SWBCCG Board Meeting - Sandwell and West Birmingham CCG

Transcription

Sandwell and West Birmingham Clinical Commissioning Group
Governing Body Meeting
Date: Wednesday 4th May 2016
Venue: Kingston House
Time: 12.30 pm – 15:30hrs
Room: Boardroom
AGENDA
Non-Confidential – Please ensure your phone is on silent throughout the meeting.
No
Subject
Lead
Time
INTRODUCTION
1.
2.
Apologies for Absence;
Andy Williams, Joyti Atri
Declarations of Interest
Verbal
Dr N Harding
12.30
Verbal
Dr N Harding
12.35
To request members to disclose any interest they have, direct or indirect, in any items to be considered during the
course of the meeting and to note that those members declaring an interest would not be allowed to take part in the
consideration or discussion or vote on any questions relating to that item.
th
3.
4.
Minutes of Previous Meeting held on 6 April 2016
Action Register
5.
Questions from the Public
Verbal
6.
Chairman’s Report
Verbal
7. Performance
7.1
Quality and Safety Committee Report
7.2
Finance Report
7.3
Performance Report
7.4
Partnership Committee Report
7.5
Strategic Commissioning and Redesign Committee
Report (no report)
7.6
Audit and Governance Committee Report
7.7
Auditor Panel Report
7.8
Organisational Development Committee Report
7.9
Primary Co-Commissioning Committee Report
8. Governance and Business
8.1
Elections of CCG & LCG Chair and Vice Chair
Appointment of Secondary Care Doctor
8.2
Right Care Right Here
8.3
Corporate Objectives
8.4
8.5
Proposed Change to GP Practices within the Local
Commissioning Groups
GP CCG Transfer Application
1
2
Dr N Harding
12.40
12.45
Dr N Harding
Dr N Harding 12:50
Dr N Harding 12:55
3
4
5
6
-
Dr S Mukherjee/Mrs C Parker,
Dr V Bathla/Mr J Green
Mr J Green
Dr B Andreou/Mrs S Liggins
Dr G Solomon/Mr J Dicken
13.00
13.10
13.20
13.30
-
7
8
9
To
follow
Mrs J Jasper
Mrs J Jasper
Dr N Harding
Mr Ranjit Sondhi/Mrs S Liggins
13:40
13:50
14:00
14:10
11
14:20
Verbal
To
follow
13
14:25
14:30
Alison Braham
14:40
14
Alison Braham
14:50
9. Minutes of Committees for Information (All minutes available on CCG Website)
9.1
Finance and Performance Committee Minutes
15
All
9.2
Quality and Safety Committee Minutes
16
14:55
9.3
Strategic Commissioning & Redesign Minutes
9.4
9.5
9.6
9.7
9.8
Audit and Governance Committee Minutes
Organisational Development Committee Minutes
Partnership Committee Minutes
Primary Care Commissioning Minutes
PPAG
To
follow
18
19
20
21
22
10. Minutes of Locality Commissioning Groups for Information
10.1
ICOF LCG Minutes
10.2
Black Country LCG Minutes
10.3
Pioneers for Health LCG Minutes (no meeting)
10.4
Sandwell Health Alliance LCG
10.5
HealthWorks LCG Minutes (no meeting)
11. ANY OTHER BUSINESS
11.1
Items to share with staff
12. DATE AND TIME OF NEXT MEETING
Wednesday 01 June 2016, Boardroom, Kingston House
CLOSE OF MEETING
Ranjit Sondhi/Richard Nugent
23
23
24
-
15:00
Verbal
15:05
-
15:10
Resolution adopted from the Public Bodies (Admission to Meetings) Act 1960:
That those representatives of the press and other members of the public be excluded from the
remainder of the meeting having regard to the confidential nature of the business to be transacted,
publicity on which would be prejudicial to the public interest.
Guidance on Declarations of Interest
Definition of Interests
A Governing Body/Committee member has a personal interest if the issue being discussed at a
meeting affects the well being or finances of the member, the member’s family or a close associate
more than most other people who live in the area affected by the issue.
Personal interest are also things related to an interest the member must register such as outside
bodies to which the member has been appointed by the CCG or membership of certain public
bodies.
A personal interest is also a prejudicial interest if it affects the finances of the member, the
member’s family or a close associate and which a reasonable member of the public with knowledge
of the facts would believe it likely to harm or impair the member’s ability to judge the public
interest.
Declaring interest
If a member has an interest, they must normally declare it at the start of the meeting or as soon as
they realise they have the interest.
If a member has a personal and a prejudicial interest, they must not debate or vote on the matter
and must leave the room.
Quoracy
No business shall be transacted at a meeting unless there is at least one-third of the whole number
of the Chair and member’s (including at least one member who is also an elected GP, one member
who is a Chief Officer and one member who is considered independent (from the lay members,
secondary care doctor, or registered nurse) is present.
Legend
Accountable Officer – AO
Chief Finance Officer –CFO
Chief Officer, Operations – COO
Chief Officer, Quality – COQ
Chief Officer, Partnerships - COP
Sandwell & West Birmingham CCG
Enc 1
Minutes of the Governing Body Meeting held in PUBLIC
Wednesday 02 March 2016, 12:30 – 15:00hrs
Boardroom, Kingston House
Mrs Julie Jasper (Chair)
Lay Member
Dr Basil Andreou
Dr Ayaz Ahmed
Dr Sirjit Bath
Dr Vijay Bathla
Dr Felix Burden
Mr Jon Dicken
Mr James Green
Ms Therese McMahon
Dr Inderjit Marok
Dr Sam Mukherjee
Mr Richard Nugent
Mrs Claire Parker
Dr George Solomon
Dr Ram Sugavanam
Dr Ian Sykes
Mr Andy Williams
Chair, Sandwell Health Alliance
Vice Chair, SHAC LCG
Vice Chair, Pioneers LCG
Chair, Pioneers LCG
Secondary Care Consultant
Chief Officer, Operations
Chief Financial Officer
Board Nurse
Vice Chair, ICOF LCG
Chair, ICOF LCG
Independent Committee Member
Chief Officer (Quality)
Chair, Black Country LCG
Vice Chair, Health Works LCG
Vice Chair, Black Country LCG
Accountable Officer
In attendance:
Mrs Alison Hodgson
*Mrs Jayne Salter-Scott
Ms Charley Bradley
*Mrs Liz Walker
*Dr Gwynn Harris
Mrs Helen Cooper
Deputy Chief Officer, Quality
Head of Engagement
Communications – Midlands and Lancashire CSU
Medicines Management Lead
SWBCCG
EA to the AO & Chair S&WB CCG – Minute Taker
Members of the public:
Ms D Tipton
Mr Taj Ballagan
Ms Farrah Ahmad
Ms Lisa Rosewarne
SWBHT
Takeda
Vifor Pharma UK Ltd
Tillotts Pharma UK Ltd
* part meeting
01/16 Welcome and Apologies:
Mrs Jasper welcomed those present to the meeting.
02/16 Apologies:
Apologies for absence were received from, Prof Harding, Chair, Mr Ranjit Sondhi,
Vice Chair, Janette Rawlinson, Independent Committee Member.
03/16 Declarations of Interest:
To request members to disclose any interest they have, direct or indirect, in any
Enc 1 - Minutes of the meeting held in
public on Wednesday 06 April 2016 Agenda Item 3
Page 1
Governing Body Board Meeting
Wednesday 04 May 2016
items to be considered during the course of the meeting and to note that those
members declaring an interest would not be allowed to take part in the
consideration or discussion or vote on any questions relating to that item.
Mrs Jasper declared her role as a member of the Dudley CCG Board.
Dr Ian Sykes declared a pecuniary interest in the PCAT item within the Strategic
Commissioning and Redesign
Mr Richard Nugent his role as a member of the Sandwell Voluntary Organisation,
agenda item 8.2.
No other declarations of interest were made at this point of the meeting.
04/16 Minutes of the meeting held on Wednesday 03 March 2016
The minutes were accepted and ratified with the following amendments;
05/16 Dr Burden enquired whether there was an update in relation to the concern he
raised at the last meeting that did not appear in the minutes or on the action
register relating to
the inability of senior management to communicate with vulnerable patients. Dr
Mukherjee confirmed that the quality team have included the item on their action
register and are monitoring the concern.
06/16 Ms Rawlinson forwarded by email typographical errors and comments.
07/16 Item 4 - Bradbury Day Hospital to be changed to Bradbury Day Hospice
08/16 Item 7 - should read West Birmingham Equality awards not Wet Birmingham
09/16 Item 13 - should read access to Psychological therapies not Physiological therapies
10/16 Action Register/ Matters Arising:
The action register was reviewed and update were provided by Mrs Parker in
relation to Sandwell and West Birmingham Trust sickness and absence report, Mr
Green provided an update relating to the Radiotherapy data and local Care
Programme Approach (CPA) data.
Items relating to Transforming Care,
Performance Report, Quality Report were closed.
11/16 Questions from the Public:
No questions were raised members public.
12/16 Chairman’s Report:
Mr Williams presented the report that included an update on the Black Country
Sustained Transformation Plan (STP) for the entire geographic footprint of the CCG
including West Birmingham.
13/16 Mr Williams acts as Chair of the Black Country STP membership is a combination
of Local Authority representation, Trust CEO’s and CCG Accountable Officers.
14/16 The Primary Care –Co-commissioning Committee, continue to oversee the
commissioning of primary care that brings about benefits for patients. Further
guidance has been issued by NHS England to ensure CCGs have appropriate
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measures in place to manage conflicts of interest. Sandwell and West Birmingham
CCG challenged the original governance and are pleased to see the concerns
raised noted by NHS England.
15/16 The final sixth module for the Primary Care Leadership programme took place this
month, the course supported emerging GP leaders of the future and has received
excellent feedback.
16/16 The first end of term elections for Local Commissioning Groups Chairs took place
at the end of March. Thanks were extended to all GP’s for stepping into these
roles on top of their busy doctor roles.
17/16 The CCG formerly congratulated Birmingham Community Healthcare on achieving
NHS foundation Trust (FT) status effective from 01 April 2016.
18/16 The new Birmingham Dental Hospital and School of Dentistry if now officially open
for business with its first patients being welcomed into the facility on 31 March
2016.
19/16 From the 01 March 2016 local patients are now able to benefit from increased
access to urgent eye care appointments, through a new service called MECS
(Minor Eye Conditions Service).
20/16 The CCG is one of the first to launch a new mobile phone application (app) that will
provide thousands of patients with a convenient way to manage their appointments,
and be alerted about services and receive reminders from their doctor’s surgery.
21/16 Finally, Mr Williams reported that Cllr Darren Cooper had passed away suddenly.
Members formerly expressed their deepest condolences. Dr Harding has formerly
written on behalf of the CCG to Cllr Ealing. Cllr Cooper had been actively involved
in key developments, who supported and lobbied for the Right Care Right Here
Partnership.
22/16 Responding to a question from Dr Burden in relation to the STP governance around
conflicts of interest Mr Williams agreed to take forward Dr Burdens concern at the
inaugural meeting of the Birmingham and Solihull STP on Thursday 07 April 2016
the item will also appear of the Black Country STP agenda for discussion.
23/16 Quality Report:
Dr Mukherjee spoke to this item highlighting the salient points of the report that
included one new ‘Never Event’ in February relating to a wrong site surgery at
SWBH bringing the total to a total of four in 2015/16. There were 15 serious
incidents reported in February.
A visit by the quality team was undertaken at
McCarthy Ward at Rowley Regis Hospital, no immediate causes for concerns were
recorded, but issues were noted relating to record keeping and communication.
The time2talk team have not observed any significant trends this month.
24/16 Primary Care:
GP Incident reporting rate continues to rise, and trends are being followed through.
25/16 Medicines Management
Dr Mukherjee reported that following various educating initiatives rolled out by the
Page 3
team for high prescribing GP’s to raise awareness of antibiotic overuse a decrease
is been seen in total volume of antibiotic prescribing. The team continues to be
pro-active by working with young people and community groups on antibiotic
overuse.
26/16 SWBH:
Pressure Ulcers continue to decline and patient fall are levelling to around two per
month. Complaints are at the expected level.
27/16 CQRM:
Obstetrics - Caesarean section rates were recorded YTD 25.2%, which is about the
25% target. Nationally this is being monitored. There were no cases of MRSA
reported in December. Last minutes cancelled operations increased to 1.0% above
the 0.8% target. This was thought to be a result of the junior doctors strike.
28/16 BCPFT:
Unexpected deaths continue to decline.
29/16 Mrs Parker thanked GP’s for promoting the GP Incident Reporting system with
colleague, the system enables the team to catch any trend analysis and drive
quality improvement and learning forward.
30/16 Mrs Parker reported that the reduction in antibiotic prescribing is in the lowest
quartile nationally and has reduced by another 1%. This is a great achievement by
GP practices.
31/16 Mrs Parker confirmed that issues relating to McCarthy Ward, are being monitored
by the Quality and Safety Committee.
32/16 Mrs Parker reported that Sandwell and West Birmingham CCG have cleared a
backlog of previously un assessed retro appeals relating to Continuing Healthcare.
33/16 Ms Rawlinson commented by email, asking members to note that drug names
ought to be explained in brackets as they are incomprehensible in public papers.
On page 14 of the report, the word compliance requires changing complaints. Mrs
Rawlinson thought the report was good and was pleased to see that on page 66 of
the report 3301 people did not need another service. How can the CCG direct such
patients in future?
34/16 Dr Burden commented that the seriousness of the complaints have not increased,
and the increase relates to the system being used more.
35/16 Dr Sykes suggested that reports avoid the use of acronyms. Mrs Jasper confirmed
that a glossary would accompany future public meeting papers.
36/16 Responding to a question from Dr Sykes about unexpected/avoidable deaths
(BCPT) Mrs Parker confirmed that a full table-top review is on-going. Mrs Hodgson
confirmed that BCPFT report all unexpected deaths and explained the process of
how deaths are downgraded if the coroner’s report rules that the death was due to
natural causes.
37/16 Mrs Jasper enquired about the medication incidents. Mrs Parker confirmed that
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BCPFT record every incident and gave assurance to Mrs Jasper that the team are
sighted on each incident.
38/16 Responding to a question from Dr Andreou regarding referrals, Mrs Parker
confirmed that an audit is in progress around CQUINs.

