 2013, the NHS Commissioning Board (now known as NHS England) published the “Accountability and Assurance Framework: Safeguarding Vulnerable People in the Reformed NHS”. Safeguarding accountabilities of CCGs are set out in the Accountability and Assurance Framework: Safeguarding Vulnerable People in the Reformed NHS (NHS England 2013), and include: • Plans to train staff in recognising and reporting safeguarding issues; • A clear line of accountability for safeguarding properly reflected in the CCG governance arrangements; • Appropriate arrangements to co-operate with local authorities in the operation of Local Safeguarding Children Boards (LSCBs) and Safeguarding Adult Boards (SABs) • Securing the expertise of a designated doctor and nurse for safeguarding children and for looked after children and a designated paediatrician for unexpected deaths in childhood; • Have a safeguarding adult lead and a lead for the Mental Capacity Act, supported by the relevant policies and training. This accountability and assurance framework was commissioned by NHS England in order to set out clearly the responsibilities of each of the key players for safeguarding in the future NHS. It has been developed in partnership with colleagues from the Department of Health (DH), the Department for Education (DfE) and the wider NHS and social care system. Page 65 of 163 The Mandate from the Government to the NHS Commissioning Board, now known as NHS England, for April 2013 to March 2015 (published in November 2012) says: “We expect to see the NHS, working together with schools and children's social services, supporting and safeguarding vulnerable, looked-after and adopted children, through a more joined-up approach to addressing their needs.” The Mandate also sets NHS England a specific objective of continuing to improve safeguarding practice in the NHS, reflecting also the commitment to prevent and reduce the risk of abuse and neglect of adults. 3. Safeguarding Children Working Together to Safeguard Children 2013 This statutory guidance clarifies the responsibilities of professionals towards safeguarding children, and strengthens the focus away from processes and onto the needs of the child. Last published in 2010, Working Together has been revised and came into force on April 15th 2013. In response to recommendations from Professor Eileen Munro’s report, ‘A Child Centred System’, Working Together to Safeguard Children guidance clarifies the core legal requirements on individuals and organisations to keep children safe. It sets out, in one place, the legal requirements that health services, social workers, police, schools and other organisations that work with children, must follow – and emphasises that safeguarding is the responsibility of all professionals who work with children. 3.1 Multi-agency safeguarding arrangements CCGs have a statutory duty to be members of Local Safeguarding Children Board working in partnership with local authorities to fulfil their safeguarding responsibilities. Kent and Medway have separate safeguarding boards, both are chaired independently. These statutory duties fall under Section 11 of the Children Act 2004 and apply to a range of organisations as well as the health economy. Section 11 the Children Act 2004 Page 66 of 163 Section 11 of the Children Act 2004 places a duty on key persons and bodies to make arrangements to ensure that whilst doing their jobs they have regard to the need to safeguard and promote the welfare of children. The Health service is one such key body, This section also states that these key bodies must take any guidance given to them by the Secretary of State and have clear reasons for not doing g so. However this duty does not give any other health professional any new functions, nor does it override their existing functions. Simply it requires them to carry out their existing functions in a way that takes into account the need to safeguard and promote the welfare of children. Local Safeguarding Children Boards have a responsibility to assess whether their local partners are fulfilling their statutory obligations under section 11 of the Children Act 2004. Both MSCB and KSCB do this every two years via a multi-agency audit. Organisations should have in place arrangements that reflect the importance of safeguarding and promoting the welfare of children, including: a clear line of accountability for the commissioning and/or provision of services designed to safeguard and promote the welfare of children; a senior board level lead to take leadership responsibility for the organisation’s safeguarding arrangements; a culture of listening to children and taking account of their wishes and feelings, both in individual decisions and the development of services; arrangements which set out clearly the processes for sharing information, with other professionals and with the Local Safeguarding Children Board (LSCB); a designated professional lead (or, for health provider organisations, named professionals) for safeguarding; Safe recruitment practices for individuals whom the organisation will permit to work regularly with children, including policies on when to obtain a criminal record check; appropriate supervision and support for staff, including undertaking safeguarding training: employers are responsible for ensuring that their staff are competent to carry out their responsibilities for safeguarding and promoting the welfare of children and Page 67 of 163 creating an environment where staff feel able to raise concerns and feel supported in their safeguarding role; staff should be given a mandatory induction, which includes familiarisation with child protection responsibilities and procedures to be followed if anyone has any concerns about a child’s safety or welfare; and all professionals should have regular reviews of their own practice to ensure they improve over time; clear policies in line with those from the LSCB for dealing with allegations against people who work with children. Local Safeguarding Children Boards LSCBs were established in law by the Children Act 2004 (section 13) and have two main responsibilities: To co-ordinate what is done by each person or body represented on the Board for the purpose of safeguarding and promoting the welfare of children in their local community. To ensure the effectiveness of what is done by each such person or body for those purposes. Kent and Medway local authorities have complied with this regulation and each have a safeguarding children board which is chaired by an independent person. Executive leads for safeguarding represent their organisations at board meetings Kent Safeguarding Children Board (KSCB) There are 322,700 children and young people living in Kent, making up 22% of the population. Many groups of children in Kent are vulnerable. Kent Safeguarding Children Board is a partnership, working to safeguard and promote the welfare of children. It places a statutory responsibility on all agencies in Kent, including CCGs to provide assurance that they are working hard to ensure that all children and young people in Kent stay safe and are adequately protected. It is responsible for coordinating and ensuring the effectiveness of Kent services in protecting Page 68 of 163 and promoting the welfare of children and young people and provides the vital link between various statutory and voluntary organisations. The Board is made up of senior representatives from all main agencies and organisations. CCGs are represented, by agreement by one Chief Nurse from the Kent CCGs who will represent the interests of all CCGs. The subgroups are formed to tackle the various area of concern to the KSCB on a more targeted and thematic basis. Health providers across Kent are members of all subgroups and The Designated Nurses for Safeguarding Children are active members who give the strategic health expertise and oversight of the whole health economy. KSCB develops an annual Business Plan which sets out what it intends to achieve and how its success will be measured. www.kscb.org.uk KSCB set three priorities for 2013/14 which were Positive outcomes for all children and young people across Kent Holding partner agencies to account for their part in collectively improving safeguarding of all children in Kent. Demonstrating a robust safeguarding partnership that can effectively undertake the work of Kent’s Improvement Board KSCB Strategic Priorities 2014 - 2015 Version 5 (2).docx An improvement notice was put on KCC’s children’s services in 2010 after they were found to be ‘inadequate’ but a determined improvement programme was put in place which has achieved significant results. Following significant multiagency collaboration KCC was praised of the progress made by the department which has achieved muchimproved Ofsted reports in all three areas of the service in the past year. On the 11 th December 2013 The Children’s Minister has lifted the Improvement Notice on Kent County Council’s children’s services. Page 69 of 163 Medway Safeguarding Children Board –MSCB There are 69,000 children and young people living in Medway which is 26% of the total population. The Medway Safeguarding Children Board is a strategic group that ensures that the Child Protection and Safeguarding objectives are coordinated, monitored and effective. It is made up of senior strategic managers of partner agencies. It is the key group that, whilst operating in the context of the local children’s trust arrangements and developing a strong relationship with the wider strategic partnerships within Medway, has a unique statutory role in Safeguarding and promoting the welfare of children MSCB develops an annual Business Plan which sets out what it intends to achieve and how its success will be measured. In order to do this in a way that is responsive to safeguarding priorities across Medway, the MSCB invites single agencies each year to identify their own safeguarding objectives and report on how these have been achieved throughout the year. Individual partner agencies are also asked to identify overarching objectives and priorities for the Board, which are then considered by the Board and worked into the plan. The plan also contains how recommendations from inspections, SCRs and other reviews and changes in government guidance will be implemented as well as priorities identified through the MSCB’s annual safeguarding needs analysis contained within the annual report. www.mscb.org.uk Main aims were: To ensure the effective co-ordination of local work to safeguard and promote the welfare of children. To ensure the effectiveness of the work of local partners to safeguard and promote the welfare of children To protect and promote the well-being of vulnerable groups of children. (MSCB) was reviewed in July 2013 in the context of an OFSTED inspection finding of inadequate effectiveness of safeguarding services therefore any amendments to the business plan will be addressed in the 2014/15 plan. Page 70 of 163 3.1.1 KSCB/MSCB sub-groups KSCB/MSCB sub-groups The Safeguarding Children boards are required to have subgroups to carry out the business of the board. Each subgroup is chaired by a member of the safeguarding board. They are made up of all organisations that provide a service to children locally. The Designated Nurses for Safeguarding Children are active members of the subgroups and offer their expertise on all issues relating to the whole health economy. LSCBS subgroups are chaired by a member of the LSCB and are made up of safeguarding professionals from all organisations which provide a service to children. Health providers are represented on each subgroup. Their function is to tackle various areas of concern to the LSCB on a more targeted and thematic basis. They report into and are accountable to the Board. CCG representation at Board level is achieved by the Chief Nurse. Some of the subgroups are joint ventures between both boards. Health is represented on all subgroups. These include: Policy and Procedures subgroup The Policy and Procedures Sub Group is responsible for developing policies and procedures for safeguarding and promoting the welfare of children and ensuring they are compliant with national requirements. The group has the responsibility for co-ordinating the development of local multiagency policies, procedures and guidance for safeguarding and promoting the welfare of children on behalf of KSCB. The group keeps such policies under review, ensuring their timely revision and undertakes focused pieces of work at the request of the Board, co-opting additional professionals as required. The new Kent and Medway Safeguarding Children Procedures are live and available to professionals on their respective websites. A programme to ensure they are reviewed and updated regularly is supported by Triax. Page 71 of 163 Trafficking Subgroup The Trafficking Children and Sexual Exploitation Sub Group is a joint venture between the Kent Safeguarding Children Board and Medway Safeguarding Children Board. It is working to develop an integrated strategy to identify, address and reduce incidents of child trafficking and child sexual exploitation. One of its principle objectives is to raise awareness and encourage the reporting of concerns about trafficked children and sexual exploitation. Each Safeguarding Board will also have common subgroups which include: Child Death Overview Panels From the 1st April 2008, Each LSCB has had a duty to evaluate and analyse all child deaths (0-18 years old), Both MSCB and KSCB have CDOP panels which are independent from each other and well established processes in place to do so. CDOPs are responsible for reviewing information on all child deaths, and are accountable to the LSCB chairs. The LSCB has responsibility for reviewing the deaths of all children resident in its geographical area. The purpose of the process is to provide better support and information to the families of children who have died and to ensure that the death of their child is properly investigated. It also helps to understand the reasons for child deaths across Kent & Medway and therefore contribute to future child safety. The lessons learned from the local and strategic Child Death Overview Panel should inform the Strategic planning processes for children’s services. CCGs must ensure that they secure a Consultant Paediatrician for child deaths that will lead on the response from health to all unexpected deaths and bring a clinical view to the panels. The panels are multiagency and chaired by the director of Public Health; each Child Death overview panel produces an annual report which is available on respective websites for Kent and Medway LSCBs. Page 72 of 163 Child death figures - In the last financial year across Kent and Medway there were 90 child deaths. Medway had 18 child deaths and Kent 72. In Kent & Medway the most common reason for the death of a child is in the neonatal category which includes premature births and is in line with national trends. Each CDOP produces an annual report which can be found on www.mscb.org.uk and www.kscb.org.uk Serious Case Review Subgroup Both MSCB and KSCB have SCR subgroups/panels which are independent from each other and well established processes in place The Case Review Sub Group is responsible for reviewing cases where a child has died or has been seriously harmed in circumstances where abuse or neglect is known or suspected and for coordinating and disseminating learning from these. The group provides advice to the Independent Chair of KSCB on whether the criteria for conducting a Serious Case Review (SCR) has been met and will support the Chair in establishing the initial scope for any SCR that is commissioned. In 2013/14 there were 12 cases referred the KSCB SCR panel, none of which progressed to a full SCR investigation, but in line with recommendations in Working Together to Safeguard Children (2014) 7 of the cases were investigated through a multiagency case review process. This process was well evaluated by frontline staff and attendees, with outcomes and findings being used by KSCB to inform their training programme and content. KSCB has been considered against its comparator authorities and evidenced to be proactive in undertaking multiagency case reviews. Further information on Kent and Medway serious case reviews can be found in 3.6 Page 73 of 163 Learning & Development Subgroup Both MSCB and KSCB have Learning & Development Subgroup s which are independent from each other and have well established processes in place to disseminate training and learning. The Learning and Development Sub Group is responsible for planning and coordinating multi-agency training on child protection and safeguarding children. The Learning and Development Sub Group co-ordinates, promotes and quality assures multi-agency training opportunities to meet local needs for safeguarding. It develops an annual strategy and training plan in line with KSCB priorities, ensuring recommendations from inspections, audits and SCRs are reflected. The group is responsible for promoting and taking forward learning and development within Kent informed by legislation, government guidance and good practice requirements and includes the evaluation of the effectiveness of training put in place. Additional MSCB Subgroups Executive The key role of executive group is to support and drive the effectiveness of the board and ensure statutory duties are met including how the board evaluates early help pathways and engages with children, young people and practitioners and responds to what they say. Performance and Quality Assurance (PMQA) The key role of the Performance Management and Quality Assurance Sub Group is to monitor and evaluate the effectiveness of safeguarding children activities undertaken by the agencies constituent to the Board and to advise on ways to improve. A key function of the sub group will be to review and scrutinise the safeguarding children performance across all MSCB member agencies. Page 74 of 163 Lessons Learned This group supports the MSCB to satisfy its statutory function to assess the effectiveness of the help being provided to children and families, including early help and quality assure Practice, through joint reviews and work closely with the case file audit group involving practitioners and identifying lessons to be learned. The MSCB is also responsible for undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. Additional KSCB Subgroups Quality & Effectiveness Subgroup The Quality and Effectiveness Sub Group supports the Board and its partners in ensuring that a safe, effective and accountable safeguarding children system operates within Kent. The group provides high quality information relating to safeguarding performance across all agencies and makes recommendations to the Safeguarding Board in relation to aspects of performance that cause concern. It has a role to provide professional challenge to agencies as appropriate in relation to performance and the data they submit. Health Safeguarding group The Health Safeguarding Group (HSG) has been established to enable health representatives from the SHA, NHS Kent and Medway, Kent County Council and all Health Trusts and agencies to meet together in order to fulfil their responsibility to safeguard children in an integrated way. The group provides a common health voice at the KSCB and oversees the Safeguarding Board’s decisions and recommendations relating to health services. It defines the strategic direction in relation to planning, commissioning and delivery of services to vulnerable children in order to achieve a consistent and responsive approach. The aim of this group is to identify any deficits in health services to safeguard children and ensure the deficits are addressed. Key areas of work have Page 75 of 163 been bring all health providers together in one forum to progress safeguarding within health, monitoring the Serious Case review look back exercise and scrutiny and support of the local providers of adolescent mental services. Health Reference Group The Health Reference Group (HRG) is a subgroup of HSG and is attended by All Designated & Named professionals and health providers across Kent. This is an operational group that will monitor action plans and identify any deficits in health services to safeguard children. Health information and recommendations for the area are reported up to the HSG. 3.2 Serious case reviews – Children and Young People These are undertaken when a child dies and abuse or neglect is known or suspected, or a child is seriously harmed and there are concerns as to how professionals worked together to safeguard the child. The purpose of SCRs is to learn lessons and make improvements to services but also consolidate good practice. They are carried out under the auspices of the LSCB and they should oversee the implementation of action plans. The revised Working Together guidance states that from 2013 a national panel of experts will be in place to advise LSCBs on the initiation and publication of SCRS. Medway Safeguarding Children Board undertook one SCR in 2012 which was published on 8th May 2013 and can be found on http://www.mscb.org.uk/seriouscasereviews/medwayseriouscasereviews.aspx Also in 2012 Medway providers were involved in a SCR undertaken by Tower Hamlets following the death of a 15 year old boy who was looked after under the care of Tower Hamlets Local Authority but in foster care in Medway since he was 7 years old. At the time of his death he was on remand in Cookham Wood the Young Offenders Institute in Rochester. Tower Hamlets Safeguarding Children Board published the review on 18 th August 2013 and is available on http://www.mscb.org.uk/pdf/Child-F-Serious-CaseReview-Executive-Summary.pdf In order to assure KSCB around learning lessons from previous SCRs across Kent a looked back exercise was undertaken. The purpose of the exercise was to seek assurance that Page 76 of 163 practice had changed positively following a number of serious case reviews in Kent. All NHS Trusts have provided acceptable evidence that recommendations have been embedded into practice. All actions plans for health were monitored by the Designated Nurses Throughout the period of 2013/14 there were no SCRs commissioned by either safeguarding board. 3.3 Looked After Children (LAC) Children and young people who are looked after are amongst the most socially excluded groups. They have profoundly increased health needs in comparison with children and young people from comparable socio-economic backgrounds who have not needed to be taken into care. Whilst within the care system, there is opportunity for this imbalance to be addressed, these children and young people need to be able to access universal services as well as targeted and specialist services where necessary. National data shows that there were 68,110 looked after children at 31 March 2013, an increase of 2 per cent compared to 31 March 2012 and an increase of 12 per cent compared to 31 March 2009. At 31 March 2013 Kent County Council (KCC) had 1800 LAC, which is 56 per 10 000 children under 18 years. There were also 1144 children placed into Kent by other local authorities. The factors contributing to their becoming ‘Looked After’ in the first place, compounded by the experience of being in the care system, multiple transitions, risk of having inequitable access to health, both universal and specialist place them at significant risk of poor emotional and mental health. Under the Children Act 1989, a child is defined as being “looked after” by a local authority if he or she is in their care or is provided with accommodation for a continuous period of more than 24 hours by the authority. This will include Unaccompanied Asylum Seeking Children. There have been a number of legislative and guidance changes over the past year which have an impact on our looked after children. The Children and Families Bill 2013 sets out its support for the reforms to adoption and the Family Justice System. An Action Plan for Page 77 of 163 Adoption: Tackling Delay (DfE, 2011) is the Governments vision for how Local Authorities will put an increased number of children through the adoption process in a shorter time, reduce delay, and breakdown barriers to becoming an adoptive parent. This action plan is supported by the Children and Families Bill 2013. Reforms to the Family Justice System looks at tackling delay and ensuring the best interest of the child is at the centre of any court proceedings. The Bill sets out a new time frame of 26 weeks for care proceedings; this will have a significant impact on children whose care plan is for adoption and the capacity of community paediatricians to meet the new time scale for medical assessment and reports. A policy briefing published in May 2103 set out the Local Authority responsibilities towards children looked after following remand. The document makes clear that children/young people who become looked after by virtue of being remanded do not require a health assessment. However, the health of children/young people whose status was as a looked after child/young person prior to being detained remain subject to the statutory health assessments and health care as set out in the Statutory Guidance (DCSF, 2009). Quality Standard for the Health and Well-being of looked after children and young people (QS 31) was published by NICE in April 2013. It covers the health and well-being of all looked after children/young people from birth to 18 years and care leavers. It applies in all settings and services working with or caring for LAC and care leavers, including where they live. The standard describes high-priority areas for quality improvement, there are eight quality statements and these can be used by commissioners to commission efficient and effective services, by providers and users to assess the quality of services they are involved in and for people to hold commissioners to account for the quality of services. 4 Safeguarding Adults 4.1 National context Safeguarding adults involves a range of measures taken to protect people in the most vulnerable circumstances. No Secrets (DH 2000) defined the term ‘vulnerable adults’ as ‘a person aged 18 and over who may be in need of community care services by reason of mental health or other disability, age or illness and who may be unable to take care of Page 78 of 163 him or herself or unable to protect him or herself from harm or exploitation’. The Care Act 2014 revises the definition of vulnerable adult to that of ‘adult at risk’ who has needs for care and support (whether or not the authority is meeting any of those needs), is experiencing, or is at risk of, abuse or neglect, and as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it. The government has reaffirmed the principles of adult safeguarding which are: Empowerment -Presumption of person led decisions and informed consent. Prevention -It is better to take action before harm occurs. Proportionality – Proportionate and least intrusive response appropriate to the risk presented. Protection -Support and representation for those in greatest need. Partnership -Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. Accountability and transparency in delivering safeguarding 4.2 Multi-agency safeguarding arrangements 4.2.1 Kent and Medway Safeguarding Vulnerable Adult Board (K&MSVAB) SVAB covers all eight Kent and Medway CCGs and both local authorities. This Board is chaired by Kent County Council Corporate Director for Families and Social Care, Andrew Ireland. All four Chief Nurses are invited to be present on the Board to represent CCGs and the Associate Director of Safeguarding is also a member. All health provider leads for adult safeguarding are also Board members. Designated Nurses for adult safeguarding are represented on the sub-group structure; Serious Case Review panel Learning and Development Quality Assurance Policy and protocols Mental Capacity Act and Deprivation of Liberty Safeguards (currently this is a standalone Board and further discussion and agreement is required) Page 79 of 163 4.2.2 Multi-agency safeguarding assurance Kent Adult Social Services (KASS) operate a Central Referral Unit (CRU), which is a multiagency hub that evaluates and assesses safeguarding for both children and adult concerns, bringing together the information held within the multi-agency environment, evaluating the level of risk and planning the necessary action through strategy discussions. The CRU is made up of staff from different agencies including Police, Social Services, Health and Probation. The Families and Social Care (KCC) part of the CRU is the County Duty Team (CDT). The Central Referral Unit covers the KCC boundaries; Medway have different arrangements for evaluating and assessing adult safeguarding. KASS provides a weekly update on sanctions on care homes in Kent, and as of 17th May there were 16 homes with AP3 flags, many of which also have poor practice and/or contract compliance flags. There were in addition 14 homes with AP2 flags, and a further 5 homes with PP1/2/3 flags where there are no AP concerns at present. This information can be filtered by CCG and Designated Nurses will be able to provide to individual CCGs. We do not currently receive the same level of information from Medway Council. Sanctions AP2 AP3 PP1 PP3 An Adult Protection alert is being investigated and it is possible that other service users may be at risk of significant harm due to abuse, or poor practice. Some or all service users are being assessed in relation to these concerns. An adult protection alert is being assessed and/or investigated and there is evidence of significant risk to other service users due to abuse or poor practice. KASS and CHC placements on hold. Poor practice concerns have been identified and are being investigated. There is a low risk of harm, abuse or neglect to service users Serious poor practice concerns have been raised and are being investigated. There is a significant risk of harm, abuse or neglect to service users. KASS and CHC placements on hold 4.3 Care Homes and Safeguarding The team has developed a system to efficiently receive and process all safeguarding alerts from the local authorities. The Single Point of Access is managed on a rota basis and all alerts are triaged by the team for allocation. The Designated Nurses and Specialist Nurses continue to work closely with the local authorities and to support the adult protection investigation process for care homes. The Designated Nurses provide Mental Page 80 of 163 Capacity Act and safeguarding advice and guidance for complex cases. The specialist nurses co-work with local authority safeguarding leads to progress investigations, produces specialist reports, attend case conferences and develop actions plans for quality improvements. 5 Domestic abuse Domestic abuse is defined as: any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. The NICE guidance (February 2014) “Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively” makes a number of recommendations for CCGs, including developing an integrated commissioning strategy through local strategic partnerships and commissioning integrated care pathways domestic violence and abuse service and Swale Action to End Domestic Abuse. The Kent and Medway Domestic Abuse Strategy Group, a multi-agency group, is responsible for setting the strategy, accountable to the Community Safety Partnerships. The Domestic Abuse Strategy (2013 – 2016) and Delivery Plan is available on the Kent and Medway domestic abuse website. On 1 April 2013, NHS England became responsible for commissioning health services for people who experience sexual assault or rape. This includes responsibility for overseeing the commissioning of services from sexual assault referral centres (SARCs). NHS England is committed to ensuring that all victims can access safe, confidential and high quality support, health care and forensic examinations from a local SARC. NHS England’s Kent and Medway Area Team and the Police Crime Commissioner’s Office have been working in partnership with Kent Police and other partner organisations to establish a new sexual assault referral centre (SARC) for Kent and Medway and to improve the services that are available to support victims of sex assault. They have worked at pace to develop a new high quality service as quickly as possible and have now commissioned a new SARC service, which will be delivered by Kent and Medway NHS and Social Care Partnership Trust (KMPT). Page 81 of 163 The service has been commissioned in line with the national service framework which has been developed by NHS England and various partners to ensure the highest quality support for victims and equity of provision. 5.1 Domestic Homicide Review (DHRs) DHRs were established on a statutory basis under section 9 of the Domestic Violence, Crime and Victims Act (2004). This provision came into force on 13th April 2011. Revised guidance has been issued and is applicable from August 2013. A DHR is a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect perpetrated by: (a) a person to whom he/she was related or with whom he/she was or had been in an intimate personal relationship, or (b) a member of the same household as himself/herself, held with a view to identifying the lessons to be learnt from the death. An ‘intimate personal relationship’ includes relationships between adults who are or have been intimate partners or family members, regardless of gender or sexuality. The table below shows the eleven DHRs for Kent and Medway. Published reports can be found at: http://www.kent.gov.uk/about-the-council/partnerships/kent-community-safetypartnership/domestic-homicide-reviews DHR Locality No* CCG Date CSP notified Submitted to Home Office Identifier Published March 2012 Returned from Home Office July 2012 1 Rochester Medway 2 3 5 6 7 8 Chatham Gravesend Margate Canterbury Ashford Dover Medway DGS Thanet C4G Ashford SKC August 2011 Sept 2011 Sept 2011 Oct 2011 Nov 2011 May 2012 May 2012 Mrs A/2011 no July 2013 Oct 2013 Nov 2013 Jan 2013 July 2013 Sept 2013 Oct 2013 pending pending June 2013 pending Nov 2013 Cydney/2011 Alan 2011 Christopher/2011 FL/2011 B/2012 BC/2012 yes Page 82 of 163 yes yes 9 11 Margate Broadstairs Thanet Thanet Oct 2012 Nov 2013 In progress In progress NA NA NA NA *DHR4: subsequent to the notification this case was found not to be a homicide *DHR10: Due to a lack of any agency involvement a decision taken not to conduct a DHR was relayed to the Home Office in January 2013 6 Deprivation of Liberty Safeguards The supervisory body responsibility for authorising Deprivation of Liberty applications in health placements transferred from PCTs to Local Authorities on 1st April 2013. As a result the Section 75 agreement between the three PCTs and two LAs has been dissolved. The transition happened smoothly, with no problems occurring. CCGs remain accountable for commissioning health services that are compliant with the DoLS legislation. A number of reports published revealed that the DOLS process is poorly understood and not used appropriately. A national audit was completed by EMIAS of DoLS usage in hospitals based on survey returns. The audit showed that a large number of staff are permitted by their organisations to authorise an urgent deprivation of liberty without necessarily completing advanced, specialist training, therefore potentially breaching patients’ Article 5 rights. Additionally, not all Trusts/Hospitals are reporting applications to the Care Quality Commission as they are legally required to. CQC produced their annual report: Monitoring the use of the Mental Capacity Act Deprivation of Liberty Safeguards in 2011/12 (Executive Summary). This report concurred with the finding of the EMIAS audit and added there is wide variation in how local authorities carry out their functions as supervisory bodies. 7 Safeguarding achievements and areas for Development in 2014/15 7.1 Safeguarding Children Key Achievements in 2013/14 Following external review of Safeguarding service, Thanet and South Kent Coast secured the allocation of one whole time designated Nurse for safeguarding children. Page 83 of 163 Safeguarding input at key CCG meetings and KSCB and MSCB sub-groups. Development of robust networks and relationships with Designated Nurse across CCG to ensure robust arrangements and application of thresholds to protect children. Initiation of safeguarding training across CCGs. Successful multiagency working to protect and safeguard children and young people i.e. Operation Lakeland. CCG led scoping exercise across provider health organisations to review their preparedness to recognise, sexual exploitation. Advice and support to GP staff. Immersive learning event in conjunction with KSCB for Executive leads in the CCGs. KSCB Section 11 assessment of CCGs. Implementation of robust KPIs relating to safeguarding in all North Kent Contracts for 14-15 Challenges New NHS architecture and commissioning structures. Capacity within the hosted model to meet demands. Align systems, policies and strategy across CCG Competing priorities e.g. Operation Lakeland and significant workload generated from Lakeland CCGs seeking to withdraw from hosted model New NHS architecture and commissioning structures and governance agreements regarding safeguarding across CCGs in Kent and Medway. Reduced capacity of hosted safeguarding team due to recruitment difficulties Recommendations from external safeguarding review required agreement and action across all CCGs. Future Plans -Going forward in 2014/15. Ensure achievement against actions required from NHS England following their assurance process Page 84 of 163 Deliver recommendations from the recent CQC review of safeguarding services and services for Looked after Children within West and North Kent Implement Service Level Agreements Job Plans and JDs for all designated doctors across K&M, securing this statutory provision Successfully recruit to designated doctor post in Ashford and Canterbury CCGs ??? Following the Area Teams recruitment to Named GP in Medway and East Kent locality, ensure collaborative working Review policies, strategies and guidance in line with recent key national documents, national and local SCR/DHR/Case Reviews and legislation Transfer the Child Death Function into a CCG Deliver training for CCG employed staff and Governing Bodies Explore developmental posts to create a career pathway, due to continued difficulties in recruitment Consolidate designated nurses alignment to CCGs and chief nurses Build on work already completed to develop robust arrangements and relationships Continued attendance and influence at KSCB and MSCB subgroups Develop standardise assurance and data collation Implement Safeguarding Work plans for all CCGs 14/15. Align the CCGs Safeguarding children work plan with CCGs children’s strategy to ensure the particular needs of vulnerable children are identified within the strategy and through effective commissioning secure the provision of timely and appropriate services in collaboration with KSCB, MSCB and partner agencies. Continue to develop robust arrangements and relationships with provider organisations including standardisation of data collation and safeguarding representation at local operational meetings. The CCG will continue to develop a clear communication strategy for diffusion of safeguarding issues/ lesson learnt from SCRs to its members and local health providers. The CCG will continue to develop systems to assure that safeguarding practice across the CCG reflects learnings from SCR. Page 85 of 163 CCG will contribute to completion and implementation of recommendations from safeguarding review in collaboration with other Kent and Medway CCGs. Looked After Children 7.2 Key achievements in 2013/2014 The Ofsted Inspection Report on Kent County Council’s services to Looked After Children was published in August 2013 it showed that a number of improvements had been made to looked after children/young people’s health care with some further recommendations for additional improvement. The report states that health outcomes for looked after children and care leavers have improved since the last inspection and are now adequate. Significant work has been done to improve the uptake of health assessments and dental examinations and the improvement is demonstrated in performance data. The appointment of a full-time Children-in-Care Coordinator to manage the requests for initial and adoption health assessments has greatly improved the performance and timeliness of the assessments, while also improving communication with social care and reducing delay for the child. Progress around the Adoption Process has also been made over the past year; this includes improving the quality of the assessment, the development of a benchmarking tool for all Health Practitioners and Commissioners in adoption work and Medical Advisors input into preparation groups for prospective adopters. Future Plans – Going Forward 2014/15 Align health and social care procedures with in the new 26 week Care Proceedings time frame across Kent and Medway. Put in place job descriptions and service level agreements with the Designated Doctors. Further improve multi-agency working to improve the health outcomes of our looked after children. Deliver recommendations from the recent CQC review of safeguarding services and services for Looked after Children within West and North Kent Page 86 of 163 Successfully recruit to Designated Looked after Children Nurse post Process map the current and future integrated health and social care approach to supporting Looked After Children and those children and adults going through the adoption process. Write a single service specification for the Looked After Children health service (to include adoption) and look at single service provider. Develop and embed robust arrangements for the quality assurance of health assessments. 7.3 Safeguarding Adults Key achievements in 2013/2014 Following external review of Safeguarding service, a further Designated Nurse has been secured across East Kent. This brings the total to four wte Designated Nurses for Adult Safeguarding across Kent and Medway. Safeguarding input at key CCG meetings and SAB sub-groups. Collation and completion of Health IMR for Domestic Homicide Review. Commissioning health participation into Multi-agency information provision and development of safeguarding adults experience under Making Safeguarding Personal Project. Completion of annual required Best Interest Assessments to enable Designated Nurses to keep fully up to date with case law and Mental Capacity Act and Deprivation of Liberty Safeguards. Future Plans -Going forward in 2014/15. Further partnership working with social care partners about how best to encourage improvement in quality and safety in the care home sector to reduce the number of poor practice and adult safeguarding concerns. Ensure that CCGs are sighted on emerging adult safeguarding risks, including compliance with the Mental Capacity Act following the House of Lords select committee report, and the implications of the Supreme Court judgements on the Deprivation of Liberty Safeguards. Page 87 of 163 Continue to develop GP awareness and response to adult safeguarding concerns, including their training levels and contribution to adult protection processes, working in partnership with NHS England Key challenges The number of requests for assistance and support in investigating allegations of abuse in the care home sector continue to rise. The specialist nurses for safeguarding in care homes have continued to provide support where possible. The future of these specialist roles is under consideration by CCGs. North and West Kent have agreed to employ a joint post to support adult safeguarding and this remit is being scoped GP awareness of adult safeguarding is improving, albeit from a low baseline. Responsibility for GP training rests with NHS England (Kent and Medway Area Team) Ensuring that health organisations remain compliant with current statutory requirements and respond effectively to changes in legislation and best practice. 