Resolution: The Governing Body received the report for assurance
and approval.
13:15 hrs Ms Elizabeth Walker (Head of Medicines Quality) and Dr Gwynn Harris
joined the meeting
39/16 Prescribing Development Scheme:
Ms Walker spoke to this item explaining the aim of the scheme. The team will be
focussing on three areas; enteral nutrition, respiratory prescribing and chronic pain
management.
40/16 Mrs Parker confirmed that the report had been discussed at a recent Quality and
Safety process and was being presented to members for approval. Ms Walker
confirmed that on-line training and education events would be held for member
practices.
41/16 Dr Burden commented emphasis seems to be on switching than ‘not giving’. Ms
Walker confirmed how the education process is to address all options.
42/16 Mr Green enquired whether there was a structure process to monitor compliance
with measure, Ms Walker confirmed that there was, and data would be received on
either a monthly or a quarterly basis.
43/16 Responding to a question from Dr Bath relating to payment, Ms Walker reported
that further discussions with the finance team are being undertaken.
44/16 Dr Sykes highlighted a potential conflict regarding payment. Mrs Jasper asked the
communications representative to prepare a response.
45/16 Responding to a question from Mrs Jasper relating to the success of reviewing the
scheme, Ms Walker confirmed that a review would be undertaken at the end of the
year
46/16 Dr Sykes highlighted a typographical error on page 84 of the pdf document that
required the word ‘CCG’ being inserted in the final paragraph within the table.