8 Health Providers across Kent and Medway CCGs Medway NHS Foundation Trust The Trust provides Accident & emergency services Paediatric acute and community, LAC Health team, midwifery, school nursing and general medical and surgical services. The Executive Lead for Safeguarding children, adults and Looked after Children (LAC) is the Chief Nurse. They have governance arrangements in place via their Children services committee and through Governance to the Quality and Risk committee. They have a fulltime Named Nurse who supports and advises professionals in the acute setting as well as School Nurses and midwives’ in the Community. There are two Named Doctors who cover the community in Medway and Swale and a Named Doctor, who covers the in-patient areas, a Named Midwife is also in place. There is a Paediatric Liaison Nurse who liaises with community services and primary care when a child attends Accident and Emergency or there is a child death. The Safeguarding Adults Lead also has Page 88 of 163 the role of leading on the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DOLS). MFT is represented on both Kent and Medway Safeguarding Boards and at the Health Safeguarding group which is a subgroup of KSCB and SVAB. Section 11 Audit MFT has assessed themselves as fully compliant in five out of eight standards. The standards that are partially met and are around having a child friendly Accident and Emergency Department, more staff trained to provide supervision and more trained in safer recruitment, there are action plans in place to address these. Actions will be monitored by the designated nurse and MSCB. Medway Community Healthcare (MCH) Medway Community Healthcare is a Community Interest Company (CIC) which provides a wide range of community health services for Medway residents; from health visitors and community nurses to speech and language therapists and out of hour’s urgent care. The executive lead for Safeguarding is the Director of Clinical standard who attends the Medway Safeguarding Children Board and Kent and Medway SVAB. They currently have one Named nurse for safeguarding children and a Safeguarding and MCA Lead who are active members of MSCB and SVAB subgroups. MCH also has a Specialist Health Visitor for Domestic Abuse and a Safeguarding Adults Advisor. MCH completed a Section 11 Audit with which they assessed themselves as compliant with no recommendations. Dartford and Gravesham NHS Trust Darent Valley Hospital has an emergency department with separate adult and paediatric facilities; in-patient paediatric services including a 5 bedded paediatric assessment unit; and maternity services including neonatal and special care facilities. The Director of Nursing provides Executive lead at trust board level. Their Safeguarding team is made up of Named nurse, Named midwife, Named doctor, Operational lead midwife, senior sister, safeguarding children Paediatric liaison safeguarding nurse. The Page 89 of 163 Safeguarding Adults lead is also the lead for the Mental Capacity Act and the Deprivation of Liberty Safeguards. There is concern relating to the capacity of these staff as they have a range of other responsibilities within their portfolios. DVH conduct a Section 11 report for KSCB their current actions as a result of audit are to develop a system of safeguarding supervision for all staff that come into contact with children. South East Coast Ambulance Service (SECAMBS) This service is commissioned by Swale CCG and their safeguarding is currently being scoped to ensure that they are meeting their statutory requirements. Maidstone and Tunbridge Wells NHS Trust The Trust provides services on two acute hospital sites, namely Maidstone hospital and Tunbridge Wells Hospital at Pembury (known as Pembury hospital). Both hospital sites have emergency departments for both adults and paediatric attendances, although there are no separate paediatric treatment facilities at Pembury. There are paediatric inpatient services at Pembury, with a paediatric day service at Maidstone hospital. Pembury hospital has maternity services including a postnatal ward and a neonatal unit offering intensive care, high dependency and special care for pre-term and sick new-born babies, and there is standalone midwifery led birthing centre located in the grounds of Maidstone Hospital. The Executive Lead for Safeguarding children and adults is the Chief Nurse and she came into post in July 2013. The Chief Nurse meets bi-monthly with the Designated Nurses. They have governance arrangements in place via their Safeguarding Children and the Safeguarding Adult Committees and through Governance to the Quality and Risk committee. The Safeguarding Adult Matron is support in her role by the Patient Experience Lead. Recognition that the Named Nurse for Safeguarding Children required extra support was realised and two part time safeguarding children advisors were employed. Page 90 of 163 Emphasis on Safeguarding children level three training has ensured that compliance has improved and a robust action plan to ensure that all staff are trained to the required level continues. Kent & Medway NHS and Social Care Partnership Trust The Trust provides adult mental health services and is commissioned by the CCGs across Kent. This includes an early intervention in psychosis service for people aged 14-35 years old, and MIMHS – a mother and infant mental health service. The Named Nurses for Safeguarding Children are active in Kent and Medway in ensuring that practitioners recognise the ‘Think Family’ agenda and have developed a checklist for practitioners to use with adult clients to ensure that children are considered in all assessments and consultations. The Head of Safeguarding is supported by the MCA and DOLS lead, who has worked closely with the local authority to embed the legislation within mental health services. The Trust also manages the service for the supply of Section 12 doctors for DOLS assessment. Sussex Partnership Foundation Trust (SPFT) The Trust provides Tier 2-3 services (targeted and specialist support) which are commissioned by the CCGs, with West Kent CCG having a lead commissioning role. SPTFs focus on early engagement with Designated Nurses was not as strong it could have been. This has now been resolved and strong links and open lines of communication now exist and SPFT have become active members of both safeguarding boards. SPTF has reviewed and updated the Trust’s Safeguarding Strategy to reflect changes to the Kent and Medway services and reflect the appointment in 2013 of a permanent and full time Named Nurse within Kent. South London & Maudsley NHS Trust Tier 4 specialist in-patient CAMHS services are commissioned and funded by NHS England and provided by the South London & Maudsley NHS Trust (SLAM) across Kent. The Page 91 of 163 Designated Nurses meet regularly with the safeguarding team who are active in both safeguarding boards. East Kent Hospital University Foundation Trust (EKHUFT) EKHUFT provide services on three acute hospital sites, Queen Elizabeth, Queen Mother (QEQM) and William Harvey Hospital (WHH) and Kent and Canterbury Hospital (K&C). Both QEQM and WHH have full emergency departments for both adults and paediatric attendances. K&C operate an Emergency Care Centre that treats adult with acute medical illness and all age groups for minor injuries. The Trust also has a Minor Injury Unit at Buckland Hospital. There are paediatric in-patient services at QEQM and WHH. Additional to the paediatric outpatients’ services at all sites, there is a Children’s Assessment Centre at K&C and day facilities at Buckland Hospital, Dover. Both QEQM and WHH hospitals have maternity services including, midwifery led units, postnatal wards and a special care and neonatal intensive care unit respectively, offering intensive care, high dependency and special care for preterm and sick new-born babies The Executive Lead for Safeguarding children and adults is the Chief Nurse and Director of Quality and Operations. They have governance arrangements in place via their Safeguarding Children Committee, which the Designated Nurses are invited to attend and also through Governance to the Quality and Risk committee, which the Head of Safeguarding Adults also attends. The safeguarding team consists of the Head of Safeguarding and two safeguarding advisors who support and deliver a comprehensive safeguarding children training programme to hospital staff. This has ensured that compliance has improved. They have updated their training strategy for 2014, and have a robust action plan in place to ensure that all staff are trained to the required level. Additionally they have completed a robust scoping exercise in preparedness to recognise child sexual exploitation, and have developed a “health checklist” to assist staff in the detection of child sexual exploitation. This arrangement is mirrored for safeguarding adults with Head of Safeguarding supported by a safeguarding lead and a practitioner. The Designated Nurses regularly Page 92 of 163 meet with the team for updates on safeguarding compliance. This information is reported to the CCG Quality committees. Kent Community Healthcare Trust Kent Community Health NHS Trust (KCHT) was formed on 1 April 2011 from the merger of Eastern and Coastal Kent Community Services NHS Trust and West Kent Community Health. KCHT is one of the largest NHS community health providers in England, serving a population of about 1.4 million in Kent through its workforce of 5,500 staff. The Executive Lead with the responsibility for safeguarding in Kent Community Health NHS Trust is the Director of Nursing and Quality, who is also a standing member of the Kent Safeguarding Children and Vulnerable Adults Boards. KCHT actively participates at the Kent Safeguarding Children and Vulnerable Adults Board sub-groups. KCHT provides wide-ranging NHS care for people, in a range of settings, which includes: people's own homes (adult and children’s universal & specialist community services); nursing homes; health clinics; community hospitals (12 community hospitals located across Kent); minor injury units ( 6 units across Kent); a walk-in centre (1 in Folkestone); mobile units (community dental Services). KCHT provides the health support at the Central Referral Unit (CRU) for the Kent Health economy to improve information sharing and decision making in relation to preventive and reactive safeguarding work to protect children, young people and adults at risk. Safeguarding assurance within KCHT is provided by the Head of Safeguarding and her team, which includes named doctors and nurses and designated doctors. KCHT_Safeguarding_ Declaration_2014[1].pdf 8.1 Quality Assurance Page 93 of 163 CCG Quality assurance mechanisms: Dartford Gravesham and Swanley, Swale and Medway CCGs - North Kent CCGs Safeguarding accountability sits within the portfolio of the Chief Nurse, who provides strategic direction on child and adult safeguarding, including Looked After Children and has direct or delegated representation on the local Safeguarding Children’s Board and the Adult Safeguarding Board for Kent and Medway. Governance is achieved via the Quality Committee which is established in accordance with North Kent Clinical Commissioning Group’s Constitution, Standing Orders and Scheme of Delegation. There is subgroup of this committee known as the safeguarding Group the role of which is to ensure the CCGs are assured about their own and their commissioned provider safeguarding accountabilities, understand safeguarding processes and systems and performance. There is not an expectation that the Safeguarding Group will replicate existing multi-agency statutory fora, therefore membership is limited initially to health commissioners. The purpose of the Safeguarding Group is to assist the Medway Quality Committee, Dartford, Gravesham and Swanley, Finance and Performance Committee and Swale Finance and Performance Committee in an assurance role to enable the CCGs to deliver their statutory responsibilities for safeguarding. North Kent CCGs are required to secure the expertise of Designated Professionals for Safeguarding Children. These include: Designated Nurse for Safeguarding Children A Designated Nurse is in place employed by Medway CCG via the hosted safeguarding arrangements; accountability for safeguarding is directly aligned to the Chief Nurse. The Designated Nurse meets regularly with the Chief Nurse. Designated Nurse and doctor for Looked After Children. (See below) Designated Doctors for Safeguarding Children This function has been delivered by a Consultant Paediatrician employed by Medway Foundation Trust for Medway CCG and Dartford and Gravesham Hospitals for DGS CCG and East Kent Hospital for Swale. Service Level Agreement and Job description have been formalised and agreed. Negotiations have been Page 94 of 163 commenced to secure this expertise in order that the CCG can meet its statutory obligations. Designated Doctor (Paediatrician) for Sudden and Unexpected Child Death (SUIDIC). In Medway this function has been delivered by two Consultant Paediatricians employed by Medway Foundation NHS Trust. A Service Level Agreement and Job description have been formalised and agreed this ensures that the CCG will meet its statutory obligations. In DGS this function is delivered by a consultant paediatrician from Dartford and Gravesham Hospitals Trust. Historically this post was covering West Kent PCT. A Service Level Agreement and Job description have been formalised and negotiations are underway to secure and this expertise for DGS in a substantive manner. This ensures that the CCG will meet its statutory obligations. In Swale CGG this function is delivered by a consultant paediatrician from East Kent Hospital University Foundation Trust. A Service Level Agreement and Job description have been formalised and agreed this ensures that the CCG will meet its statutory obligations. West Kent CCG Safeguarding accountability sits within the portfolio of the Chief Nurse, who provides strategic direction on child and adult safeguarding, including Looked After Children and has direct or delegated representation on the local Safeguarding Children’s Board and the Adult Safeguarding Board for Kent. Governance is achieved via the Quality Committee which is established in accordance with NHS West Kent Clinical Commissioning Group’s Constitution, Standing Orders and Scheme of Delegation. The purpose of the West Kent Quality Committee is to ensure that the Clinical Commissioning Group demonstrates capability to deliver the statutory and mandatory responsibilities for care quality and this includes safeguarding children and adults. Page 95 of 163 The Quality Committee provides assurance to the CCG Board and meets bi-monthly. Within the quality committee both the designated nurses for safeguarding and children provide, using hard and soft intelligence, reports on safeguarding within the West Kent CCG so that any serious failures are prevented or identified at an early stage and resolved through the effective implementation of agreed actions; this includes benchmarking and comparative information regarding safeguarding outcomes. West Kent CCG is required to secure the expertise of Designated Professionals for Safeguarding Children. These include: Designated Nurse for Safeguarding Children A new Designated Nurse was secured in August 2013. Although employed by Medway CCG via the hosted safeguarding arrangements, accountability for safeguarding is directly aligned to the Chief Nurse. The Designated Nurse meets regularly with the Chief Nurse. Designated Doctor for Safeguarding Children This function has been delivered by a Consultant Paediatrician employed by Kent Community Healthcare Trust. However no formal arrangement is in place for West Kent CCG to secure her expertise. This has been recognised as a risk and has been placed on the corporate risk register. A Service Level Agreement and Job description have been formalised and agreed. Negotiations have been commenced to secure this expertise in order that the CCG can meet its statutory obligations. Designated Doctor (Paediatrician) for Sudden and Unexpected Child Death (SUIDIC). Due to historic arrangements this function has been delivered by a Consultant Paediatrician employed by Maidstone and Tunbridge NHS Trust but delivered in his own time. Payment for this post has been informal. The current post holder retired in March 2014. This has been recognised as a risk and has been placed on the corporate risk register. A Service Level Agreement and Job description have been formalised and agreed. Negotiation were successfully completed to secure and this expertise in a substantive manner. This ensures that the CCG will meet its statutory obligations. Page 96 of 163 Designated Nurse and doctor for Looked After Children. (See below) Ashford and Canterbury CCGs Safeguarding accountability sits within the portfolio of the Chief Nurse, who provides strategic direction on child and adult safeguarding, including Looked After Children and has direct or delegated representation on the local Safeguarding Children’s Board and the Adult Safeguarding Board for Kent. From July 2013 Ashford and Canterbury CCG designated nurse support provision was through the hosted safeguarding model. Successful recruitment to the Designated Nurse for Safeguarding children for East Kent was achieved in August 2013 and there have been regular meetings between the designated nurse and the Chief Nurse. The Designated Nurse for Safeguarding Children regularly attended quality meetings within the CCGs and submitted reports to inform and influence the CCG Board. Designated Nurse and doctor for Looked After Children. (See below) Thanet and South Coast Kent CCGs Safeguarding accountability sits within the portfolio of the Chief Nurse, who provides strategic direction on child and adult safeguarding, including Looked After Children and has direct or delegated representation on the local Safeguarding Children’s Board and the Adult Safeguarding Board for Kent. Thanet and South Kent Coast CCGs are required to secure the expertise of Designated Professionals for Safeguarding Children. These include: Designated Nurse for Safeguarding Children A new Designated Nurse was secured in August 2013. Although employed by Medway CCG via the hosted safeguarding arrangements, accountability for safeguarding is directly aligned to the Chief Nurse. The Designated Nurse meets regularly with the Chief Nurse and Head of Quality. Designated Doctor for Safeguarding Children Page 97 of 163 This function is delivered across East Kent by a Consultant Paediatrician employed by East Kent Hospitals University Foundation Trust. The Designated Doctor has been in post since April 14. Designated Doctor (Paediatrician) for Sudden and Unexpected Child Death (SUIDIC) This function is delivered across East Kent through a shared agreement by three Consultant Paediatricians employed by East Kent Hospitals University Foundation Trust. Designated Nurse and doctor for Looked After Children. (See below) Governance for safeguarding is via the Quality Committee which is established in accordance with Thanet and South Kent Coast Clinical Commissioning Group’s Constitution, Standing Orders and Scheme of Delegation. The function of the both Thanet and South Kent Coast CCGs Quality Committee is to ensure that the Clinical Commissioning Group demonstrates capability to deliver the statutory and mandatory responsibilities for care quality and this includes safeguarding children and adults. The Quality Committee provides assurance to the CCG Governing Body and meets monthly. Within the quality committee both the designated nurses for safeguarding and children provide a written report on safeguarding issues within the Thanet and South Kent Coast in order to ensure any known risks or failures are highlighted and the mitigations where possible and remedial agreed actions are implemented. This includes benchmarking and comparative information regarding safeguarding outcomes. Designated Nurse and doctor for Looked After Children Clinical Commissioning Groups need to secure the expertise of a designated doctor and nurse to provide strategic and clinical leadership and advice, not only for themselves but also for the local authority. The role of these designated professionals is to assist the Page 98 of 163 CCGs in fulfilling their responsibilities as commissioners of services to improve the health of looked after children. The Designated Nurse for Looked After Children is employed full time and covers all 8 CCGs in Kent and Medway. There is a Designated Doctor for LAC for Medway CCG who covers Medway and has 4 sessions a week; some of this time is used for clinical work. A Designated Doctor is in post to cover West Kent CCG, and one for Dartford, Gravesham and Swanley CCGs, these three posts need to have a job description and service level agreement put in place. There is a Designated Doctor that covers East Kent (Ashford, Canterbury and Coastal, Thanet and south Kent Cost CCGs), a review of the job description and service level agreement for this post is needed to ensure it is appropriate for the role. Currently there is no designated doctor in place for Swale, this is being rectified by a contract variation with Kent Community Healthcare Trust. 