Resolution: The Governing Body approved the recommendations of
the report and approved the Prescribing Development scheme for
2016/17
13:30 Ms Walker and Dr Harris left the meeting.
47/16 Finance Report:
Dr Bathla highlighted the salient points of the report.
48/16 Mr Green presented the report in further detail confirming that the CCG is
forecasting a surplus of £12m for the financial year 2015/16, and explained that the
Page 5
report continues trends from previous months.
49/16 The final outturn position has been agreed with Sandwell and West Birmingham
Hospital Trust.
50/16 Over performance continues on the Dudley Group of Hospitals contract and is
consistent with previous levels.
51/16 The WMAS contract has seen some over-performance in February this will slightly
reduce the year-end figures.
52/16 Trends continue around prescribing performance. The CCGs financial position
was within the 1.25% ceiling set by NHS England (NHSE).
53/16 The CCG continues to remain within the 95% target in relation to the Better
Payment Practice Code.
54/16 Mr Green explained that the Quality Innovation Price Productivity (QIPP) plans for
2015/16 were not achieved around non-recurrent measures. A plan for 2016/17 is
being submitted to NHSE. Mr Green went on to explain the challenges around
meeting future targets.
55/16 Responding to a question from Dr Bath concerning the monetary increase for
Vanguards. Mr Green responded and explained that funding has been released by
the central UK models team to develop vanguards proposal. A resource of £200m
has been set aside by the Government, the money is released on a quarterly basis
on completion of certain targets and milestones.
13:40 a member of the public left the meeting.
56/16 Responding to a question from Dr Solomon about QIPP activity, Mr Green
explained that the team has more work to undertake
57/16 Mr Nugent enquired whether the CCG is engaging with providers on the QIPP
agenda. Mr Green responded by explaining that at present there is no specified
scheme however a proposal is being prepared ready to engage with providers. Mr
Williams explained how the Black Country STP has agreed a principle of
subsidiarity to work through ways to ensure primary care is resourced effectively,
work with SRGs locally to support QIPP, and system intervention.
58/16 Dr Burden requested that the QIPP working group look at the ‘complex patient’
position as there is an opportunity to improve care to patients simultaneously
reducing duplication care and cost. Mr Green responded confirming that the entire
remit of Right Care would be explored. The new CSU will be looking at the total
portfolio of contracts with the CCG.
Appendix 1 accompanied the report.

Resolution: The Governing Body accepted the report and noted the
associated risks.
59/16 Performance Report:
Page 6
Mr Green presented the report highlighting the salient points. Black Country
Partnership Foundation Trust is forecasting improvement albeit they remain below
target.
60/16 Referral to Treatment Times (RTT)
The CCG and the Trust continue to be within target despite breaches.
61/16 Accident and Emergency (A&E)
Performance fell below 90%.
62/16 Cancer Waits
2 Cancer Waits have been achieved; 31-day cancer wait target was not met, as 2
patients were not treated within target.
63/16 WMAS
There was a slight dip in red 2 categories due to the volume of activity.

The Governing Body received the report for assurance
64/16 Partnerships Committee:
Dr Andreou confirm that the committee has met but there was no report was
submitted.
65/16 Strategic Commissioning and Redesign Committee Report:
Dr Solomon spoke to this item reporting on the items of business discussed at the
meeting held on Thursday 25 February 2016 that included a review of the risk
register, an update from the programme management office, and update from the
Capital Review Group, the committee noted an extension to the Stone Road Health
Service contract.
66/16 The focus for the committee was a presentation relating to the Primary Care
Assessment and Treatment Scheme Assessment (PCAT). The committee agreed
to issue a notice of change to Sandwell and West Birmingham Hospitals NHS
Trust, undertake a clinically lead options appraisal to determine the nature and
location of the future service and to develop a communication and engagement
plan around the service. Dr Ian Sykes declaration of interest was noted at this point
of the meeting.
The committee-ratified decisions taken by the Commissioning Business Planning
67/16 Group, relating to the Bethel Doula Service, a support service that provides help
and advice during childbirth. An extension to the existing Interpretation Service
was also ratified.

Resolution: The Governing Body noted the contents and accepted the
report for assurance.
68/16 Audit & Governance Committee Report
Mrs Jasper provided members with an update on the business discussed at the
committee meeting held on Thursday 17 March 2016 where the Internal Audit Plan
for 2016/17 was agreed.
69/16 The Counter Fraud Audit plan was accepted. The committee noted the timetable for
submission of the draft accounts and the annual governance statement.
Page 7
70/16 Areas to note from the Internal Auditors included a rating of significant assurance
for the progress report although areas of moderation and limited remain.
71/16 Following the limited assurance on the CCGs recruitment process, progress has
been made and an extension was agreed with an understanding that an amended
action place will be submitted to reflect the new timescales.

72/16
Resolution: The Governing Body received the report for assurance.
Auditor Panel Report:
Mrs Jasper provided members with a verbal update. The Committee discussed
and approved the CCGs Constitution of terms of reference for the Auditor Panel
and allocated a timeline for the procurement exercise.

73/16 OD Committee Report:
Mr Williams spoke to this item, reporting on the issues discussed at the committee
meeting held on Tuesday 15 March 2016 that included a significant increase in
compliance for mandatory training and PDR compliance.
74/16 An action plan is in place to address outcomes from the staff survey relating to
Discrimination, Bullying, and Harassment.
75/16 The Flexible Working Policy is under review and the outcomes are to be shared
with staff council.
14:12hrs – member of public entered the room.

76/16 Primary Care Co-Commissioning Report:
Mrs Liggins presented the report highlighting the outcomes of the public session of
the meeting held on Thursday 03 March 2016.
77/16 The committee approved the Malnutrition Community Project Scheme as part of the
Primary Care Reserves plan.
78/16 The risk and issues register was updated. Following feedback from Clinical Leads
and Directors, the committee agreed to the proposed changes to the Primary Care
Co-Commissioning Framework.

.Resolution: The Governing Body noted the contents and decisions
taken by the committee.
79/16 Transforming Care in Birmingham:
Ms Jenny Belza joined the meeting to seek approval on the draft Transformational
Plan, that has been developed with partners across Birmingham prior to the final
plan submission to NHS England on 11 Aril 2016. The programme has been
created to develop and deliver a citywide 3 year Transformation Plan for clients with
Learning Disabilities with or without Autism who display behaviour that challenges.
Ms Belza went on to talk the programmes key focus.
Page 8
80/16 Responding to a question from Dr Mukherjee relating to patient lists, Ms Belza
confirmed that the programme would provide an opportunity for registers to be
defined and developed across both the health service and local authority.
81/16 Responding to a question from Dr Solomon regarding what choice client’s would
have regarding supported living. Ms Belza responded explaining the arrangements
to meet client’s needs.
14:72 member of public entered the room
82/16 Ms Atri enquired how risks would be managed. Ms Belza explained the processes
in place to manage risks effectively.

Resolution: The Governing Body approved the Transformational Plan
and the proviso that any changes made by Birmingham South Central
and Birmingham Cross City CCG are agreed by members. Mr Dicken
agreed to feed back any changes to members.
83/16 Transforming Care in Sandwell:
Mr Colin Marsh, SRO Black Country STP joined the meeting.
Mr Dicken explained that the Black Country Transforming Care Plan joint footprint
covers the population that spans into Birmingham; he went on to explain the
progress of the current work being undertaken. The three key areas agreed are;
reducing reliance on inpatient services, improving quality of life for people in
inpatient and community setting, and improving quality of care for people in in
patient and community settings. Mr Dicken reported that there is good engagement
with the CCG and the Local Authority who all the support from moving from an
institutional model into a community model.