8.1.1 Other multi-agency quality assurance mechanisms In 2013/14 Medway Safeguarding Children Board carried out a section 11 audit of all agencies including health. The Director of Medway Children and Adults Services arranged a safeguarding children peer review which took place in February 2014. Verbal feedback relating to health was that the review team visited MFT and were very positive about safeguarding children. Within Kent all CCGs were required to undertake a self-assessment under section 11 of the children Act 2004 with the intention that all CCGs and health providers will be required to undertake a full assessment in January 2015. Page 99 of 163 Kent and Medway NHS [Type the document title] [Type the document subtitle] Page 100 of 163 Strategic Priorities: 2014-15 Priority 1 Co-ordinate, monitor and challenge the effectiveness of local arrangements for the quality and appropriateness of early help and preventative services. To address this priority detailed actions will focus on: o Ensuring there is an embedded awareness and understanding of the Kent threshold document o Continuing to develop safeguarding policies and procedures in line with Working Together 2013 o Ensuring effective early help is provided at the CAF/TAF stage of support o Undertaking consistent and holistic assessments o How early help and early intervention features in mental health support for young people o Effective participation of all partners o Ensuring that the voice of children and their families are listened to, and influence practice and services o Priority 2 Ensure multi agency and joined up working which protects and supports children with specific vulnerabilities, including the provision of timely and appropriate services. To address this priority detailed actions will focus on the following groups of vulnerable young people, although this is not an exhaustive list: o Missing young people o CSE young people o Those being trafficked o Those affected by gangs o Those affected by ‘on line’ safety and those at risk of on line threats o Those with emotional health vulnerability, at all levels o Children with disabilities, including those with autism o Victims of sexual abuse o Victims/perpetrators of domestic abuse o Those bullying or being bullied o Victims of FGM Priority 3 Develop a family focused approach in relation to substance misuse, mental health problems and domestic abuse. This will be developed into an action plan to focus on: o The impact on children and young people and what happens next as a result o The impact of working between adults and children's services Page 101 of 163 o The knowledge of staff of these specialist areas Priority 4 Provide evidenced assurance to the KSCB through robust monitoring, scrutiny and challenge, that multi-agency safeguarding practices are improving and there is ongoing learning and development for staff. To address this priority detailed actions will focus on: o Implementation of the Quality and Effectiveness Framework o Implementation of the Case Review processes o Implementing a robust multi-agency audit programme o Lessons learnt from case reviews and audits o Learning from CDOP reviews o Implementation of the Learning and Improvement Framework o Response to Ofsted Review Framework o Reporting from each KSCB Sub Group o Feedback to staff Key threads that run through all priorities: o Voice of the Child o Multi-agency partnership working (including the voluntary and community sectors) o Lessons are identified and learned from case reviews and multi-agency audits undertaken and the monitoring of the implementation of recommendations (Learning and Improvement Framework o Knowledge and understanding of the children’s workforce Page 102 of 163 Integrated Performance Report July 14 Page 103 of 163 Patient focused Providing quality, improving outcomes Contents: Page: Executive Summary Scorecard Are health outcomes improving for local people? Are people getting good quality care? Are patient rights under the NHS Constitution being promoted? Local Outcomes Indicators Finance Indicators Activity Analysis Financial Individual Outcomes Indicators: Overall Financial Position Resource Limit Cash Running Costs Capital Budget Breakdown Deployment of headroom 2.5% 2014/15 CCG Risks 2014/15 Appendix A – Outcomes Indicators Appendix B – Glossary of acronyms Page 104 of 163 3 4 5 7 8 10 11 12 15 19 20 21 22 23 25 26 27 29 Performance Report – July 14 Executive Summary Key performance issues arising in Month 4 include: CDiFF cases remain below trajectory and MRSA is nil YTD. (page 6) Admitted patients to start treatment within 18 weeks from referral have dropped below the 90% target; this was expected as per the RTT Recovery Programme, however they have consistently achieved the 90% target in July. (page 8) A decrease in the number of patients waiting more than 35 weeks. (page 8) Category A (Red 1) Ambulance emergency response have dropped below the 75% target for SECAMB. (page 9) Significant adverse performance is being experienced in Acute care settings. This is occurring across most settings of care, but particularly in A&E, Short Stay emergency admissions, and outpatients including outpatient procedures These pressures in acute care contribute to an overall year to date position which means that the CCG is not achieving its planned surplus level on a year to date basis (page 16) Financial performance is currently forecast to achieve our planned surplus of £5.523m on a forecast outturn basis (page 16) To achieve this position, £1.1m of available headroom monies is being utilised to support the CCG’s position and the £2.47m available contingency is being deployed in full (pages 25 & 26) The risk of WKCCG losing allocation due to specialist commissioning is not being mitigated at Month 4 (page 26) Page 105 of 163 Scorecard Indicator Target 2013/14 YTD Movement Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Target CCG Assurance Framework Local Are health outcomes improving for local people? G A/R A/R G Are local people getting good quality care? G A/G A/G G Are patient rights under the NHS Constitution being promoted? G A/R A/G G Finance G A/G A/R G Local G A/G G G ` Are health outcomes improving for local people? G All relev ant indicators on track for achiev ement of quality premium A/G Not all indicators on track for achiev ement of the quality premium A/R At least one indicator statistically significantly off track for achiev ement of the quality premium R All indicators statistically significantly off track for achiev ement of the quality premium Are local people getting good quality care? G All 'No' responses A/G One or More 'Yes' responses w ith action plan that successfully mitigates patient risk A/R One or More 'Yes' responses and no action plan in place/plan does not significantly mitigate patient risk R Enforcement action is being undertaken by the CQC, Monitor or TDA and CCG is not engaged in proportionate action planning to address patient risk Are patient rights under the NHS Constitution being promoted? G No indicators rated red A/G No indicator rated red but future concerns A/R One indicator rated red R Tw o or more indicators rated red A/G Less than three Primary indicators rated Amber/Red A/R One Primary Indicator rated Red or more than Three are Amber/Red R Tw o or more red primary indicators A/G Not all indicators on track A/R At least one indicator statistically significantly off track R All indicators statistically significantly off track Finance G All primary indicators are indiv idually rated green Local G All relev ant indicators on track Page 106 of 163 Are health outcomes improving for local people? The CCG is within the ceiling for C-Diff as at the end of June 14 – 24 vs. a ceiling of 26. Friends and Family Test uptake rates are below the 20% target for A&E – 15.5% and Inpatients are well above the 30% target – 46.4%. They have been no reported incidents of MRSA so far this year. Are health outcomes improving for local people? Overall RAG rating: A/R Baseline National and local Quality measures YTD Period NHS E CCG CCG Target 2011/12 89% 90% 89% 93% 86% 2011/12 70% 69% 64% 71% 68% 2012/13 77% 74% 2013/14 77% 77% 77% Response Rate 2014/15 N/A 30% Jun-14 46.4% 30% 38% • Friends and family test for A&E. Response Rate 2014/15 N/A 30% Jun-14 15.5% 20% 20.8% • Potential years of life lost from causes considered amenable to healthcare Rate per 100,000 population 2009 & 2010 2,163 1,773 2009 2012 1,899 1,704 2,061 • Potential years of life lost from causes considered amenable to healthcare: Male Rate per 100,000 population 2011 2,048 1,756 2009 2012 2,050 1,700 2,232 • Potential years of life lost from causes considered amenable to healthcare: Female Rate per 100,000 population 2011 1,716 1,549 2009 2012 1,746 1,499 1,891 Rate per 100,000 population 2011 68 50 2009 2012 54 48 65 • Under 75 mortality from respiratory disease Rate per 100,000 population 2011 23 24 2009 2012 20 23 27 • Under 75 mortality from liver disease Rate per 100,000 population 2011 16 9 2009 2012 10 9 15 • Under 75 mortality from cancer Rate per 100,000 population 2011 122 102 2009 2012 108 99 123 • Patient experience of GP services • Patient experience of GP out of hours services Ensuring that people have a positive experience of • Patient experience of hospital care care • Friends and family test for acute Inpatient care Preventing people from • Under 75 mortality from cardiovascular disease dying prematurely % who report their experience as "very good" or "fairly good" Weighted av e at CCG's 5 main prov iders Page 107 of 163 Period 07/1309/13 07/1309/13 Movement NHS E Action in progress National and local Quality measures Period Baseline Nat Average YTD Value Period Actual Target Movement Nat Average • Health-related quality of life for people with long-term conditions Rate per 100,000 population 07/1103/12 0.74 0.78 07/1203/13 0.78 0.78 0.74 • People feeling supported to manage their condition Rate per 100,000 population 07/1103/12 66.7 68.6 07/1203/13 68.4 68.6 65.6 Rate per 100,000 population 2011/12 711 743 Q3/12-13 Q2/13-14 615 743 788 Rate per 100,000 population 2011/12 272 198 Q3/12-13 Q2/13-14 181 198 311 Enhancing the quality of • Unplanned hospitalisation for chronic ambulatory care life for people with longsensitive conditions term conditions • Unplanned hospitalisations for asthma, diabetes and epilepsy in under 19s • Estimated diagnosis rate for people with dementia Treating and caring for • Incidence of healthcare associated infection: MRSA people in a safe environment and • Incidence of healthcare associated infection: C difficile protecting them from harm Rate per 100,000 population Acutal number of breaches Acutal number of breaches Under Development 2014/15 N/A 0 Jun-14 0 0 N/A 2014/15 N/A 98 Jun-14 24 26 N/A • Emergency admissions for acute conditions that should not usually require hospital admission Rate per 100,000 population 2011/12 814 885 Q3/12-13 Q2/13-14 911 885 1,187 • Emergency readmissions within 30 days of discharge from hospital Rate per 100,000 population 2010/11 11 11 10/11 11/12 11 11 12 Rate per 100,000 population 2011/12 354 204 Q3/12-13 Q2/13-14 220 204 385 health gain 2011/12 0.42 0.44 2013/14 0.46 0.44 0.43 % of improvement 2011/12 87.5% 90.6% 2013/14 90.8% 90.6% 89.7% health gain 2011/12 0.31 0.32 2013/14 0.33 0.32 0.32 % of improvement 2011/12 78.8% 77.1% 2013/14 82.8% 77.1% 80.6% health gain 2011/12 0.09 0.09 2013/14 0.06 0.09 0.09 % of improvement 2011/12 51.0% 51.6% 2013/14 50.0% 51.6% 50.2% • Emergency admissions for children with lower respiratory Helping people to recover tract infections from episodes of ill health or following injury • PROMs for elective procedures: hip replacement • PROMs for elective procedures: knee replacement • PROMs for elective procedures: groin hernia Individual RAG Red Below Target Amber Improving - above baseline Green Met or exceeded Target Page 108 of 163 Action in progress Are local people getting good quality care? MTW continues to work to increase the response rate for the Friends and Family Test and has now exceeded the 15% requirement both for Inpatients and A&E. The rate of C Diff at the CCG and MTW remains below trajectory. The CCG has had no reported MRSA cases in the year to date. Are local people getting good quality care? Overall RAG rating: Indicator A/G Period MTW KMPT KCHT SECAMB Has local provider been subject to enforcement action by the CQC? Jul-14 No No No No Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions? Jul-14 N/A N/A N/A No Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? Jul-14 No No No No Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern? Jul-14 No No No No Has the provider been identified as a 'negative outlier' on SHMI or HSMR? Jul-14 No No No No Providers Do provider level indicators from the National Quality Dashboard show that: MRSA cases are above zero Jul-14 No No No No the provider has reported more C difficile cases than trajectory Jul-14 No No No No MSA breaches are above zero Jul-14 No No No No Does the provider currently have any unclosed Serious Untoward Incidents (SUIs)? Jul-14 Yes Yes Yes Yes Has the provider experienced any 'Never Events' during the last quarter? Jul-14 No No No No Jul-14 No Concerns around quality issues being discussed regularly by the CCG governing body Jul-14 No Clinical Governance Does the CCG have any outstanding conditions of authorisation in place on clinical governance? Has the CCG self-assessed and identified any risks associated with the following: CCG Concerns around the arrangements in place to proactively identify early warnings of a failing service Jul-14 No Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events Jul-14 Yes Concerns around being an active participant in its Quality Surveillance Group Jul-14 No Jun-14 No Jun-14 Yes EPRR If there was an emergency event in the last quarter, has the CCG self-assessed and identified any areas of concern on the arrangements in place for dealing with such an event? Winterbourne Review Has the CCG self-assessed and identified any risk to progress against its Winterbourne View action plan? Page 109 of 163 Are patient rights under the NHS Constitution being promoted? Admitted patients to start treatment within a maximum of 18 weeks from referral have dropped below the operational target of 90% for the first time this year; this was expected due to the implementation of the RTT Recovery Programme and in July they have consistently achieved the 90% target. The number of patients waiting over 52 weeks has increased from 7 to 8 over the last month, all at King’s; 7 in Neurosurgery and 1 in General Surgery. The CCG is proactively focussing on patients who have waited more than 35 weeks and currently has 125 patients – down from 153 last month who were waiting in excess of 35 weeks. There was no additional Mixed Sex Accommodation breach since May 2014. SECAMB ambulance response times for Category A (Red 1) has dropped below the operational target for the first time this year. Are patient rights under the NHS Constitution being promoted? Overall RAG rating: Operational Lower Target Threshold 87.50% 90% 85% Jun-14 96.4% 95% 90% Jun-14 95.1% 92% 87% Number of patients waiting more than 52 weeks Jun-14 8 0 10 Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral Jun-14 0.3% 1% 6% 03-Aug-14 95.6% 95% 90% YTD 95.0% 95% 90% Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP Qtr 1* YTD 96.0% 93% 88% Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) Qtr 1* YTD 94.6% 93% 88% Indicator Admitted patients to start treatment within a maximum of 18 weeks from referral Non-admitted patients to start treatment within a maximum of 18 weeks from referral Referral To Treatment waiting times for non-urgent consultant-led treatment Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral Diagnostic test waiting times A&E waits Cancer waits – 2 week wait A/G Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department - MTW Page 110 of 163 Period Actual Jun-14 Movement Trend Operational Lower Target Threshold 96.5% 96% 91% Qtr 1* YTD 97.0% 94% 89% Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen Qtr 1* YTD 98.4% 98% 93% Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy Qtr 1* YTD 99.1% 94% 89% Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer Qtr 1* YTD 85.4% 85% 80% Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers Qtr 1* YTD 93.3% 90% 85% Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) Qtr 1* YTD 86.2% 11-Aug-14 72.38% 75% 70% 2014-15 74.56% 75% 70% 11-Aug-14 65.71% 75% 70% 2014-15 71.60% 75% 70% 11-Aug-14 72.64% 75% 70% 2014-15 73.97% 75% 70% 11-Aug-14 68.58% 75% 70% 2014-15 69.48% 75% 70% 11-Aug-14 97.97% 95% 95% 2014-15 98.34% 95% 95% 11-Aug-14 100.00% 95% 95% 2014-15 97.82% 95% 95% Jun-14 0 0 9.9 YTD 1 0 9.9 All patients who have operations cancelled, on or after the day of admission, for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice. Qtr 1* YTD 35 Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period Qtr 1* YTD 100.0% Indicator Period Actual Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers Qtr 1* YTD Maximum 31-day wait for subsequent treatment where that treatment is surgery Movement Trend Cancer waits – 31 days Cancer waits – 62 days Category A calls resulting in an emergency response arriving within 8 minutes (Red 1) - SECAMB Category A calls resulting in an emergency response arriving within 8 minutes (Red 1) - CCG - for information only, does not form part of assessment framework Category A calls resulting in an emergency response arriving within 8 minutes (Red 2) - SECAMB Category A ambulance calls Category A calls resulting in an emergency response arriving within 8 minutes (Red 2) - CCG - for information only, does not form part of assessment framework Category A calls resulting in an ambulance arriving at the scene within 19 minutes - SECAMB Category A calls resulting in an ambulance arriving at the scene within 19 minutes - CCG - for information only, does not form part of assessment framework Mixed Sex Accommodation Breaches Minimise breaches Cancelled Operations Mental Health * Data Source - NHS England Local Outcomes Indicators Page 111 of 163 No operational standard set Not Rated - MTW total 95% 90% The local outcome for 2014-15 is Cardiac Rehab – number of patients with coronary heart disease (CHD) who complete cardiac rehabilitation. Completion is defined as the end of the cardiac rehabilitation delivery phase and second assessment, as collected by the national audit of cardiac rehabilitation (NACR). Baseline 2014-15 Local Quality Measures Local Outcomes Indicators Period Baseline YTD Period Actual • Cardiac Rehabilitation Completion Target 65% Additional Quality Indicator In addition, the CCG is monitoring IAPT coverage, this does not form part of the assurance framework. The CCG did not achieve this requirement for 2013-14, only achieving 10.4%. A number of actions have been taken to address this including increasing the number of providers from June 2014. Baseline Additional Quality measures Others Period • IAPT Coverage - performance against plan Page 112 of 163 Baseline YTD Period Actual Target Qtr 4 - YTD 10.4% 15% Finance Indicators Finance Indicators Overall RAG rating: Period YTD Plan YTD Actual YTD Variance Surplus - Year to Date (£'000) Jul-14 1,841 510 -1,331 Surplus - Full Year Forecast (£'000) Jul-14 Running Costs (£'000) Jul-14 This covers Internal and external audit opinions, and an assessment of the timeliness and quality of returns Jul-14 Balance sheet indicators including cash management and BPPC Jul-14 Indicator 3,944 Page 113 of 163 3,639 305 A/R FOT Plan FOT Actual FOT Variance 5,523 5,523 0 11,701 10,796 905 YTD FOT Activity Analysis – Month 4 This following few pages looks at the real time activity for NHS West Kent CCG at MTW and highlights a series of variations, analysis and trends for the period August 2012 - July 2014. Page 114 of 163 Page 115 of 163 Page 116 of 163 Overall Financial Position Month 4 The reported position for month 4 in the CCG’s programme areas show a deterioration in both the year to date and forecast outturn positions. On a year to date basis programme costs are overspent by £2.8m, which is mainly due to the Acute Programme area worsening and specifically at Maidstone and Tunbridge Wells NHS Trust. The overall position will be mitigated in part by the availability of earmarked programme reserves that will not be deployed. The adverse position for Programme costs is being further mitigated by the deployment of contingency and an element of available Headroom monies, as follows: Contingency Year to date Budget Cost £000 £000 822 0 Variance £000 822 Forecast Budget £000 2,466 Cost £000 0 Page 117 of 