Resolution: The Governing Body endorsed the plan for Transforming
Care for the Black Country TCP in Sandwell with a proviso that Mr
Dicken would circulate the template to members.
14:45hrs Mr Colin Marsh, left the meeting
84/16 Corporate Social Responsibility Strategy:
Mrs Salter Scott presented a report that sets out the progress on the Development
of a Corporate Social Responsibility Strategy, for the CCG to implement a plan
around its engagement with the Voluntary and Community Sector. The CCG has
approached Birmingham Voluntary Service Council (BVSC) and Sandwell Council
for Voluntary Service (SCVO), to co-design the strategy to assist the CCG
implement the plan.
The overarching aim of the strategy is to have a strong,
viable, and active voluntary and community sector that can support the health and
wellbeing of citizens in the Sandwell and West Birmingham CCG footprint.
The full strategy is to be presented at the next meeting of the Governing Body.

Resolution: The Governing Body approved the work to date around
the development of a Corporate Social Responsibility Strategy.
Page 9
85/16 Communications and Engagement:
Mrs Salter-Scott spoke to this item and circulated the Engagement Work
Programme to members. The detailed report contained updates relating to what
the year ahead looks like for the team, a written work plan and a corporate events
calendar. Mrs Salter-Scott talked in detail about the statutory duties of the CCG
under section 14zs of the Health and Social Care Act 2012.
86/16 Mr Solomon asked whether all the clinical PLT’s were within the calendar. Mrs
Salter-Scott agreed to check the dates. Mrs Jasper formerly thanked Mrs SalterScott and her team for detailed update to members.
87/16 Responding to a question from Ms Atri about a future Governing Body meeting
being facilitated by young people, a scheme that the Local Authority are in support
of. Members agreed that the CCG would consider taking part in the project.

Resolution: The Governing body noted and accepted the report.
88/16 Mrs Lynda Scott was invited to join the meeting and was formerly thanked for all
her hard work and dedication. Mr Williams stated that Mrs Scott has been
supportive to the organisation.
89/16 Sustainability and Transformation Plan Update (STP):
Mr Dicken spoke to this item highlighting the salient points of the report that
included confirmation of the geographical footprint and its association with
Birmingham; partners include NHS England, Local Authorities, Hospital Trusts
West Midlands Ambulance Service, and CCGs. To scale the challenge three-work
streams have been identified to focus on the gaps Health & Wellbeing, Care and
Quality and Finance and Efficiency.
90/16 A key priority is to identify initiatives that will benefit by closing gaps across the
Black Country and draw down on Transformational funding from a national reserve.
A shortfall return will be submitted by 15 April 2016, which will focus on the
governance and the approach to gap analysis and the priority of actions required.
91/16 Mr Green and finance colleagues across round the Black Country are undertaking
the gap analysis centred on a base line analysis of each organisation and the
Rightcare packs, in addition to and high-level work by Directors of Public Health.
92/16 Mr Dicken went on to explain the governance structure and the functionality of the
Transformational and Operations group. The four values adopted by the Black
Country STP are Subsidiarity, Mutuality, Added value and No boundaries. Prior to
the final submission of the plan in June 2016, the plan will be shared with a wide
range of organisations.
93/16 Mr Williams explained that the CCG is leading in all three leadership roles, Mr
Dicken is the leading on Operations, Mr Green on Finance, and Mr Williams is
chairing the group.
94/16 Mr Williams stated that there is currently no structured way of approaching general
practice. Mr Williams asked members for a steer on extending an invitation to all
member practices. Following a discussion, the consensus was that the Black
Country STP would hold an engagement event for its members.
Page
10

Resolution: The Governing Body received the report for information.
95/16 DRAFT Operating Plan 2016/17:
Mr Dicken presented a draft Operational Plan for 2016/17, and highlighted the
significant points within the plan. Mr Dicken has encouraged senior colleagues to
review priorities over the last few years. Interventions have been identified on the
9 ‘must do’ areas and an update on the Better Care Fund position. Mr Dicken is
working with finance and quality colleagues. The plan will be submitted on Monday
11 April 2016. Mrs Jasper thanked colleagues for working to produce the plan.
96/16 Mr Williams asked if the content of the plan could be shared with staff.

Resolution: The Governing Body received the report for information.
97/16 Corporate Objectives:
Mrs Hodgson presented the report explaining that the corporate objectives for
2015/16 have been reviewed and updated by officers of the CCG. Mrs Hodgson
reported how closed objectives and updates appear within in the report. All on
going objectives will be transferred over to new objectives for 2016/17.

Resolution: The Governing Body approved the updates to the
Corporate Objectives.
98/16 Assurance Framework:
Mrs Hodgson spoke to this item highlighting the development of the Assurance
Framework for 2016/17. The framework focuses on key risks and drives the
delivery of the corporate objectives.

Resolution: The Governing Body approved the updates association
with the Assurance Framework.
99/16 Minutes of the Committees for information:
9.1 Finance & Performance Committee
9.2 Quality & Safety Committee
9.3 Strategic Commissioning & Redesign Committee
9.4 Audit & Governance Committee
9.5 Organisation Development Committee
9.6 Partnership Committee Minutes
9.7 Primary Care commissioning Minutes

Resolution:
The Governing Body accepted the minutes for
information and assurance.
100/16 Minutes of the Locality Commissioning Groups for Information:
10.1 ICOF LCG Minutes
10.2 Black Country LCG Minutes
10.3 Pioneers for Health LCG Minutes
10.4 Sandwell Health Alliance LCG Minutes
10.5 HealthWorks LCG Minutes