163 Variance £000 2,466 Headroom 380 0 380 6,260 5,121 1,139 After deployment of these reserves into the financial position, the CCG is achieving a surplus of £0.5m, against a planned position of £1.841m – an adverse movement of £1.3m. It is likely that an element of Acute costs seen in the period April to July relates to the RTT initiative. Funds are available for this from NHS England, but at this stage the resources have not been formally released to the CCG. Commissioners are currently quantifying the extent of additional costs incurred under the initiative but initial estimates suggest that it may be within a range of £0.3m to £0.8m. Once the full impact is understood, and resources are made available, the CCG will be in a position to reflect this within the overall financial position. At this stage, it is assumed that the position will improve, but will not be sufficient to bring the CCG back to planned surplus levels. On a forecast year end basis, it is expected that the position will worsen further still, primarily as a result of further deterioration in the Acute programme area. Some further Headroom funds are available to cushion further deterioration (£2.2m), and the CCG has identified a number of other opportunities that may provide mitigation. Lead clinicians and commissioners are currently reviewing the drivers of cost experienced in the period April to July, and are in the process of developing a plan to mitigate these financial pressures. Given that there is potential for further risks to emerge, it is vital that corrective actions are taken promptly if the CCG is to achieve its planned control total surplus for the year. Page 118 of 163 Finance Report Month 4 2014/15 Overall Financial Position The reported position for month 4 in the CCGs programme areas show a deterioration in both the year to date and forecast outturn positions, On a year to date basis programme costs are overspent by £2.8m, which is mainly due to the Acute Programme area worsening and specifically at Maidstone & Tunbridge Wells NHS Trust. The overall position will be mitigated in part by the availability of earmarked programme reserves that will not be deployed. The adverse position for Programme costs is being further mitigated by the deployment of contingency and an element of available Headroom monies and contingency, as below. After deployment of these reserves into the financial position, the CCG is achieving a surplus of £0.5m, against a planned position of £1.841m – an adverse movement of £1.3m. It is likely that an element of acute costs seen in the period April to July relates to the RTT initiative. Funds are available for this from NHS England, but at this stage the resources have not been formally released to the CCG. Commissioners are currently quantifying the extent of additional costs incurred under the initiative but initial estimates suggest that it may be within a range of £0.3m to £0.8m. once the full impact is understood, and resources made available, then the CCG will be in a position to reflect this within the overall financial position. At this stage, it is assumed that the position will improve, but will not be sufficient to bring the CCG back to planned surplus levels. On a forecast year end basis, it is expected that the position will worsen further still, primarily as a result of further deterioration in the Acute programme area. Some further Headroom funds are available to cushion further deterioration (£2.2m), and the CCG has identified a number of other opportunities that may provide mitigation. Lead clinicians and commissioners are currently reviewing the drivers of cost experienced in the period April to July, and are in the process of developing a plan to mitigate these financial pressures. Given that there is potential for further risks to emerge, it is vital that corrective actions are taken promptly if the CCG is to achieve its planned control total surplus for the year. Year To Date Year End Forecast Plan Overall Financial Position Year To Date £'000 165,449 Actual Variance to plan Expenditure As at M4 £'000 £'000 164,939 510 Plan Variance to plan Based on M4 As at M12 £'000 5,523 Variance to plan Based on M3 As at M12 £'000 0 Movement in variance £'000 494,353 Forecast Outturn As at M4 £'000 488,830 Plan £'000 269,067 40,641 79,376 38,132 38,862 2,325 468,403 Forecast £'000 274,791 41,241 79,376 38,106 38,889 510 472,913 Variance £'000 (5,724) (600) 0 26 (27) 1,815 (4,510) Forecast £'000 (2,976) (300) 0 20 (52) 29 (3,279) Forecast £'000 (2,748) (300) 0 6 25 1,786 (1,231) Headroom Contingency Total Programme Contingencies 6,260 2,466 8,726 5,121 0 5,121 1,139 2,466 3,605 0 2,466 2,466 1,139 0 1,139 Corporate (Running Costs Allowance) Total Administration 11,701 11,701 10,796 10,796 905 905 813 813 92 92 Overall Financial Position Plan £'000 91,022 13,547 26,459 12,711 12,954 1,770 158,462 Actual £'000 94,369 13,732 26,272 12,702 12,963 1,262 161,300 Variance £'000 (3,347) (185) 187 9 (9) 508 (2,838) Headroom Contingency Total Programme Contingencies 380 822 1,202 0 0 0 380 822 1,202 Corporate (Running Costs Allowance) Total Administration 3,944 3,944 3,639 3,639 305 305 TOTAL 163,608 164,939 -1,331 TOTAL 488,830 488,830 0 0 0 Surplus Grand Total 1,841 165,449 0 164,939 1,841 510 Surplus Grand Total 5,523 494,353 0 488,830 5,523 5,523 5,523 5,523 0 0 Acute Mental Health Primary Care Continuing Care Community Health Services Other Total Programme costs Year End Forecast As at M12 £'000 0 Acute Mental Health Primary Care Continuing Care Community Health Services Other Total Programme costs Mental Health The forecast Mental Health programme expenditure of £600,000 over expenditure is due to the following key areas of activity: Over performance on the KMPT PbR contract £0.4m Over Performance on adult placement and CAMH activities £200,000 Page 119 of 163 With the recent launch of more new providers for West Kent patients to access psychological therapies, there may be future upward expenditure pressure on the mental health programme area that isn’t currently being highlighted as activity data is not yet available. The key financial risk for the mental health programme area remains the potential over performance of the KMPT contract which has a maximum over performance tolerance of £1m. This financial risk can be mitigated to some extent by delaying planned mental health investments for the current financial year. Acute The YTD and Forecast financial position for the Acute programme have deteriorated and the key driver for this position is significant overperformance observed against Maidstone and Tunbridge Wells NHS Trust SLA. Although the final payment will be made based on final reconciliation through SUS, due a timing lag in availability of this data the CCG is using a number of sources such as our Real Time data to inform and give early indications of the position. Activity and costs have risen sharply, in particularly in the last month for Maidstone and Tunbridge Wells NHS Trust (MTW). This has resulted in significant over-performance within most Points of Delivery, but the highest contributors are Outpatient New and Follow Up attendances, Outpatient Procedures, A&E attendances and Short Stay Non-Elective admissions. There is a considerable over-spend in Direct Access Pathology. The Trust is currently working to achieve Referral to Treatment National Targets, and this could be a contributor towards this elevated level of activity. Commissioners are reviewing this in order to quantify how much of the over-performance is directly attributable to clearance of the backlog. The CCG has identified a number of areas where activity and cost pattern may relate to Coding and Counting change by the Trust without the required notice. This is being pursued through contractual route. Activity is particularly high in July and this may lead to further worsening of the overall position once this is quantified. Page 120 of 163 There is also a significant over-performance at King’s Foundation Trust and Guy’s and St Thomas’s Foundation Trust. There is currently no agreed SLA with King’s so at this moment it is difficult to establish which areas are causing this increase. The early indication tools identify increased Outpatient activity as the main driver. Guy’s and St Thomas’s over-performance is driven by a high number of critical care bed days and over-spend on Renal transport. Lead clinicians of the CCG and Commissioners have met on the 12th of August to examine some of the key areas of performance to date. This meeting has resulted in a plan of action to mitigate this position. Primary Care The forecast financial position for the Primary Care programme area continues to remain stable at Month 4. GP prescribing activity is a key area of risk in Primary Care where PPA forecast expenditure has the potential to vary by £1m each month. More reliable data is expected to be available from the Prescription Pricing Authority from September. Continuing Care The forecast financial position for the Continuing Care programme area currently shows this remaining within budget; however the volatility of this area remains a risk to the CCG. WK CCG has noted that referrals into the End of Life Fast Track (EOL FT) service are high and in excess of patients leaving the service – it is unclear at this early stage in the year whether this is an ongoing trend on whether this will even out throughout the coming months. The forecasting for continuing care is provided by KMCS which is subsequently reviewed and challenged by the CCG, robustness of data is still a concern and this is being taken forward by the Kent wide review of continuing care arrangements at KMCS. Community Health Services The forecast financial position for the Community Health services and Other programme areas show an overspend of 100k which is attributable to the AQP Physiotherapy service - all other small community contracts are expected to remain within budget. The main community contract is Kent Community Health (KCHT) and as this is contracted on a ‘block’ basis the financial risks associated with activity performance do not impact directly on the 2014/15 financial position for the CCG. Page 121 of 163 Resource Limit Finance Report Month 4 2014/15 There were no additional resource allocations in Month 4. Full Year Forecast Resource Limit Plan £'000 493,169 Forecast £'000 494,354 Variance £'000 1,185 Plan Actual Variance £'000 £'000 £'000 Opening Resource Limit 476,809 476,809 0 Running Cost Allowance 11,701 11,701 0 Closing Resource Limit 488,510 488,510 4,659 4,659 0 1,185 1,185 4,659 5,844 1,185 493,169 494,354 1,185 0 0 Confirmed Carry forward GP IT Confirmed Resource Limit Total Resource Limit Page 122 of 163 Cash Finance Report Month 4 2014/15 The CCG is holding a balance of cash at the month end of £9.1m. The CCG has now been notified of it's Maximum Cash Drawdown for 2014/15, which is based on the revenue resource limit at June 2014 (month 3) and is £488,107. The MCD will be formally issued on the cash reports produced on 1 September 2014. Maximum Cash Drawdown is the maximum drawdown available to a CCG including the amounts spent on prescribing on behalf of CCGs by NHS BSA. There will be two further opportunities for the CCG to revise the MCD in year to reflect their actual cash requirements through two annual cash forecast exercises in October 2014 (based on September 2014 financial position) and January 2015 (based on December 2014 financial position). In addition, the CCG will also retain flexibility to manage their year-end cash position by being able to make supplementary drawdowns or pay back excess cash, with the oversight and sign off of the Area Team and Regional teams and the availability of cash centrally. Year To Date Year End Forecast Cash Balance Plan £'000 409 Actual £'000 9,079 Variance £'000 8,670 Plan £'000 Actual £'000 Variance £'000 0 5 0 154,500 164,000 9,500 200 200 Year to Date Cash Balance Forecast £'000 409 Variance £'000 0 Plan £'000 Forecast £'000 Variance £'000 0 0 0 416,294 416,294 Year End Forecast Balance B/F Balance B/F Receipts Receipts Drawdown BACS RFT Other 0 Drawdown Chaps 0 BACS 0 Chaps 0 608 608 404 283 (121) 154,904 165,096 10,187 153,527 126,688 (26,839) 968 28,258 27,290 BACS 1,071 1,071 Other 154,495 156,017 1,522 409 9,079 8,670 Payments RFT Other 0 1,212 1,212 0 417,506 417,506 0 412,353 412,353 0 4,744 4,744 0 417,097 417,097 0 409 409 0 Payments RFT (NHS) BACS Other Balance C/F Plan £'000 409 RFT Balance C/F Page 123 of 163 0 Running Costs Finance Report Month 4 2014/15 The CCG's running costs show an underspend against plan of £0.3m in M4 and the forecast outturn has also been revised to show a slight improvement from M3. The costs relating to GPIT have now been moved out of running costs and into Primary Care IT where the budget sits. Currently the charges from NHS Property Services are expected to break even with budget although the indicative charges from them are much higher than expected. Detailed investigations and negotations are currently under way with NHSPS to understand and agree these charges. Year To Date Year End Forecast Plan Actual Variance Expenditure As at M4 £'000 £'000 £'000 Running Costs 3,944 3,639 305 Year To Date Plan Forecast Variance Outturn As at M12 £'000 £'000 £'000 Running Costs 11,701 10,796 905 Full Year Plan £'000 Actual £'000 Variance £'000 CCG Pay Costs 1,407 1,597 (190) CSU Recharge 1,477 1,499 (22) 238 238 0 822 3,944 305 3,639 517 305 Cost Type Plan £'000 Forecast £'000 Variance £'000 Pay Costs 4,220 4,791 (571) Non-pay Costs-CSU Recharge 4,298 4,306 (8) 715 715 0 984 10,796 1,484 905 Cost Type NHS Property Services re-charge Other Non-pay Total Running Costs Non-pay Costs-NHS Propco charge Non-pay costs-All other 2,468 Total Running Costs 11,701 Page 124 of 163 Capital Finance Report Month 4 2014/15 The CCG has a confirmed capital allocation of £1,440m for 2014-15. This will be added to the Maximum Cash Drawdown when it is set. The CCG will request release of the allocation in year when the cash is required and Area Teams and Regions need to approve the allocation. It is then submitted to Financial Performance to issue the resource allocation limit. The NHS England Cash management team will add the capital allocation to the MCD on notification from the Financial Performance Team and CCGs can then draw down the cash. Costs relating to the Care Plan Management System project are starting to come through now and these costs are expected to accelerate in the latter part of this financial year. The CCG has developed an application for the Digital Technology Fund in relation to the Care Plan Management System. If this is successful it will enable rapid expansion and deployment in West Kent. Year To Date Year End Forecast Capital Plan £'000 480 Actual £'000 158 Variance £'000 322 Budget £'000 480 0 0 480 Actual £'000 0 Variance £'000 (480) 0 0 (480) Capital £'000 Capital Plan £'000 1,440 Forecast £'000 1,440 Variance £'000 0 Budget £'000 1,440 Actual £'000 1,440 1,440 1,440 Variance £'000 0 0 0 0 600 240 250 150 150 50 600 240 250 150 150 50 0 0 0 0 0 0 1,440 1,440 0 1,440 1,440 0 Capital £'000 Source of Funds Capital Funds Allocation Legacy Capital Transfer Transfer from Revenue 0 Application of Funds Source of Funds Capital Funds Allocation Legacy Capital Transfer Transfer from Revenue Application of Funds ITF Data Warehouse Care Plan Management Self Care GP IT HQ IT refresh Total 200 80 83 50 50 17 96 10 8 104 80 39 50 40 9 480 158 322 480 158 322 44 ITF Data Warehouse Care Plan Management Self Care GP IT HQ IT refresh Total Page 125 of 163 Budget Breakdown Finance Report Month 4 2014/15 Year To Date Overall Financial Position Year To Date MAIDSTONE AND TUNBRIDGE WELLS NFT GUY'S AND ST THOMAS'S NHS FOUNDATION TRUST KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST MEDWAY NHS FOUNDATION TRUST EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST HORDER CENTRE EAST SUSSEX HOSPITALS NFT BMI HEALTHCARE LTD BENENDEN HOSPITAL TRUST UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST DARTFORD AND GRAVESHAM NFT SPIRE HEALTHCARE LTD ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST LEWISHAM & GREENWICH NHS TRUST GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST ST GEORGE'S HEALTHCARE NFT IMPERIAL COLLEGE HEALTHCARE NFT ACUTE COMMISSIONING SOUTH EAST COAST AMBULANCE SERVICE NHS FT SECAMB-111 ACUTE CHILDRENS SERVICES END OF LIFE HIGH COST DRUGS NCAS/OATS PLANNED CARE URGENT CARE WINTER PRESSURES Acute CENTRAL DRUGS COMMISSIONING SCHEMES LOCAL ENHANCED SERVICES OUT OF HOURS OXYGEN PRESCRIBING MEDICINES MANAGEMENT - CLINICAL PRIMARY CARE IT Primary Care Budget Breakdown £'000 Plan 165,450 £'000 Actual 164,940 Plan £'000 61,313 3,144 3,018 2,066 1,580 1,494 1,127 632 414 401 397 309 249 233 141 141 119 111 102 29 4,699 313 94 () 2,909 1,930 2,694 1,400 (38) 91,022 Actual £'000 63,364 3,389 3,632 2,129 1,628 1,484 1,232 722 275 366 422 542 268 273 168 121 44 173 47 251 4,699 306 94 () 2,715 1,930 2,694 1,400 938 929 1,235 207 22,568 187 395 26,459 94,369 221 809 930 1,237 177 22,395 186 317 26,272 £'000 Year End Forecast Variance 510 Overall Financial Position Variance £'000 (2,051) (245) (614) (63) (48) 10 (105) (91) 139 35 (25) (233) (19) (40) (27) 21 75 (61) 55 (222) 7 194 () (38) (3,347) (221) 128 (1) (2) 30 173 1 78 187 £'000 Plan 494,354 £'000 Forecast 488,830 £'000 Variance 5,523 Plan £'000 MAIDSTONE AND TUNBRIDGE WELLS NFT 179,940 GUY'S AND ST THOMAS'S NHS FOUNDATION TRUST 9,433 KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 9,053 MEDWAY NHS FOUNDATION TRUST 6,199 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST 4,741 QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST 4,482 HORDER CENTRE 3,382 EAST SUSSEX HOSPITALS NFT 1,895 BMI HEALTHCARE LTD 1,242 BENENDEN HOSPITAL TRUST 1,203 UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 1,190 DARTFORD AND GRAVESHAM NFT 926 SPIRE HEALTHCARE LTD 747 ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST 699 MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST 424 LEWISHAM & GREENWICH NHS TRUST 424 GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST 356 ST GEORGE'S HEALTHCARE NFT 334 IMPERIAL COLLEGE HEALTHCARE NFT 305 ACUTE COMMISSIONING (213) SOUTH EAST COAST AMBULANCE SERVICE NHS FT 14,398 SECAMB-111 938 ACUTE CHILDRENS SERVICES 283 END OF LIFE HIGH COST DRUGS 8,727 NCAS/OATS 5,790 PLANNED CARE 8,082 URGENT CARE 4,201 WINTER PRESSURES (115) Acute 269,067 CENTRAL DRUGS COMMISSIONING SCHEMES 2,813 LOCAL ENHANCED SERVICES 2,787 OUT OF HOURS 3,705 OXYGEN 620 PRESCRIBING 67,705 MEDICINES MANAGEMENT - CLINICAL 561 PRIMARY CARE IT 1,185 Primary Care 79,376 Forecast £'000 184,440 9,683 9,753 6,199 4,741 4,482 3,382 1,895 1,242 1,203 1,190 926 747 699 424 424 356 334 305 187 14,272 938 283 Variance £'000 (4,500) (250) (700) Year End Forecast Page 126 of 163 8,727 5,790 8,082 4,201 (115) 274,790 2,813 2,787 3,705 620 67,705 561 1,185 79,376 (400) 126 (5,724) KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST CHILD AND ADOLESCENT MENTAL HEALTH DEMENTIA IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LEARNING DIFFICULTIES MENTAL HEALTH CONTRACTS MENTAL HEALTH SERVICES - ADULTS MENTAL HEALTH SERVICES - ADVOCACY MENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY MENTAL HEALTH SERVICES - OTHER MENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING Mental Health CHC AD FULL FUND PERS HLTH BUD CHC ADULT FULLY FUNDED CHC ADULT JOINT FUNDED CHC CHILDREN CONTINUING HEALTHCARE ASSESSMENT & SUPPORT FUNDED NURSING CARE CHC CHILD PERS HLTH BUD CHC AD JNT FUND PERS HLTH BUD Continuing Care KENT COMMUNITY HEALTH NHS TRUST CARERS COMMUNITY SERVICES HOSPICES INTERMEDIATE CARE LONG TERM CONDITIONS WHEELCHAIR SERVICE PALLIATIVE CARE Community Health Services PATIENT TRANSPORT REABLEMENT COMMISSIONING - NON ACUTE GENERAL RESERVE - PROGRAMME HEADROOM CONTINGENCY Other Corporate Corporate 1% surplus 9,842 1,185 101 581 228 84 1,377 43 14 21 71 13,547 88 9,039 173 757 211 2,434 8 1 12,711 11,035 126 426 596 Total 240 489 41 12,954 840 221 105 604 380 822 2,972 3,944 3,944 1,841 165,450 9,892 1,240 104 643 98 106 1,493 43 42 71 13,732 50 9,037 116 902 213 2,369 15 12,702 11,017 126 476 596 219 489 40 12,963 839 300 124 1,262 3,639 3,639 164,940 (50) (55) (3) (62) 131 (22) (116) (28) 21 (185) 38 2 57 (145) (3) 64 (7) 1 9 18 (50) () 22 () 1 (9) (79) (18) 604 380 822 1,709 305 305 1,841 510 KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST CHILD AND ADOLESCENT MENTAL HEALTH DEMENTIA IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LEARNING DIFFICULTIES MENTAL HEALTH CONTRACTS MENTAL HEALTH SERVICES - ADULTS MENTAL HEALTH SERVICES - ADVOCACY MENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY MENTAL HEALTH SERVICES - OTHER MENTAL HEALTH SERVICES - COLLABORATIVE COMMISSIONING Mental Health CHC AD FULL FUND PERS HLTH BUD CHC ADULT FULLY FUNDED CHC ADULT JOINT FUNDED CHC CHILDREN CONTINUING HEALTHCARE ASSESSMENT & SUPPORT FUNDED NURSING CARE CHC CHILD PERS HLTH BUD CHC AD JNT FUND PERS HLTH BUD Continuing Care KENT COMMUNITY HEALTH NHS TRUST CARERS COMMUNITY SERVICES HOSPICES INTERMEDIATE CARE LONG TERM CONDITIONS WHEELCHAIR SERVICE PALLIATIVE CARE Community Health Services PATIENT TRANSPORT REABLEMENT COMMISSIONING - NON ACUTE GENERAL RESERVE - PROGRAMME HEADROOM CONTINGENCY Other Corporate Corporate 1% surplus Total Page 127 of 163 29,526 3,555 302 1,743 685 253 4,130 130 42 62 213 40,641 265 27,117 520 2,270 632 7,301 24 2 38,132 33,105 379 1,278 1,789 29,926 3,655 302 1,743 685 253 4,230 130 42 62 213 