Resolution:
The Governing Body accepted the minutes for
Page
11
information and assurance.
101/16
Any Other Business:
Ms McMahon reported on a workforce event focussing on Work stream Profiles
Apprenticeships and Student Nurse Placements. The event is scheduled on
Tuesday 17 Mary 2016 and being run by Health Education West Midlands.
102/16
Share with Staff:
 The death of Cllr Darren Cooper
 The Operating Plan 2016/2017
 Corporate responsibility
 The Engagements team graphic to be uploaded to the office TVs.
 Acknowledge the work Lynda Scott
The meeting closed at 16:12hrs.
103/16
Date and Time of the Next Meeting
The next meeting will be held on Wednesday 04 May 2016, Boardroom. Kingston
House, High Street, West Bromwich, from 12:30 - 15:00 hrs.
Page
12
Enc 2
SWBCCG Governing Body Meeting
Action Register: Wednesday 4th May 2016
Action
060416
06042016
06042016
06042016
06042016
By Whom
Deadline /
update
Action Register
Claire Parker
To investigate the concern that
consultants at the children’s Hospital
do not communicate effectively with
vulnerable people
Chairs Report
Andy Williams
To discuss with members of the next
STP meeting the issue of Conflicts of
Interest
June 2016
Quality Report
If name of drugs are used within the
report to provide an explanation.
Tom Richards
May 2016
Avoid the use of Acronyms in reports
All
May 2016
To provide an updated glossary of Alison Hodgson
terms
Transforming Care
Strategic
Commissioning
and Jon Dicken
Redesign Committee to review the
templates before submission.
Comment / Response
Date
Completed
May 2016
May 2016
April 2016
Corporate Social Responsibility
Strategy
To consider objectives and outcomes Jyoti Atri
as well as environmental impact
Enc 2 – Action Register
Page 1
4th May 2016
Enc 2
Action
030216
020316
020316
Quality Report
To
investigate
consultants to GPs
By Whom
requests
from Claire Parker
Deadline /
update
June 2016
Comment / Response
Date
Completed
We have asked for examples
from GP colleagues to raise to
MD of appropriate trust.
Sickness/Absence
Report
–
Sandwell and West Birmingham
Trust
To discuss leadership in management Raffaela
at a future meeting
Goodby
To review imaging waiting times
Claire Parker
GP Transfers
To determine where the risk lies Sharon Liggins
during the 1st year of transfer
May2016
May 2016
Closed Items
071015
Minutes of the last Meeting
Claire Parker
Clarification of expensive COPD
drugs being used at the request of
hospitals
January 2016
Mrs Parker reported that there
were no issues following in
depth investigation
February
2016
071015
Performance Report
To clarify if all 59 patients over 2
week wait was due to patient choice.
February 2016
Request for an audit as to
whether patients understood
the potential implications of 2
week wait.
February
2016 – Mrs
Parker’s team
is working
with the Trust
James Green
Page 2
4th May 2016
Enc 2
Action
061115
061115
By Whom
Quality Report
Claire Parker
SWB Hospitals To identify the
percentage of newly qualified staff.
Deadline /
update
Comment / Response
January 2016
Information requested at the
Clinical Quality Review
meeting 9th November 2015. A
formal request has been made
for further detail
Consider misuse of SIP feeds as a
KPI in contracts.
Patients are assessed within
24 hours of admission as part
of the ten out of ten checks.
Confirmed at clinical Quality
Review Meeting 9th November
2015
To request an Audit to determine if
patients on the two week wait are
aware of the reason they are being
referred.
Finance & Performance Report
James Green
Waiting Lists – to identify the specific
procedure or treatment the patient
has been referred for.
Information requested at the
meeting 9th November 2015
RTT - To determine if there were James Green
empty beds during the summer
period.
Page 3
Date
Completed
Closed
January 2016
Closed –
completed.
January 2016
4th May 2016
Enc 2
Action
By Whom
Quality and Safety Report
Claire
To clarify where the Hear and Treat Parker/Alison
Target of 6% derived
Hodgson
Deadline /
update
Comment / Response
January 2016
To determine % of cancelled Jon Dicken
appointments due to the proposed
Junior Doctors strike
CLOSED
ALL
ACTIONS
COMPLETED
To review incident reported about
UHB in respect of GP referrals being Claire Parker
returned by UHB
021215
020915
It has been confirmed there
are 4 incidents and 1 concern
entered on to Datix. The Q&S
team will go out to practices to
see if there are any further
incidents and raise the issue
through the Clinical quality
Review meeting
Cancer 62 day target. Is it possible to Claire Parker
identify the specialities which are
missing the target
Organisational
Development
Report
Alison Hodgson
To confirm if there is a carers policy
February 2016
SWBH Staff Sickness
Claire Parker
A briefing report of staff sickness at
Sandwell and West Birmingham
Hospital to be presented at the March
meeting.
March 2016
Page 4
Date
Completed
January 2016
Special Leave Policy includes
a section entitled Emergency
(personal and domestic) leave.
Closed
December
2015
Report received and Head of
HR and OD has been invited
to February meeting but due to
work commitments cannot
attend until March 2016
On the
agenda
4th May 2016
Enc 2
Action
021215
061115
030216
020316
020316
By Whom
Urgent Care Programme Report
To
clarify
the
cabinet
office Nighat Hussain
procurement policy to ensure there
are no implication in relation to the
proposed action
Transforming Care
To provide a report to Governing Jon Dicken/SCR
Body on how Learning Disability Committee
placements are commissioned.
Deadline /
update
March 2016
March 2016
Quality Report
To
include
a
key
differentiating colours.
April 2016
table Tom Richards
To question the increase in pressure Claire Parker
ulcers in Dudley
Performance Report
To determine if there is local CPA James Green
data that can be shared
Page 5
April 2016
April 2016
Date
Completed
Closed
March 2016
January 2016
Performance Report
To review the inconsistency with James Green
Radiotherapy data
to
Comment / Response
Final submission will be April
2016
Closed April
Meeting
The report will be updated for
the April Governing Body
meeting
Closed April
Meeting
Included within the report
Closed April
2016
Query has been raised at the
Dudley CQRM
Team in discussion with the
Trust and if information is
available it will be incorporated
in future F&P reports
Close April
2016
4th May 2016
GOVERNING BODY
Report Title: Quality Report
Report author and Title: Tom Richards
Date of Governing Body4th May 2016
Contact Details: 0121 612 2769
Agenda No: 7.3
Sign off from Chief Officers: (Before the report is presented to the Governing Body any
implications relating to Finance, Quality and Commissioning must be agreed and signed by
the Chief Officer. (see guidance note) Without this information the report will not be taken to
the Governing Body)
Chief Finance Officer:
Chief Officer for Quality:
Chief Officer for Operations:
Chief Officer for Partnership:
Supporting Documents/further Reading: (Highlight any documents or further reading for
members which supports this report)
Previous Decision (Inform the Governing Body/Committee if the paper has been reviewed or
monitored by another committee and their recommendation or decision)
Summary of purpose and scope of the report:
Quality Report:
 Good rate of GP Incident Reporting – 119 incident reported by GP practices. Also, more than
half of all CCG practices reported during March.
 [Feb 2016 – No Clinical Quality Review Meeting(CQRM)] Sandwell and West Birmingham
Hospitals (SWBH) – Pressure Ulcers continuing to decline; C-Section rate met the target for
December 2015; Staff vacancy issues highlighted - to be addressed at next CQRM; Task and
Finish group to be set up to manage transition to e-referrals in Cardiology; Healthwatch
alerted to complaints by CQC – to be picked up by Quality Team.
 [March 2016] Black Country Partnerships Foundation Trust (BCP –Unexpected Deaths trend
continuing to decline with no new incidents since Jan 2016; LD workforce issues highlighted
(re: sickness levels), but reduction in Long Term sickness since December 2015;
 [March 2016] West Midlands Ambulance Service (WMAS) – WMAS working towards
addressing Double-Crewed Ambulance skill mix following review of Serious Incidents which
highlighted staff experience as a recurrent contributory factor.
CHC Report:
 Activity: Impact of holding data pertaining to Section 117 individuals is being explored within
the team – potential inconsistencies may be contributing to an over estimation of
Continuing Healthcare (CHC) activity.
 Continuing Healthcare Assurance Tool: new facility to create standard surveys in response to
Care Quality Commission (CQC) Compliance feedback aimed at: Staff and Managers, Service
User / Resident, Friends and Relatives, Assisted Service User / Resident, Visiting
Professionals.
 Meeting taking place with Local Authority to streamline the service for patients, with good
progress being made.
Page 1 of 49
Safeguarding Report:
Initial Child Protection Conferences engagement rates were generally good, with 100%
compliance ICOF, 71% for Healthworks.
Medicines Management:
 Opioid Medicines to relieve chronic pain advice/guidance for GPs ratified.
Recommendations:
The Governing Body/Committee are requested to:
Action
Approve
Assurance
Decision


Conflicts of Interests:
The recommended action by the author of the report is:

No conflict identified
Conflict noted, conflicted party can participate in clinical discussion but
not decision
Conflict noted, conflicted party can remain in committee but not
participate in discussion
Conflicted party is excluded from discussion (this would be rare
circumstances only)
Please state rationale for above decision:
Strategic Priorities related to the report:
Quality & Safety
Finance & Performance
Partnership
Strategic Commissioning and Redesign
Organisational Development
Primary Care Co-Commissioning
Collaborative Commissioning
Implications:
Financial
Assurance Framework
Risks and Legal Obligations
Equality and Diversity
Statutory and External Influences
Further implications not stated
Consultation: X
Patients
Staff
Committees
Public

Page 2 of 49
Partners
Sponsored By: (Chief Officer or Committee
Chair)
Date Report received for Governing Body
Claire Parker, Chief Officer, Quality
26th April 2016
Page 3 of 49
Quality Report
March 2016 – Q&S
Page 4 of 49
Contents
1. Sandwell & West Birmingham CCG ........................................................................................................................... 7
Serious Incident Summary .......................................................................................................................................... 13
Never Events ............................................................................................................................................................... 13
STEIS Incidents by Provider ......................................................................................................................................... 13
STEIS Trends by Provider............................................................................................................................................. 13
Quality Assurance Visits .............................................................................................................................................. 14
Complaints & Concerns ............................................................................................................................................... 14
2. Safeguarding Children ................................................................................................................................................. 14
Please see appendix for this report. .................................................................................. Error! Bookmark not defined.
3. Primary Care................................................................................................................................................................ 14
GP Reporting Rates ..................................................................................................................................................... 15
GP Incident Reporting by Severity .............................................................................................................................. 15
Incident Reporting Rates per LCG ............................................................................................................................... 16
Incident Reporting Rates per LCG, weighted by Population ....................................................................................... 16
Medicines Quality Update .......................................................................................................................................... 17
Trends and Investigations ........................................................................................................................................... 18
4. Sandwell & West Birmingham Hospitals ..................................................................................................................... 19
STEIS Types & Status ................................................................................................................................................... 19
Pressure Ulcer Trends ................................................................................................................................................. 20
Patient Fall Trends ...................................................................................................................................................... 20
We can see that Patient Falls meeting SI criteria are declining once more, after a period where the incident
numbers levelled off in mid 2015. There are no wards/units experiencing significant trends within the last 6
months. ....................................................................................................................................................................... 20
CQRM Summary (September 14th 2015) ................................................................................................................... 22
Commissioning for Quality and Innovation (CQUIN) Update ..................................................................................... 23
Page 5 of 49
The Commissioning for Quality and Innovation (CQUINs) payments framework
encourages care providers to share and continually improve how care is
delivered and to achieve transparency and overall improvement in healthcare. ...................................................... 23
The Trust has agreed a number of CQUINs with the CCG. Each CQUIN scheme is summarised below. ................... 23
5. Black Country Partnerships Foundation Trust ............................................................................................................ 24
Serious Incident Update .............................................................................................................................................. 24
SQPR Data ...................................................................................................................... Error! Bookmark not defined.
The Commissioning for Quality and Innovation (CQUINs) payments framework encourages care providers to share
and continually improve how care is delivered and to achieve transparency and overall improvement in
healthcare. .................................................................................................................................................................. 29
6. Birmingham & Solihull Mental Health Trust ............................................................................................................... 30
Incidents Summary ..................................................................................................................................................... 31
7. West Midlands Ambulance Service............................................................................................................................. 32
STEIS Types & Status ................................................................................................................................................... 32
CQRM Summary – 29th September 2015 .................................................................................................................... 33
and continually improve how care is delivered and to achieve transparency and overall improvement in
healthcare. .................................................................................................................................................................. 35
8. Urgent Care ................................................................................................................................................................. 36
9. Dudley Group of Hospitals .......................................................................................................................................... 41
10. Birmingham Community Healthcare ........................................................................................................................ 43
11. Birmingham Childrens Hospital NHS FT .................................................................................................................... 45
12. University Hospital Birmingham NHS FT ................................................................................................................... 46
13. Smaller Provider Contracts ....................................................................................................................................... 47
14. Local Authority - Nursing/Care Homes ..................................................................................................................... 49
Incidents ...................................................................................................................................................................... 49
Incidents Summary - September 2015........................................................................................................................ 49
Page 6 of 49
Executive Summary
Service
CCG
[Mar 2016]
Primary
Care
[Mar 2016]
Item
Never
Events
Serious
Incidents
Visits
Time2Talk
GP Incident
Reporting
Other Primary
Care Items
Summary
Zero new Never Events in March. Four so far in 2015/16
11 reported in March. 5x BCP, 5x SWBH, 1x WMAS. Trend changes: SWBH Pressure Ulcers –
Declining; SWBH Falls – No change (av. 2 per month; BCP Unexpected Deaths – declining;
No Quality Assurance visits undertaken this month.
36 Queries; 23 Concerns; 2 Compliment, 12 Complaints
Complaints Trends identified: Trends Highlighted in GBPH (Access to Services); Issues with making
patients aware of the CHC Process.
Continued upward trend in Incident Reporting rate. Monthly total is 119. 52 different surgeries
reported incidents (joint highest ever). 100% of incidents reported were graded Very Low to
Moderate. Numbers of incidents were once again within relative ranges based on LCG population
lists, for the 5th month in a row.
Item
Bluestream
Geese Training Company
Primary Care Dashboard
CQC Supporting Visits
PLT
Incident Trends
Practice Nurse Forum
Primary Care Dashboard Data
Detail
Primary Care Quality Lead involving with training of Bluestream
roll-out. Bluestream is an e-learning training package for Practice
Staff.
Planning in place for Drama/Theatre based training for GP
Practice staff, with view to roll out in Summer 2016.
Consideration being given to the inclusion of action plan and
lessons learned to PC Dashboard.
CCG continuing to support CQC supporting visits for member
Practices.
Mental Health Themed Protected Learning Event being planned
for late April 2016.
There has been an increase in reporting of incident pertaining to
Pharmacies over-ordering meds. This follows an awareness
exercise carried out by Medicines Quality Team.
A forum being set up for Practice Nurses.
Primary Care dashboard data is showing a trend towards less
variance in total scores, with more practices falling into the
middle-range of data.
Trends &
Investigations
SWBH
[Feb 2016]
Medicines
Quality
Update
N/A
Incidents
SI Trends:
Pressure Ulcers – Continuing to decline.
Patient Falls – Levelling off at around 2 per month.
No new trends identified.
6 monthly trends:
All aspects of Treatment; Attitude of Staff; Appointments, and Failures to Follow agreed
Procedure.
Five new complaints and concerns received in March 2016.
Trust Complaints – number of first complaints rising, indicating better quality of response; less
than 10% of responses exceed response time (near 80% in Nov 14)
February CQRM – (March CQRM Cancelled)
Infection Control – 3x Cdiff in Dec (20 YTD – below target of 23); No MRSA
Harm Free Care – 94.5% (Harm Free Care) Below target of 95%.
Obstetrics – Caesarean Section rate = 23.1%, (YTD 25.2%, which is above the 25% target). Latest
Complaints
CQRM
Page 7 of 49
CQUIN
Black
Country
Partnerships
MH Trust
[Mar 2016]
Incidents
Time2Talk
CQRM – LD
adjusted perinatal mortality rate increased to 10.71, which is above the target level of less than
8.0. Group consideration of risk. 6/9 months this year delivering within target – indicator
represents an in-month position and which, together with the small numbers involved provides
for some natural variation. Nationally, this is monitored using a 3 year cumulative trend, based
on which the Trust is within normal confidence limits.
Cancer Care – Trust met 62-day RRT target of 85% with 90.3%.
Patient Experience – MSA and Complaints – No MSAs in December.
Patient Experience – Cancelled Operations – Last minute cancellations increased to 1.0%, above
the <0.8% target.
Workforce – PDR compliance = 86.2%, Sickness = 5.5%; Trust vacancies = 320 WTE. Bank and
Agency usage still high, though some improvement in group usage. A high proportion of the file
shifts have been with Bank nurses.
Trust has provisionally passed all milestones for Q3, except trajectory target for AKI.
Meds/Falls CQUIN Added. Data to be backdated at the end of Q4.
SI Trends:
Unexpected Deaths – Trend declining; No new incidents in March.
Concerns regarding communication and access to services.
March CQRM
LD Quality and Safety Report:
 Incident Reporting has increased since September 2015, coinciding with the opening of the
Lurches Unit at Hallam Street.
 Physical assaults/aggression is the top rated staff incident category, though this is showing a
decrease between Oct and Dec 15.
 Slight decrease in Self Harm incidents in Q3 (107). Q2 (111)
 Record Keeping incidents reduced from 80 to 58 in Q3.
 Rise in falls in Q3 (82), compared to 68 in Q2.
 Medication incidents levelling off at around 130 per quarter.
 Four informal complaints received and responded to.
 Zero compliments have been recorded.
 Facility now exists to record compliments on Datix.
 Workforce turnover for Jan was 11.7%, which is within the expected range.
 Long Term sickness = 3.8%; Short Term Sickness = 2.6% of the 6.4% total sickness total.
There has been a reduction of long term sickness since December 2015.
 Agency costs decreased in Jan 2016.
SPQR Exceptions:
 EIS Indicators not meeting target – Exception reports supplied. CCG to continue to monitor
LQRs going forward.
 HCAIs (IPC Training) – BCP to focus training on staff whose competence is out-of-date
(previously, this was delivered as part of annual mandatory training)
 Psychosis Medication Review – Current challenges exist regarding how the information for
this indicator is captured.
CQUINs
Birmingham
& Solihull
MHT
[Mar 2016]
CQRM
Service User Website:
BCP are developing a website specifically designed to provide information about the service to
user.
Trust has not passed all milestones for Q3, failing to achieve Quetiapine for the second quarter in