41,241 150 27,112 348 2,705 640 7,108 45 721 1,468 123 38,862 2,519 662 316 (1,171) 6,260 2,466 11,051 11,701 11,701 5,523 494,354 656 1,468 120 38,889 2,517 662 316 (2,985) 5,121 38,106 33,051 379 1,427 1,789 5,631 10,796 10,796 488,830 (400) (100) (100) (600) 115 6 172 (434) (8) 193 (21) 2 26 54 (149) () 65 3 (27) 1 1,813 1,139 2,466 5,420 905 905 5,523 5,523 Deployment of headroom 2.5% 2014/15 As part of business planning by the CCG a level of non-recurrent spending in 2014/15 has been increased to create funds for service change and prepare for 2015/16. The CCG has set aside 2.5% for non-recurrent spending (including 1% for transformation) in 2014/15. £1m shown below in the YTD actual has been embedded in the financial position reported at month 4. CCG Risks 2014/15 Page 128 of 163 As part of business planning by the CCG, the financial risk of the CCGs current activities is assessed each month and at Month 4; the table below summarises how the CCG is able to mitigate currently £9.34m of risk by utilising its contingency reserve and 2.5% headroom monies not yet deployed. However, at this point in time the CCG is not able to mitigate the risks associated with a further reduction in CCG allocations with respect to specialist commissioning. Page 129 of 163 Appendix A – Outcomes Indicators NHS OF Objective Current Performance Target Clinical Rationale • Potential years of life lost from causes considered amenable to healthcare: Male 1756 1700 • Potential years of life lost from causes considered amenable to healthcare: Female 1549 1499 Causes considered amenable to health care are those from which premature deaths should not occur in the presence of timely and effective health care. The concept of ‘amenable’ mortality generally relates to deaths under age 75, due to the difficulty in determining cause of death in older people who often have multiple morbidities. The Office for National Statistics (ONS) produces mortality data by cause, which excludes deaths under 28 days (for which cause of death is not classified by ICD-10 codes). These indicators therefore relate to deaths between 28 days and 74 years of age inclusive. Outcomes Indicator Domain 1 • Under 75 mortality from cardiovascular disease Preventing people from dying prematurely • Under 75 mortality from respiratory disease The potential years of life lost (adjusted for sex and age) from amenable mortality for a CCG population will need to reduce by at least 3.2% between 2013 and 2014. (rate per 100,000 pop) 50 48 One of four improvement areas which account for the large portions of the disease burden amenable to health care. Progress in these outcomes therefore provides a useful initial analysis of what accounts for progress in the overarching indicators. This indicator measures premature mortality from cardiovascular disease, and seeks to encourage measures such as the prompt diagnosis and effective management of cardiovascular conditions and treatments to reduce the re-occurrence of cardiovascular disease events and to prevent or to slow the process of chronic cardiovascular conditions. The detection of risk factors for, and the diagnosis and effective treatment of, cardiovascular disease will influence mortality associated with cardiovascular disease. 23 One of four improvement areas which account for the large portions of the disease burden amenable to health care. Progress in these outcomes therefore provides a useful initial analysis of what accounts for progress in the overarching indicators. This indicator measures premature mortality from respiratory disease, and seeks to encourage measures such as early and accurate diagnosis, optimal pharmacotherapy, physical interventions, prompt access to specialist respiratory care, structured hospital admission and appropriate provision of home oxygen. The detection of risk factors for, and the diagnosis and effective treatment of, respiratory disease will influence mortality associated with respiratory disease. 24 NB Information available at CCG level will involve small numbers • Under 75 mortality from cancer 102 99 One of four improvement areas which account for the large portions of the disease burden amenable to health care. Progress in these outcomes therefore provides a useful initial analysis of what accounts for progress in the overarching indicators. This indicator measures premature mortality from cancer, and seeks to encourage measures such as early and accurate diagnosis, optimal pharmacotherapy, physical interventions, prompt access to specialist cancer care, structured hospital admission and appropriate provision of home oxygen. • Health-related quality of life for people with long-term conditions 0.77 0.77 The overarching indicator (together with complementary improvement indicators) provide a picture of the NHS contribution to improving the quality of life for those affected by long-term conditions. 52% 52% Together with the overarching indicator, this improvement indicator should provide a picture of the NHS contribution to improving the quality of life for those with long-term conditions. 743 743 The intent of this indicator is to measure effective management and reduced serious deterioration in people with ambulatory care sensitive (ACS) conditions. Active management of ACS conditions such as COPD, diabetes, congestive heart failure and hypertension can prevent acute exacerbations and reduce the need for emergency hospital admission. 198 198 Enhancing the quality • Unplanned hospitalisation for chronic of life for people with ambulatory care sensitive conditions long-term conditions • Unplanned hospitalisations for asthma, diabetes and epilepsy in under 19s • Estimated diagnosis rate for people with dementia Reduction or a zero per cent change in emergency admissions for these conditions for a CCG population between 2012/13 and 2013/14. (rate per 100,000 pop) Monitoring Frequency Annual • Under 75 mortality from liver disease • People feeling supported to manage their condition Domain 2 Threshold To be developed Page 130 of 163 Domian 3 • Emergency admissions for acute conditions that should not usually require hospital admission 885 885 Preventing conditions such as ear, nose or throat infections; kidney or urinary tract infections or heart failure) from becoming more serious. Some emergency admissions may be avoided for acute conditions that are usually managed in primary care. Rates of emergency admissions are therefore used as a proxy for outcomes of care. • Emergency readmissions within 30 days of discharge from hospital 11 11 Effective recovery from illnesses and injuries requiring hospitalisation. Some emergency re-admissions within a defined period after discharge from hospital result from potentially avoidable adverse events, such as incomplete recovery or complications. Emergency re-admissions are therefore used as a proxy for outcomes of care. 204 204 Preventing lower respiratory tract infections (LRTIs) in children from becoming more serious, for example, by preventing complications in vulnerable children and improving the management of conditions in the community, whilst taking into account that some children's conditions and cases might require an emergency hospital admission as part of current good clinical practice. For example, a clinical guideline for bronchiolitis published in November 20061 recommends that children showing low oxygen saturation as measured by pulse oxymetry should be admitted to in-patient care. 1 SIGN - Scottish Intercollegiate Guidelines Network (November 2006). Guideline 91. Bronchiolitis in Children - a national clinical guideline. Accessed: http://www.sign.ac.uk/guidelines/fulltext/91/index.html • PROMs for elective procedures: hip replacement 0.46 0.46 • PROMs for elective procedures: knee replacement 0.3 0.3 • PROMs for elective procedures: groin hernia 0.08 0.08 • Patient experience of GP services 90% CCGs not responsible for commissioning services. Data will be available for transparency purposes. • Patient experience of GP out of hours services 69% Improvement in patients’ experiences of GP out of hours services. Helping people to recover from • Emergency admissions for children with lower episodes of ill health respiratory tract infections or following injury Reduction or a zero per cent change in emergency admissions for these conditions for a CCG population between 2012/13 and 2013/14. (rate per 100,000 pop) Domian 5 Domain 4 • Patient experience of hospital care Measuring health gained as assessed by patients for planned treatments. Improvement in patients’ experiences of NHS inpatient care. There will need to be: 1) assurance that all relevant local providers of services Ensuring that people commissioned by a CCG have a positive have delivered the experience of care nationally agreed roll-out • Friends and family test for acute inpatient care plan to the national and A&E. NHS OF indicator in development timetable, 2) an improvement in average FFT scores for acute inpatient care and A&E services between Q1 2013/14 and Q1 2014/15 for acute hospitals. • Incidence of healthcare associated infection: Treating and caring for MRSA people in a safe environment and protecting them from harm • Incidence of healthcare associated infection: C difficile Quarterly and Annual Quarterly and Annual Improving the number of positive recommendations to friends and family by people receiving NHS treatment for the place where they received this care. 81% No cases of MRSA bacteraemia for the CCG’s population (rate per 100,000 pop) 1.7 C. difficile cases are at or below defined thresholds for CCGs. (rate per 100,000 pop) 29 0 Reducing the incidence of healthcare associated infections (HCAI) Quarterly and Annual 29 Reducing the incidence of healthcare associated infections (HCAI). Page 131 of 163 Appendix B - Glossary Glossary A&E BACS BPPC C Diff CCG Chaps CQC EKHUFT EPRR GP Guy’s HSMR IAPT KCHT Kings KMCS KMPT LA Accident and Emergency Bankers' Automated Clearing Services Better Payments Practice Code Clostridium difficile Clinical Commissioning Group Clearing House Automated Payment System Care Quality Commission East Kent Hospitals University Foundation Trust Emergency preparedness, resilience and response General Practitioner Guy's and St Thomas' NHS Foundation Trust Hospital Standardised Mortality Ratio Increasing Access to Psychotherapy Treatment Kent Community Health NHS Trust King's College Hospital NHS Foundation Trust Kent and Medway Commissioning Support Kent and Medway NHS and Social Care Partnership Trust Local Authority MRSA MSA MTW NCB NHS TDA NHSE NR PROMs QIPP RA RAG SUIs RFT SECAMB SHMI SLAs YTD Methicillin-resistant Staphylococcus aureus Mixed Sex Accommodation Maidstone and Tunbridge Wells Hospitals NHS Trust National Commissioning Board NHS Trust Development Agency NHS England Non Recurrent Patient Reported Outcome Measures Quality, Innovation, Productivity and Prevention Running Yearly Average Red, Amber, Green Serious Untoward Incidents Internal NHS BACS payment South East Coast Ambulance NHS Foundation Trust Summary Hospital-level Mortality Indicator Service Level Agreements Year to Date Page 132 of 163 Clinical Strategy Group (CSG) report: August 2014 Dr Sanjay Singh Chief GP Commissioner Page 133 of 163 Patient focused The Clinical Strategy Group (CSG) met on Tuesday 12th August 2014 and discussed the following matters. MTW Stroke Services MTW recognised that the current stroke service does not provide the best care for its patients in a consistent manner. Further to this they met with the CSG to seek input and support to the: Governance arrangements – consisting of Stroke Improvement Board, Stroke Clinical Steering Group and Clinical Strategy Joint Engagement Group Phased approach Case for Change Model of Care Engagement Programme CSG discussed the matter and concluded that whilst any service specification redesign would require approval of the Commissioners, the CSG agreed the case for change and the process set for achieving the same. Integrated COPD Service for High Risk Patients – Business Case A business case was presented to the CSG seeking approval for NHS West Kent CCG regarding the 2014/15 and 2015/16 commissioning intention for the service redesign of existing patient pathway and implementation of an integrated consultant-led respiratory service for the management of high risk Chronic Obstructive Pulmonary Disease (COPD) patients within West Kent CCG. The service is to be delivered by Maidstone & Tunbridge Wells Hospital Trust (MTW) under a single lead provider model. The CSG approved the business case with the proviso that section 9 (procurement) should be redrafted to emphasise that this was a service improvement with integration and not a service redesign. It was also agreed after discussion to tweak the service specification to reflect the need for this service to engage with the IAPT services and the Expert patient programme, School Nursing A paper was presented to the CSG for discussion and to note the interface with School pathway and what the CCG is to commission. The CSG noted that school nursing was recently taken over by Public Health and further noted that the service would be commissioned according to national requirements. The CSG were assured that there would be no duplication of services in Healthy Schools and School Nursing therefore it was not necessary to integrate the services. Page 134 of 163 The CSG considered the paper and requested further information on how the service impacts West Kent CCG. Health Help Now A paper was presented to the CSG seeking that the group ask KMCS to extend the Health Help Now mobile optimised website and, imminently, the Health Help Now native applications for Apple and Androids to cover West Kent. The CSG was also asked to decide on governance arrangements it wishes to put in place to assure itself in future of the contents of Health Help Now. The CSG noted that considerable work had been carried out on the website from earlier in the year by KMCS, largely based on comments from West Kent CCG, which has resulted in significant improvements to the site. Further to CSG discussion, five members voted for the app, 1 member was against it and others abstained. The decision was to extend the Health Help App to West Kent residents. Care Home Concept Paper A concept paper was presented to the CSG recommending that the CCG commences a planned process of communication and implementation during 2014-15 to discontinue the existing Visiting Medical Officer Scheme and rely on GMS/PMS provision. It was further recommended that the CCG commission additional support in medicines management, Complex Care nurses to cover residents in all 136 care homes, and £200k from the VMO LES should be reinvested in GPs developing and sharing advance care plans for all care home residents. The concept paper proposed a care home strategy to redesign the current system and provide equitable proactive care across all care homes in West Kent. The paper further proposed a planned process of communication and implementation is undertaken to achieve the agreed framework from April 2015. Further to consideration, the CSG supported the paper and the direction of travel, however the CSG did not support consideration of mitigation for VMO practices i.e. making the sum of 30% of the current payment of the scheme on a non-recurrent basis in order that each VMO GPs providing the current service can deliver additional services during the transition period. Page 135 of 163 Integrated Respiratory Service for the management of high risk COPD patients This paper is for: Information Recommendation: The objective of this business case is to seek approval from NHS WK CCG regarding the 2014/15 and 2015/16 commissioning intention for the following project: Service improvement of existing patient pathway through the implementation of an integrated Consultant-led respiratory service for the management of high risk Chronic Obstructive Pulmonary Disease (COPD) patients within West Kent CCG. The service is to be delivered by Maidstone & Tunbridge Wells Hospital Trust (MTW) as a single lead provider model. The Public Governing Body is asked to note the following: 1). To implement the NHS WK CCG strategic objective 2014/15 to 2018/19 as outlined below; fewer exacerbations for patients living with long term respiratory conditions; reduced number of unplanned hospital admissions for respiratory disease by 20% ensure the commissioning of effective prevention programmes including smoking cessation, healthy weight and exercise expansion of the Pulmonary rehabilitation service and provision of an integrated respiratory service 2). To commission an integrated COPD model of care encompassing Pulmonary Rehabilitation and Oxygen Service Therapy as mandatory elements of service provision; 3). To implement an integrated COPD model of care with MTW as single lead provider with service commencement date as 1st November 14; 4). To approve financial investment required for the proposed service to the sum of £315k (PYE 14/15) and £757k (FYE 15/16). Commissioners will invest in the integrated service for a minimum of 2 years (with a 12 month break clause in the event of non-achievement against Key Performance Indicators). Page 136 of 163 Proposed Costs for an Integrated Respiratory Service (FYE) WTE Pay Pay Total Non Pay Grand Total (FYE – 15/16) Grand Total (PYE - 14/15) 0.80 5.09 3.42 2.07 2.98 0.24 0.50 Clinical Lead Nurse Physiotherapy Assistant Admin AHPs Consultant 15.10 Home Oxygen Pulmonary Rehab 56,758 28,379 79,461 19,806 5,659 11,352 14,294 COPD Pathway 55,416 142,699 115,039 32,487 58,806 71,053 3,616 144,657 21,290 35,582 440,029 76,960 74,669 165,947 516,989 Total 55,416 227,836 194,500 52,293 78,759 11,352 35,582 655,738 101,866 757,604 315,668 For further information or for any enquiries relating to this report please contact: Naz Chauhan, Commissioning Manager Email: [email protected] Reporting Officer: Dr Sanjay Singh / Naz Chauhan, Commissioning Manager Lead Director: Gail Arnold, Chief Operating Officer Report Summary: (A précis of the contents of the report) Date: 26/08/14 Agenda Item: Version: Respiratory diseases are a major cause of morbidity and mortality and place significant demand on NHS resources. Chronic Obstructive Pulmonary Disease (COPD) is the fifth biggest cause of death in the UK; it has consistently given rise to between 25,000 and 30,000 deaths each year over the last 25 years with 15% of those admitted to hospital dying within 3 months of admission, 25% dying within 12 months and 50% dying within 2 years. The number of people suffering from the disease at any given time (prevalence) is difficult to accurately estimate, however one recent estimate suggested that there are currently 900,000 diagnosed cases in England and Wales and that, allowing for underdiagnosis, the true prevalence could be 2.8 million. For West Kent CCG, from a GP registered population of 466,241, QOF 2012/13 data indicated that 6,463 patients have been diagnosed and recorded on the COPD disease management register, however it is assumed that there is a level of under-diagnosis – West Kent CCG prevalence 1.39% against England average 1.69% (0.3% gap which is an equivalent to approximately 1000 patients). In England, COPD is the second most common cause of emergency admission to hospital (accounting for approximately 10% of hospital medical admissions) and one of the most costly inpatient conditions to be treated by the NHS. It is estimated that the direct cost of providing care in the NHS for people with COPD is almost £500 million a year, more than half of which relates to hospital care. In 2013/14 there were 790 unplanned admissions at MTW for COPD (primary diagnosis) across West Kent CCG at a cost of circa £1.9M with an average cost of £2,400 per patient. Page 137 of 163 The national aspiration is to reduce the number of people with COPD dying prematurely. It requires proactive care and management at all stages of the disease, with a particular focus on disadvantaged groups and areas with high prevalence. The aim is to improve respiratory health and wellbeing of all communities and to minimise inequalities between communities. The 2011 Outcomes Strategy for COPD and Asthma recommends a proactive approach to prevention, early identification, diagnosis and intervention. Integration is required across the NHS, Public Health and Social Care services to achieve the goal of a positive experience of care and support right through to end of life. In addition, an integrated approach to commissioning high-quality care for people with COPD is also recommended in NICE clinical guidance 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. The accompanying business case has been developed to 1). support implementation of NHS WK CCG strategic objective 2014/15 to 2018/19 in respect of respiratory conditions; 2). to commission an integrated COPD model of care encompassing Pulmonary Rehabilitation and Oxygen Service Therapy as mandatory elements of service provision; 3). to implement an integrated COPD model of care with MTW as single lead provider with service commencement date as 1st November 14 and 4). to approve financial investment required for proposed service. In summary, the service requires a total annual investment of £757k for the provision of an integrated COPD model of care, as outlined below: Proposed service costs: Proposed Costs for an Integrated Respiratory Service (FYE) WTE Pay Pay Total Non Pay Grand Total (FYE – 15/16) Grand Total (PYE - 14/15) 0.80 5.09 3.42 2.07 2.98 0.24 0.50 