a row. Improving Physical Healthcare A is also under commissioner review.
8th March 2016
SQPR – Trust are unlikely to meet PREVENT training target by end of Q4; low compliance was also
noted for child safeguarding training levels 2 and 3.
Incident Reporting – Reporting rate increasing again after recent decline. The majority of
incidents reported are little to no harm.
Page 8 of 49
Health and Safety Report - There has been significant improvement in health and safety
assessments and audits. There were 10 sites with outstanding assessments and they are now all
complete.
Restraints - Restraints in total are on a downward trend. Less than 5% of the restraints reported
by the trust are for longer than 10 minutes.
Workforce - Bank & Agency spend is still high but is reducing. The Trust is continuing to try to
recruit to positions to bring this down.
West
Midlands
Ambulance
Service
CQRM
[Mar 2016]
SI Report:
19x SIs during 2015/16
6x New STEIS Incidents reported in January 2016.
WMAS are working towards improving the DCA skill mix.
SQPR Performance Exceptions:
LQR1 (Cat A Red 1 – 95th Centile Response Time) – Not meeting target during winter months due
to increased demand.
LQR3 (See and Treat) – WMAS to investigate failure as part of S&T report.
LQR7 (Ambulance calls closed with telephone advice) – Currently failing target; Investigation into
impact of NHS111.
LQR30 (Handover to A&E within 15 mins) – Currently failing target. CCGs to monitor at local
levels with Acute Providers.
CQUINs 2016/17:
1) Continuation of EPR; 2) Continuation of Paramedic Pathfinder (though the name of this will
change to avoid confusion with an existing franchise); and 3) Paramedic Skill Set.
Unplanned
Care
[Q3 15/16]
Incidents
Time2Talk
CQUINs
NHS 111
(Vocare)
December
15
Out of Hours
GPs (No
update this
month)
1 new SIs – potentially avoidable death.
No new complaints.
All CQUIN milestones passed for Q3.
Call Volume: Total Calls - 82k ↑
Quality Data:
Answered within 60 secs – 73K↓
% of abandoned calls – 2.6% (2714)↑
Call backs within 10 mins – 48.6% (2071)↓
Primecare
September KPIs – fully compliant
CQC visit – Service to improve the following: 1) Audit trails for meds, 2) Lines of accountability in
regard to Risk Management; 3) Availability of information to patients that attend the primary
care centre, 4) Confidentiality awareness for staff.
Badger – Update to be supplied in future Quality Report.
Page 9 of 49
Dudley
Group
[Mar 2016]
Urgent Care
Centres
Malling Health – Parsonage Street
Incidents- No SIs, No Duty of Candour Breaches, Datix training to be provided by CCG.
Change of management – Change of management at Parsonage street with almost all new staff.
Contract review meeting was held on 2 November 2015. KPI reporting format to be changed to
excel rather than word so data can be more easily manipulated. Additional measure of patients
leaving before being seen also to be included.
Extended opening hours on key dates over Christmas and New Year have been agreed
Virgin Summerfield UCC
Incidents- No SIs, No Duty of Candour Breaches, No SG referrals, one incident (needle stick injury)
Patient Experience – Service utilising a patient participation group to acquire feedback on service
provision; FFT has been implemented.
Activity – Patient numbers have decreased since last year – service has decreased capacity
without compromising patient care or waiting times.
Estates – Virgin meeting CCG estates manager to discuss issues with space.
Contract review meeting was held on 24 November and no quality issues raised.
Agreed to include an additional KPI of number of patients who leave before being seen into
monthly reporting.
Extended opening hours an key dates over Christmas and new year have been agreed.
Intermediate
Care
BUPA – Ryland View
CQC report turned out a ‘good’ result all round. Changes to process have yielded a significant
decrease in number of falls in the Manby unit. Process is going to be rolled out across all BUPA
homes.
Own Bed Instead
Service experience increasing waits for dom care input from STAR. Additional funding provided by
CCG to increase therapy capacity, to be used for therapy only referrals if necessary.
CQRM 1st March 2016
Speech and Language Therapy:
Longest routine appointment wait time is 8 weeks; Service has not seen impact from recent
workforce issues due to decreased referrals in Jan.
E-Referrals:
Remedial Action Plan in place to address ERS referral availability. ERS availability continues to be
rolled out to new specialities across the trust.
Serious Incidents:
39 internal SIs reported in December 2015; 29 of which are Pressure Ulcers.
Maternity:
Caesarean Section (C/S) rates remained above the target since April 2015, the noticeable recent
increase relates particularly to elective C/S. Following an audit it was reported that 31 of the
total 62 elective C/S cases in November 2015 were for the reason “previous caesarean section”.
On further investigation 16 of the 31 cases appeared to be for maternal request. This
demonstrates that woman’s choice is the most prevalent reason for elective C/S.
Learning Events:
The Surgical Division have initiated Local Joint Learning Events for theatres, critical care, pain and
anaesthetics directorates. They include all grades of the multidisciplinary team and its purpose is
to :
 Present infrequent situations that have been handled well and discuss and share the
processes.
 Discuss root cause analysis investigation outcomes.
 Highlight areas of good practice and share learning.
 Invite guest speakers to present to the meeting to enhance, develop and share processes and
practice.
CQRM
Page 10 of 49
Birmingham
Community
Healthcare
CQRM
[Mar 2016]
CQRM – 31st March 2016
Vacancies/DNAs:
Q4 -52 New Starters: 17 Band 3 (HCAs); 6 Band 4 Assistant Practitioners; 17 Band 5 Community
Nurses; 13 Band 6 DNs
In the March recruitment event on 5th March 2016 there were a total of 20 candidates
recruited: 7 Band 3 HCAs; 2 Band 4 Assistant Practitioners and 11 Band 5 Community Staff
Nurses.
Please note that currently BCHC community service is going through a transformational change
project which will mean that there will be a number of changes to the District Nursing teams/skill
mix/caseloads so this picture may look different as of the 1st April
DNA Rates Per Service (Exception Report):
Patient Experience Q3:
The Trust-wide Friends and Family Test (FFT) results for the quarter was 94.89%.
91.78% of respondents also said they considered the service to be excellent or very good, from a
total of 3133 patients who responded to the FFT question and 2955 who responded to questions
about how they would rate the service.
Glossary of Terms
BCP
Black Country
Partnerships FT
SWBH
Sandwell and West
Birmingham
Hospitals
CQC
Care Quality
Commission
CQRM
Clinical Quality
Review Meeting
RTT
Referral to
Treatment
DCA
Double crewed
Ambulance
KPI
Key performance
Indicators
SI
Serious Incident
MSA
Mixed Sex
Accommodation
LD
Learning
Disabilities
STEIS
Strategic Executive
Information
System
WTE
Whole Time
Equivalent
CQUIN
Commissioning for
Quality and
Innovation
Quetiapine
A medication used
for the treatment
of Alzheimer’s
Disease
EPR
Electronic Patient
Record
Datix
Incident Reporting
System
S&T
See and Treat
(treatment on
scene by
ambulance service)
PU
Pressure Ulcer
WMAS
West Midlands
Ambulance Service
YTD
Year To Date
CHC
Continuing
Healthcare
LQR
Local Quality
Requirement
PDR
Personal
Development
Review
UCC
Urgent Care Centre
HCA
Health Care
Assistant
DGH
Dudley Group of
Hospitals
Page 11 of 49
Page 12 of 49
1. Sandwell & West Birmingham CCG
Serious Incident Summary
Never Events
The following table shows a summary of all Never Events that have occurred in 2015/16.
ID
2924
3072
3164
4575
Date
30/04/2015
29/5/2015
13/06/2015
18/02/2016
Detail
Wrong site surgery (SWBH)
Swab left inside patient (SWBH)
STEIS Incidents by Provider
The following table shows a summary of the new STEIS incidents this month, by provider:
Service
(P) Black Country Partnerships FT (Mental Health)
Slips/Trips/Falls meeting SI criteria
Pending Review
Alleged Abuse
(P) SWBH - Hospitals & Community Services
HCAI/Infection Control incident
(P) West Midlands Ambulance Service
unexpected/ potentially avoidable death
Grand Total
Count
5
3
1
1
5
3
2
1
1
11
STEIS Trends by Provider
The following table summarises the movement of STEIS trends over the past six months. Incidents below are
grouped by ‘Incident Date’ rather than ‘Reported Date’.
Type
Oct
Nov
Dec
Jan
Feb
Mar
Trend
2
1
0
3
0
0
↓
2
3
1
2
2
2
↔
1
1
2
1
0
0
↓
Pressure Ulcer meeting SI Criteria
(CCGP) SWBH - Hospitals & Community Services
Patient Falls meeting SI Criteria
(CCGP) SWBH - Hospitals & Community Services
Unexpected Death of Community Patient (in receipt)
(CCGP) Black Country Partnerships FT (Mental Health)
Page 13 of 49
Quality Assurance Visits
There were no Quality Assurance Visits conducted this month.
Service
Site
Date
Comment
Complaints and Concerns Summary
Complaints & Concerns
The following graph shows the number of Complaints, Concerns, and Compliments received about SWB CCG and its
providers since April 2013. The CCG Customer Care Team (also known as Time2Talk) also logs general queries and
signposting requests from patients. The Time2Talk Team resolves to reduce the number of formal complaints being
made against providers by attempting to address any issues that are raised in an informal way.
Current Trends Identified:
Trend/Issue
Access issues with GBPH (GP), mostly arising via Primecare
OOH GP service
Pathway Issues with HealthHarmonie US Service
Issues with staff attitude, communication problems , and
patients not understanding the CHC Process
Actions
Continue to Monitor (New trend)
HH will use Datix to respond directly to issues/incidents
To be addressed in-house.
Other Items
Item
Patient Networks
Crisis Team Experience
Forum
Detail
The Customer Care Team continues to be involved with patient networks and patient experience
forums, and feeds intelligence gathered from these forums into the Datix system.
Time2Talk is currently working alongside the Partnerships team to gather patient views on the
Black Country Partnerships Crisis Team service.
Page 14 of 49
3. Primary Care
Data contained in this report is up-to-date and includes all data up to and
including March 2016.
GP Reporting Rates
The following chart shows the number of incidents reported by GPs per month since the inception of the CCG in April
2013. Practices are provided with Incident Reporting training by the CCG, requesting this via the Time2Talk Team. In
March 2015, 119 incidents were reported by 52 different GP surgeries. Reporting rates are continuing to rise.
GP Incident Reporting by Severity
The following chart shows the severity of incidents reported each month. As incident reporting culture becomes
more embedded within the organisation, the percentage of Major/Catastrophic incidents is expected to fall, and this
is reflected by the data shown in the chart.
Page 15 of 49
Incident Reporting Rates per LCG
The following table shows a breakdown of the number of incidents reported for each LCG for the last six months.
Month
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Black Country
23
30
19
23
64
21
Healthworks
50
38
14
21
50
38
ICOF
14
12
8
7
23
8
Pioneers
2
5
11
4
4
6
Sandwell Health Alliance
20
25
32
18
35
43
Total
109
110
84
73
176
119
Incident Reporting Rates per LCG, weighted by Population
The following table shows the same data, but is weighted against the respective population size of each LCG.
E.g. Black Country LCG has a population of 113,000 patients, representing 23% of the overall population of Sandwell
& West Birmingham CCG, therefore, it’s fair to expect that that roughly 23% of the incidents reported per month are
reported by this LCG.
Where the tone of green is darker, this indicates months where Incident Reporting is higher than the upper 25%
quartile range of expected reporting. White boxes indicate that the average reporting level has been achieved.
Sep 15
Oct 15
Nov 15
Dec-15
Jan-16
Feb-16
Mar-16
BC (122k, 23%)
65.15%
34.85%
45.45%
28.79%
34.85%
96.97%
31.8%
% of Incidents reported by LCG, respective of LCG population
HW (110k, 21%)
IC (109k, 20%)
P4H (45k, 9%)
66.67%
12.12%
7.58%
75.76%
21.21%
3.03%
57.58%
18.18%
7.58%
21.21%
12.12%
16.67%
31.82%
10.61%
6.06%
75.76%
34.85%
6.06%
57.58%
12.12%
13.64%
SHA (145k, 27%)
39.39%
30.30%
37.88%
48.48%
27.27%
53.03%
65.15%
Other Items
Item
Bluestream
Geese Training Company
Primary Care Dashboard
CQC Supporting Visits
PLT
Incident Trends
Practice Nurse Forum
Primary Care Dashboard Data
Detail
Primary Care Quality Lead involving with training of Bluestream roll-out.
Bluestream is an e-learning training package for Practice Staff.
Planning in place for Drama/Theatre based training for GP Practice staff, with
view to roll out in Summer 2016.
Consideration being given to the inclusion of action plan and lessons learned to
PC Dashboard.
CCG continuing to support CQC supporting visits for member Practices.
Mental Health Themed Protected Learning Event being planned for late April
2016.
There has been an increase in reporting of incident pertaining to Pharmacies
over-ordering meds. This follows an awareness exercise carried out by Medicines
Quality Team.
A forum being set up for Practice Nurses.
Primary Care dashboard data is showing a trend towards less variance in total
scores, with more practices falling into the middle-range of data.
Page 16 of 49
Medicines Quality Update
Please refer document appendix for details.
Page 17 of 49
Trends and Investigations
The following chart shows a diagram of all the current trends being investigated
by the Quality Improvement Leads (QIL). It shows the number of ‘trending’ issues per month, along with actions
taken by the Quality Improvement Leads to mitigate against future risks.
Issues with 2ww Pathway