15.10 Clinical Lead Nurse Physiotherapy Assistant Admin AHPs Consultant Home Oxygen Pulmonary Rehab 56,758 28,379 79,461 19,806 5,659 11,352 14,294 COPD Pathway 55,416 142,699 115,039 32,487 58,806 71,053 3,616 144,657 21,290 35,582 440,029 76,960 74,669 165,947 516,989 Total 55,416 227,836 194,500 52,293 78,759 11,352 35,582 655,738 101,866 757,604 315,668 Patient outcomes: It is noted that the investment required may not provide an immediate return on investment, however it is envisaged that the standard and quality of care provided will be in line with evidence based practice as outlined below: Page 138 of 163 An integrated approach to commissioning high-quality care for people with COPD is recommended in NICE clinical guidance 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care; National research indicates that Pulmonary Rehabilitation improves quality of life and reduces hospital bed days but does not affect mortality; National research indicates Oxygen therapy improves quality of life and survival (MRC trial showed 45% mortality at 5yrs in therapy group vs 66% in non-therapy group - a reduction of 21% in mortality). Reducing unplanned hospital admissions; Improving clinical outcomes through the development of self-management skills and helps people to deal with social issues; Overall better patient experience of West Kent CCG respiratory services FOI status: This paper is disclosable under the FOI Act Strategic objectives links: National: 2011 Outcomes Strategy for COPD and Asthma; NICE clinical guidance 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care; NICE COPD Quality Standards, QS10: July 2011 Quality & Outcomes Framework COPD 001, 002, 003, 004, 005, 007 NHS Outcomes Domain No. 1-5 Local: WKCCG is committed to keeping people well and providing care closer to home. This business case is underpinned by the following WKCCG strategic aims: WKCCG Vision and Values - A safe, sustainable and affordable patient focused healthcare service that provides quality patient experience and improves outcomes for local people; WKCCG Commissioning Ambitions 2015 - Ensure that all people using services are offered a personalised service, giving them more choice and control over the shape of support they receive wherever the care setting is; NHS WK CCG strategic objectives 2014/15 to 2018/19; Supporting delivery of Mapping the Future to ensure a holistic approach to the care of this cohort of patients with particular focus on: - New Primary - Self and informal care - New Secondary Care Identified risks & risk management actions: As per the business case, the Public Governing Body is asked to note and approve the following recommendation: Option 2: Implement integrated COPD model of care with MTW as single lead provider (through service improvement of existing patient pathway Page 139 of 163 and implementation of an integrated Consultant-led respiratory service). The Public Governing Body is asked to note the following potential risks of not adopting the recommendation: Resource implications: Legal implications including equality and diversity assessment Report history: High risk COPD patients will continue to access acute services when their condition deteriorates, potentially compromising the quality care. National research indicates that Pulmonary Rehabilitation improves quality of life and reduces hospital bed days but does not affect mortality and Oxygen therapy improves quality of life and survival (MRC trial showed 45% mortality at 5yrs in therapy group vs 66% in non-therapy group - a reduction of 21% in mortality). These 2 mandatory services have the potential to realise significant longer terms savings versus having no service(s) in place; Admission rates will remain in line with historic levels resulting in no improvement in patient care/outcomes. The costs associated with unplanned admissions will also remain significantly high; • A fragmented service will continue impacting on patient access and outcomes. Financial resource – £315k (PYE 14/15) and £757k (FYE 15/16) Organisational resource – finalise service specification/KPIs and payment structure and on-going contract performance management. No implications identified – full equality and diversity assessment undertaken. This paper has been considered at the following CCG committees: Appendices Clinical Strategy Group – 14.01.14 (concept paper) Planned Care Programme Oversight Group – 21.01.14 (concept paper) Planned Care Programme Oversight Group – 20.05.14 Clinical Strategy Group – 12.08.14 Full business case: Appendix 1: Proposed COPD Pathway Appendix 2: WKCCG Mapping the Future – Blueprint for COPD Appendix 3: Draft Service Specification Next steps: Implementation of recommendation with commencement date as 1st November 2014. Page 140 of 163 proposed service Integrated Respiratory Service for the management of high risk COPD patients Public Governing Body: 26th August 14 Dr Sanjay Singh, Clinical Lead Naz Chauhan, Commissioning Manager Page 141 of 163 Patient focused Providing quality, improving outcomes BUSINESS CASE Level 2 BUSINESS CASE APPROVAL COVER SHEET This document incorporates areas to ensure business and decision making probity is consistent with “Code of Conduct: Managing conflicts of interest where GP practices are potential providers of CCG-commissioned services, July 2012, NHS Commissioning Board” Please keep the detail within this business case concise. Business Case Title Integrated Respiratory Service for the management of high risk COPD patients Sponsoring CCG clinical lead & CCG officer Dr Sanjay Singh, Clinical Lead Reviewing Finance Officer Anna Gavrilov, Senior Finance Manager Proposed date for Executive team review Clinical Strategy Group: 12th August 2014 Proposed date for Finance, contracting & performance committee review Tbc Recommendation from Operational management team: Naz Chauhan, Commissioning Manager Recommendation from Planned Care Programme Oversight Group held on 20th May 2014 and Clinical Strategy Group held on 12th August 2014: Implementation of an integrated COPD service to be delivered by Maidstone & Tunbridge Wells Hospital Trust (MTW). Page 142 of 163 Contents 1 Outline Description 2 Strategic and Local Context 3 Options Appraisal – Non Financial 4 Options Appraisal - Finance 5 Define key benefits and outcomes 6 Performance monitoring (Benefits realisation) 7 Risks 8 Conflicts of interest 9 Procurement 10 Timescales and implementation 11. Appendices 1. Proposed COPD Pathway 2. Mapping the Future – Blueprint: COPD Services 3. Draft Integrated COPD Service Specification Page 143 of 163 1 Outline Description 1.1 Why is the business case being proposed, and what are its objectives? The objective of this business case is to seek approval from NHS WK CCG regarding the 2014/15 and 2015/16 commissioning intention for the following project: Service improvement of existing patient pathway through the implementation of an integrated Consultant-led respiratory service for the management of high risk Chronic Obstructive Pulmonary Disease (COPD) patients within West Kent CCG. The service is to be delivered by *Maidstone & Tunbridge Wells Hospital Trust (MTW) as a single lead provider model. *Commissioners will invest in the integrated service for a minimum of 2 years (with a 12 month break clause in the event of non-achievement against Key Performance Indicators). Respiratory diseases are a major cause of morbidity and mortality and place significant demand on NHS resources. Chronic Obstructive Pulmonary Disease (COPD) is the fifth biggest cause of death in the UK; it has consistently given rise to between 25,000 and 30,000 deaths each year over the last 25 years with 15% of those admitted to hospital dying within 3 months of admission, 25% dying within 12 months and 50% dying within 2 years. The number of people suffering from the disease at any given time (prevalence) is difficult to accurately estimate, however one recent estimate suggested that there are currently 900,000 diagnosed cases in England and Wales and that, allowing for under-diagnosis, the true prevalence could be 2.8 million. For West Kent CCG, from a GP registered population of 466,241, QOF 2012/13 data indicated that 6,463 patients have been diagnosed and recorded on the COPD disease management register, however it is assumed that there is a level of under-diagnosis – West Kent CCG prevalence 1.39% against England average 1.69% (0.3% gap which is an equivalent to approximately 1000 patients). In England, COPD is the second most common cause of emergency admission to hospital (accounting for approximately 10% of hospital medical admissions) and one of the most costly inpatient conditions to be treated by the NHS. It is estimated that the direct cost of providing care in the NHS for people with COPD is almost £500 million a year, more than half of which relates to hospital care. In 2013/14 there were 790 unplanned admissions at MTW for COPD (primary diagnosis) across West Kent CCG at a cost of circa £1.9M with an average cost of £2,400 per patient. The national aspiration is to reduce the number of people with COPD dying prematurely. It requires proactive care and management at all stages of the disease, with a particular focus Page 144 of 163 on disadvantaged groups and areas with high prevalence. The aim is to improve respiratory health and wellbeing of all communities and to minimise inequalities between communities. The 2011 Outcomes Strategy for COPD and Asthma recommends a proactive approach to prevention, early identification, diagnosis and intervention. Integration is required across the NHS, Public Health and Social Care services to achieve the goal of a positive experience of care and support right through to end of life. In addition, an integrated approach to commissioning high-quality care for people with COPD is also recommended in NICE clinical guidance 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. The key objectives of this business case are to implement the NHS WK CCG strategic objectives 2014/15 to 2018/19 as outlined below; fewer exacerbations for patients living with long term respiratory conditions; reduced number of unplanned hospital admissions for respiratory disease by 20% ensure the commissioning of effective prevention programmes including smoking cessation, healthy weight and exercise expansion of the Pulmonary rehabilitation service and provision of an integrated respiratory service 1.2 Describe what the business case seeks to commission? This business case seeks to commission an integrated model of care which encompasses the following components. Pulmonary Rehabilitation and Oxygen Service Therapy are mandatory elements of service provision. Service description/care pathway There are three main elements of the proposed integrated respiratory service. 1. Core Service Evidence based management of COPD within community and primary care setting within agreed clinical criteria; All COPD admissions to be assessed by the respiratory team prior to discharge. Provider to develop internal systems to ensure that all such inpatients are referred accordingly; Improve the management of COPD in high risk patients via multi-disciplinary team meetings (MDT) Specialist respiratory presence in emergency departments and Rapid Response Page 145 of 163 advice line to avoid unnecessary admissions into secondary care; Home support during acute exacerbation of COPD where appropriate, and working with community services to avoid admission; Early supported discharge to facilitate best management in the community; Provide comprehensive patient information and individualised education/selfmanagement care plans to all patients; Increase confidence and competence in primary care staff to manage COPD through education and support to general practice; Improve the management of COPD in primary care with attendance at a multidisciplinary team meeting at GP practices that have high admission rates to review high risk patients; Increase confidence and competence in community staff to manage COPD through education and training for community Health Care Professionals; Telephone advice for primary and community care health professionals during Monday to Fridays, 9am to 5pm. COPD self-management resources and support across primary and community care; Assess and refer eligible patients to Pulmonary Rehabilitation and Smoking Cessation; Work with general practice to improve flu immunisation for at risk groups of COPD; Development of advanced care planning across primary and community care; Increase awareness and support of patient choice regarding place of death, in conjunction with GP and End of Life care teams; Develop and implement a communication plan to engage secondary, primary and community care and ensure utilisation of the service. 2. Pulmonary Rehabilitation Service To deliver a high quality evidence-based service for all patients with COPD and other chronic respiratory disease who are functionally limited by breathlessness, including the provision and management of pulmonary rehabilitation services as part of the integrated team; To work within an agreed service model and integrated care pathway to ensure symmetry of service provision and access for patients across the different elements the service; In conjunction with the other elements of the service, i.e. Oxygen service etc, develop and implement a communications strategy to engage secondary, primary and community care to increase utilisation of the service; Increase confidence and competence of patients to self-manage their condition 3. Home Oxygen Service - Assessment and Review Page 146 of 163 The service will provide a specialist review of home oxygen orders and efficient management of oxygen therapy, this will include the following: Develop and maintain clinical and information governance arrangements for home oxygen assessment, management and review for West Kent CCG registered patients; Receive requests for home oxygen therapy and review as appropriate; Ensure appropriate assessment, education and ongoing clinical review of patients prescribed oxygen therapy in line with national guidance; Implement robust arrangements to avoid oxygen initiation at the start of the patient journey where relevant; Implement robust arrangements for monitoring oxygen costs in relation to ambulatory supplies; Review monthly invoices and oxygen register and determine priority list for clinical review and/or change/removal of home oxygen; Identify inappropriate prescribing by primary care and as relevant, education primary care professionals in order to reduce the numbers of inappropriate oxygen prescribing; Undertake ongoing telephone contact with oxygen patients to ensure annual clinical review for the purpose of detecting need for change/removal of home oxygen and record outcomes; Implement arrangements for visiting patients, including home visiting, for annual clinical review; Manage relationships with oxygen provider and the primary care support service ensuring clear and consistent channels for communication; Ensure appropriate representation at meetings with oxygen provider (Dolby Vivisol) for contract management, specifically via Kent & Medway Commissioning Support Unit (KMCS) contract monitoring meetings; Network with other Hospital Trusts to ensure that patients are being reviewed in the most appropriate place by the most appropriate team and that the appropriate pathways are in place; Identify, resolve and report Serious Untoward Incidents (SUIs) regarding home oxygen provision; Proposed eligibility criteria: The service will accept patients considered to be ‘high risk’ as follows. general criteria must be met to access the Service: Identify COPD patients most at risk of hospital admissions including: - Previous emergency COPD admission within 12 months; Page 147 of 163 The following - More than 2 acute exacerbations in the past 12 months; - Very Severe COPD with FEV1 less than 30% predicted; - On long-term oxygen therapy; - COPD with heart failure (including cor pulmonale); - COPD and other respiratory failure for any other reason Appendix 1 (attached) outlines the proposed patient pathway: Appendix 1 Proposed COPD Pathway.pptx This model of care is to be delivered within normal working hours i.e. Monday to Friday, 9am to 5pm. The Enhanced Rapid Response Service (ERRS) will continue to provide a rapid response for patients in crisis (i.e. COPD exacerbation) outside of these core service hours and normal GP Out of Hour’s Service arrangements also apply. Current provision: The current services and associated budgets (FYE) which will form part of the integrated model include the following: Service Home Oxygen Service Pulmonary Rehabilitation (Community) KCHT COPD (Nursing) Pulmonary Rehab (Home – Physiotherapy) MTW COPD 70/30 TOTAL Provider MTW MTW KCHT KCHT MTW Cost (£) £166,000 £334,439 £70,000 £40,000 £334,830 £945,269 At present the service(s) are provided on a fragmented basis with separate contracts held for different elements of the service. These services are often accessed by the same cohort of ‘high risk’ patients, resulting in a disjointed patient pathway with no clear personalized care plan. The intention is to integrate the service on a single lead provider model which provides a patient centered service, ensures better value for money and development of a seamless patient care pathway. The integrated model will aim to deliver a range of options including urgent assessments, early supported discharge (where a patient leaves hospital but remains under the care of the consultant and receives treatment in their home), home oxygen assessments and appropriate onward referral to pulmonary rehabilitation and smoking cessation for all eligible patients. Patients who are complex will be referred to a consultant-led Multi-Disciplinary Team (MDT), who will meet on a weekly basis. Complex patients may have had multiple admissions, co morbidities or anxiety and depression complicating their symptoms. These patients will be reviewed and a multi-disciplinary Page 148 of 163 individualised care plan developed which will be accessible to all. Decisions as to end of life pathways may be made which will avoid those patients who are at the end stage of their disease being admitted unnecessarily. The improved service will essentially aim to provide a ‘one stop shop’ through a central telephone number that gives support to GPs and other health professionals on how to best manage the needs of these patients. Robust performance management processes will be implemented to monitor service use and patient outcomes through the agreed service specification. 2 Strategic and Local Context 2.1 Which national, local and CCG commissioning priorities and targets does the business case meet? This business case supports national and local strategic plans and priorities as follows: National: 2011 Outcomes Strategy for COPD and Asthma; NICE clinical guidance 101: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care; NICE COPD Quality Standards, QS10: July 2011 Quality & Outcomes Framework COPD 001, 002, 003, 004, 005, 007 NHS Outcomes Domain No. 1 – Preventing people from dying prematurely NHS Outcomes Domain No. 2 - Enhancing quality of life for people with long-term conditions NHS Outcomes Domain No. 3 – Helping people to recover from episodes of ill-health or following injury NHS Outcome Domain No. 4 - Ensuring people have a positive experience of care NHS Outcome Domain No. 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm Local: WKCCG is committed to keeping people well and providing care closer to home. This business case is underpinned by the following WKCCG strategic aims: WKCCG Vision and Values - A safe, sustainable and affordable patient focused Page 149 of 163 - - - 2.2 healthcare service that provides quality patient experience and improves outcomes for local people; WKCCG Commissioning Ambitions 2015 - Ensure that all people using services are offered a personalised service, giving them more choice and control over the shape of support they receive wherever the care setting is; NHS WK CCG strategic objectives 2014/15 to 2018/19; Supporting delivery of Mapping the Future to ensure a holistic approach to the care of this cohort of patients, with particular focus on: New Primary Care – e.g. proactive case seeking for people with risk factors and screening; proactive risk monitoring and early intervention; rapid access to telephone advice by competent clinician who has access to patient records and care plans; complex cases are discussed and advised in MDTs with specialists; complex cases have a named lead clinician who is in charge of coordinating all care and who is the main point of contact for the patient Self and informal care – e.g. Self-monitoring for FEV1 and state of respiratory health and level of functioning Self-starting Abx and steroids for exacerbations Relaxation (meditation, behavioural therapy methods) to reduce anxiety Patients (and carers) are part of care planning and have access to care plan (incl. workflow plan) Telemetry is available where remote monitoring enables greater independence Friends & family support for patients for daily living New Secondary Care – e.g. consultant expertise available to advise New Primary Care without referral for urgent calls and for regular MTD sessions where complex, high risk cases can be discussed; in-hospital services for patients with multiple LTCs are well coordinated How does the proposal demonstrate Quality, Innovation, Productivity, and Prevention (QIPP)? Where appropriate provide detailed calculations of QIPP savings. As part of the Quality, Innovation, Productivity and Prevention (QIPP) agenda, health and social care economies are examining where improvements can be made. For Planned Care this involves identifying invest to save initiatives, reducing steps in existing pathways where safe to do so, identifying and eliminating wastage and redesigning services whilst enabling Page 150 of 163 patient choice and providing care closer to home. This initiative is primarily based on redesigning existing services to improve the management/patient pathway of high risk COPD patients through better integration between primary, secondary and community care as follows: Quality Innovation Productivity Prevention Improved respiratory services and health outcomes for COPD patients ensuring an integrated /structured approach to both acute and chronic disease management across West Kent CCG; To provide a greater range of COPD services closer to patient’s homes and to improve working with primary care and other community services; To provide support to patients and families in the community following discharge from hospital; To introduce a multi-disciplinary team (MDT) approach for the management of all those with COPD who may benefit from specialist advice; To introduce ‘Hot’ clinics for patients who have been seen by a member of the team and are at imminent risk of an admission, who may need a comprehensive senior review due to a question over diagnosis, or complicated by co morbidities, or requiring more complex medicines management. The consultant will also provide home oxygen and PR support during these sessions. Increase confidence and competence in primary and community staff to manage COPD through education and training; To remove the barriers between primary and secondary care to ensure patients admitted can be managed effectively and discharged more appropriately; To reduce hospital admissions/re-admissions through early detection/diagnosis of the disease and pro-active care in a community setting; To improve service consistency, delivery and access for patients with COPD in a cost-effective manner; To reduce hospital admissions through early detection/diagnosis of the disease and pro-active care in a community setting; To encourage self-management and empowerment through health promotion and education. This proposal makes the following financial assumptions in respect of potential savings to be realised should the aims of the business case be fully met. Page 151 of 163 Indicator KPI Target Reduction in the number of unplanned hospital 20% admissions (MTW) with a primary diagnosis of COPD Baseline (primary COPD) Activity 13/14 Target reduction (full year diagnosis impact 15/16) Cost 790 £1,939,100 158 £380,000 Activity Cost Reduction in unplanned re-admissions for patients with a primary diagnosis 20% of COPD (within 28 days of discharge) 169 £0 33 £0 NB readmission costs are included in admissions so no financial savings realised. This KPI is largely to improve quality of patient care and experience. Reduction in ambulance 20% conveyances - - 158 £20,462 Reduction in number of occupied bed days with a 20% primary diagnosis of COPD TOTAL 2.3 5.8 days (average) £0 £1,939,100 - £17,800 NB OBD is included in the admissions cost. 13/14 data indicated £89k of excess bed days which would equate to £17.8k. £418,262 Describe how key partners/stakeholders, including patients (PPAG) and the public, have been involved in the business case development and how they have been engaged and when. Page 152 of 163 In 2013/14, four events were held for patient representatives, clinicians, health and care professionals and managers covering around four clinical topics as exemplars for how systems could be reorganised: – – – – Falls and mobility Dementia and cognitive impairment Urgent and emergency care Respiratory diseases Participants considered why services need to change and evidence about what types of services have been developed elsewhere They used this and their experience and judgement to describe the characteristics of the future health and care system They looked at the whole spectrum of health from prevention through to recovery and at where services and support might be best provided The outputs from the four workshops were analysed individually which has resulted in the development of a ‘first draft’ Mapping the Future picture. Appendix 2 (attached) defines the blueprint developed for respiratory diseases (COPD): Appendix 2 Blueprint COPD Services.pptx 2.4 What is the impact of this proposal on the wider economy (health, social and the public)? This business case would have a positive impact on the wider health economy as follows: 2.5 Less unplanned hospital admissions and re-admissions; Less A&E visits; Reduces anxiety and depression for both the patient and their carers; A lower number of drugs being prescribed - due to less anxiety, depression, and other associated fitness and lifestyle benefits; Reduces all-cause and respiratory mortality rates; Improves integrated working across primary, secondary and community care; Improved patient outcomes Health Inequalities NHS WK CCG is committed to commissioning safe and effective services across West Kent regardless of a person’s protected characteristic, their physical or mental health condition or their usual place of residence. The National Institute for Health and Clinical Excellence Page 153 of 163 (NICE) Quality standard stresses the importance of ensuring that treatment and care and the information given about it, should be culturally appropriate and accessible to people with additional needs such as physical, cognitive, sensory or learning disabilities. A full health inequalities assessment to be completed. 2.6 Teaching and Research Opportunities An audit of the service will help inform future commissioning decisions and provide a learning opportunity for WKCCG. Detailed reviews of the project will be undertaken at regular intervals. Learning from the project will be presented at all relevant forums. 3 Options Appraisal – Non Financial 3.1 Describe the options that need to be considered and appraise each option, indicating the reasons for choosing the preferred option. Please include a ‘Do Nothing’ option. OPTION 1 : Do Nothing This option will mean that high risk patients will continue to access acute services when their condition deteriorates, potentially compromising the quality of care. OPTION 2: Implement integrated COPD model of care with MTW Develop the principles of the project with MTW as single lead Provider. 4 Options Appraisal - Finance 4.1 What are the costs of implementing the business case? Include a budget showing how the costs have been calculated and include any assumptions that have been made. Any additional finance information should be included within this section. The proposed cost of this service is as follows: Proposed Costs for an Integrated Respiratory Service WTE Pay Pay Total Non Pay 0.80 5.09 3.42 2.07 2.98 0.24 0.50 Clinical Lead Nurse Physiotherapy Assistant Admin AHPs Consultant Home Oxygen Pulmonary Rehab 56,758 28,379 79,461 19,806 5,659 11,352 14,294 71,053 3,616 Page 154 of 163 144,657 21,290 COPD Pathway 55,416 142,699 115,039 32,487 58,806 35,582 440,029 76,960 Total 55,416 227,836 194,500 52,293 78,759 11,352 35,582 655,738 101,866 Grand Total FYE – 15/16 Grand Total PYE – 14/15 15.10 74,669 165,947 516,989 757,604 315,668 Commissioners will invest in the integrated service for a minimum of 2 years (with a 12 month break clause in the event of non-achievement of Key Performance Indicators) and on the basis that the service will improve patient outcomes for people with COPD, provide savings and improve value via delivering the expected outcomes detailed in the specification. 4.2 Preferred Option Option 2: Implement integrated COPD model of care with MTW as single lead provider. 5 Define key benefits and outcomes 5.1 Describe the main benefits associated with the business case, who these apply to and the evidence which supports this. Patient: Improved patient experience of respiratory services; Improved quality of care for eligible patients; Patient-centred care and increased patient choice; Reduction in mortality and improved outcomes for patients with COPD in West Kent CCG; Reduces anxiety and depression for both the patient and their carers; A lower number of drugs being prescribed - due to less anxiety, depression, and other associated fitness and lifestyle benefits; Rehabilitation improves quality of life and reduces hospital bed days but does not affect mortality Oxygen therapy improves quality of life and survival (MRC trial showed 45% mortality at 5yrs in therapy group vs 66% in non-therapy group - a reduction of 21% in mortality). Organisational: Contributing to a reduction in A&E visits, admissions and re-admissions, occupied bed days and a reduction in the number of GP initiated outpatient first and follow up appointments for COPD; Reduction in acute expenditure for COPD in West Kent CCG and improve delivery of value based care; Page 155 of 163 5.2 Promote partnership working across primary, secondary, community and social care to provide integrated patient care; To improve the management of COPD in primary care; Improved patient pathway and outcomes supporting the CCG to meet national and local strategic objectives. Less unplanned hospital admissions and re-admissions; Pulmonary rehabilitation and oxygen therapy services realises significant longer term savings versus no service(s) in place Equality Impact An Equality Impact Assessment has been completed and indicates that there is no reason to suggest that the intentions of the business case will have a negative equality impact on patients and others affected by its implementation. Where appropriate, those responsible for managing the intended service will be expected to adhere to all relevant statutory and good practice guidelines. A copy of the Equality Impact Assessment is available on request. 5.3 Patient Choice A key aim of this proposal is to provide a comprehensive service which is equitable both in terms of patient access and choice. Wherever it is possible and practical to do so, patients will be supported to be actively involved in any care and treatment decisions regarding their care as will their West Kent GP, and others who may be involved in this i.e. families / carers. 6 Performance monitoring (Benefits realisation) 6.1 Outline your monitoring and evaluation plan for this proposal, who will undertake the work, how it will be funded and how, when and to whom results will be disseminated. KMCS business intelligence is providing information to identify baselines within this business case. Performance monitoring will be key to the successful implementation of the project and monitoring of patient outcomes. As a minimum, the Service will be reviewed to meet the following aims: Monitor and manage patient progress Evaluate the service in terms of clinical and patient-reported outcomes Benchmarking against local, regional and national standards Provide measures of performance and quality for commissioners; Contribute to the national audit (if appropriate); The Provider will be required to report on KPIs to ensure high quality services are provided. This will include complaints, compliments, SUIs, patient satisfaction questionnaire (which Page 156 of 163 will be agreed with the CCG), targets regarding patients being referred / seen by the service and impact on patient outcomes within an agreed timeframe. The service specification will include clear outcomes, KPIs and specify monitoring information required at service and patient level. 7 Risks 7.1 What are the key risks of the scheme? How will this impact on the deliverability of the scheme? How will these be mitigated? Are there any constraints on the scheme? Risk Impact Mitigation Inability to formally agree/sign off model of care with MTW within agreed CCG budget Admission rates will remain static in line with historic levels, resulting in no improvement in patient care/outcomes. Ensure close joint working with MTW Senior Management Team with input into service specification and costs. Commissioners will invest in the integrated service for a The intended Admission rates will remain minimum of 2 years (with a 12 aims of the static in line with historic levels, month break clause in the event business are not resulting in no improvement in of non-achievement of Key met. patient care/outcomes. Performance Indicators). The assumed financial Resulting in savings/return on service. investment is not realised. a Regular audit of service. Ensure robust performance management process in place for more costly on-going monitoring of KPIs/activity. Regular audit of service. 8 Conflicts of interest 8.1 Have all conflicts and potential conflicts of interest been appropriately declared and entered into registers that are publicly available? Page 157 of 163 It is recognised that there may be conflicts of interest, but these are thought to be minimal. The Clinical Strategy Group is responsible for ensuring these are robustly identified and appropriately managed. 9 Procurement 9.1 What is the proposed route? Why has this route been chosen? How will you determine a fair price for the service? If only one provider has been identified, what steps have been taken to demonstrate that no other provider could deliver the service? If a GP has been identified as the provider, to what extent does the service go beyond their GP contract? This business case proposes that the service is delivered by MTW. This approach has been selected based on the following reasons: One of the aims of the service is to deliver an integrated model of care with one lead provider. To avoid destabilisation, it is recommended that MTW continue to provide the service based on the fact that they already deliver key components of the service and systems/processes are in place; If contract awarded to alternative provider, decommissioning of current service provided by MTW may result in requirement to undertake public consultation which will have impact on timescale of delivery of project; Timescales and CCG resources required to undertake a full procurement may result in lack of suitable interest and eligible Providers to deliver the service; Potential delays in procurement will result in a delay in the delivery of an integrated COPD model comprehensive service by winter 2014/15. This initiative forms part of the 2 year commissioning intentions plan and requires a full service to be in place by November 14. The CCG has been in a better negotiating position and the service costs have been agreed/accepted by MTW resulting in better value for money and improved quality of service. The agreed price may fail to attract any alternative suitable providers. KCHT has been actively involved in the discussions and understand the implications of the proposal on their existing service provision. 10 Timescales and implementation 10.1 When is it likely that the business case can be implemented? Describe key timescales? Response must include contractual and resource considerations? Page 158 of 163 This business case can be implemented following formal CSG approval in August 2014 and the impact of this project is assumed to be realised part year Q4 2014/15 and full year 2015/16 and subsequent years. Draft timetable as follows: A 14 M 14 J 14 J 14 A 14 S 14 O 14 N 14 D 14 J 15 F15 M15 Business plan agreement by Planned Care POG Development of Project Group Service specification development and contract negotiation Business case agreement by Clinical Strategy Group / Governing Body Mobilisation Service implementation and ongoing performance monitoring 10.2 Post Project Evaluation Project evaluation will be undertaken 6 months into implementation. The Planned & Integrated Care Programme Oversight Group will be accountable for monitoring progress on the implementation of the service and achievement against the service specification / key performance indicators as outlined in section 2.2 above - How does the proposal demonstrate Quality, Innovation, Productivity, and Prevention (QIPP)? Where appropriate provide detailed calculations of QIPP savings. It should be recognized that the implementation of other schemes may affect the impact of this service and any external changes which occur during the period will be noted for their Page 159 of 163 impact on the outcome. 11 Appendices Draft Integrated COPD Service Specification Service Specification Integrated COPD - Draft (June 14 v1.4).pdf Page 160 of 163 Practice Engagement Committee Report August 2014 This paper is for: Governing Body Recommendation: To note For further information or for any enquiries relating to this report please contact: Richard Segall Jones, Company Secretary [email protected] Reporting Officer: Richard Segall Jones, Company Secretary Lead Director: Dr Garry Singh, Chair of the Practice Engagement Committee Report Summary: (A précis of the contents of the report) Date: 26th August 2014 Agenda Item: Version: Final This report provides an update to Governing Body on the items discussed at the 5th August 2014 Practice Engagement Committee meeting (PEC). FOI status: State either: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Report history: Appendices Next steps: All strategic objectives are served by the work of the Practice Engagement Committee. The work of the Practice Engagement Committee links to all BAF components. Not applicable. Not applicable. Not applicable. Not applicable. N/A N/A Page 161 of 163 Dr Garry Singh The Practice Engagement Committee (PEC) met on Tuesday 5th August 2014 and the following matters were discussed. Planned Care Update Dermatology The group were updated with regards to proposals for service provision. It is felt that current provision is a little disjointed and would benefit from an integrated service model. This is being considered along with neighbouring CCGs with a view to testing the market for potential suppliers. This has previously been discussed at a recent WK CCG Clinical Strategy Group (CSG) meeting and the decision was made to develop and procure an integrated service that utilises community services. It is hoped that the new redesigned service will be in operation from April 2015. Further updates will be made available to the PEC at future meetings. Ophthalmology A service redesign will be taking place following agreement by the CSG that this is a priority and should be progressed. The CCG will be working with current providers towards service development which will result in a robust service specification. A service development group (SDG) has been set up (comprising commissioners, clinicians and specialist professionals within Ophthalmology). Their remit is to advise and oversee the project of the service redesign. A whole Task & Finish group will be held on 12th August where the future direction of travel will be discussed. Individual work stream groups will also feedback to the SDG following this meeting. Glaucoma Monitoring The numbers of patients transferred with stable glaucoma patients from the Hospital Eye Service to the Community Ophthalmology Team (COT) continues to meet the agreed trajectory target. The feedback received from the COT has been positive and suggests that patients identified for transfer to date have been appropriate for the COT to manage and monitor. eReferral The PEC were advised that the new ‘eReferral’ system (to replace Choose and Book) could not be used with Internet Explorer version 6 or below. There have been difficulties with Explorer upgrades for practices in the past. The ‘go live’ date for ‘eReferral’ would be 1 st Page 162 of 163 September for those practices already signed up, with the next wave proceeding from January 2015. Integrated Care & Long Term Conditions Cardiology The current service model is delivered by MTW and unfortunately there is poor patient uptake of the service (an average of 31-38% over the last three years across both hospital sites). National research has shown that by improving uptake to 65%, patient outcomes can be significantly improved with a reduction in readmission rates. A business case has been presented to and approved by the CSG to secure additional investment to expand the existing service with MTW (as well as Governing Body approval). The first Steering Group will meet shortly to discuss progress with the recommendations of the business case. Dementia The CCG is working with KMCS to develop a business case to improve parity of esteem between mental health and physical health. This is seeking to increase the number of community psychiatric nurses to address the increasing number of referrals to the memory assessment clinics. Following the Health and Wellbeing endorsement of West Kent focusing integrated commissioning of dementia, a dementia strategy and implementation group is being established focusing on a whole system approach to meet the needs of the local population, improve rates of diagnoses, improve primary care solution to promote independence and reduce length of stays in hospital. Local Incentive Scheme (LIS) Work continues with the practices, who are all now signed up to the scheme. Practices will be written to shortly regarding the scheme. For the £5 scheme, all practices with the exception of one have opted in. The West Kent CCG team have worked closely with practices regarding these schemes and have been impressed by the level of enthusiasm and innovation displayed by the practices. Page 163 of 163