CCG have visited Rapid Access
Department at SWBH
Monitoring via CQRM
TREND RE-OPENED
Correspondence Sent to
Wrong GP



QILs contacted SWBH
Communications Team via the
Risk Team, to communicate issue
to Trust
Creation of information leaflet for
secretaries
SWBH IG Lead to be directly
copied into new incidents raised
by GPs
Incorrect Data on Hospital
Letter


QIL to contact IG lead at SWBH to
inform of issue.
TREND RE-OPENED
Choose & Book – E-Referral
System



E-Referral system was recently relaunched and experienced a
number of national ‘systemdowns’.
Information disseminated to GPs
via QILs and Primary Care
Development Managers.
TREND RE-OPENED
Page 18 of 49
4. Sandwell & West Birmingham Hospitals
Data contained in this report is up-to-date and includes all data up to and
including March 2016.
STEIS Types & Status
The following chart shows all STEIS incidents reported by SWBH in the last six months, with breakdowns of location
trends applied to the most common incident types.
Month/Type
2015
Oct
Disruptive/aggressive/violent behaviour
Nov
No Recorded
Medication incident
Dec
Screening Issues
Sub-optimal care of the deteriorating patient
2016
Jan
Maternity/Obstetric Incident - baby only
Treatment delay
Feb
Diagnostic Incident including delay
Maternity/Obstetric Incident - baby only
Surgical/invasive procedure
Mar
Count
7
1
2
2
2
6
1
3
1
1
3
1
1
1
12
2
3
3
2
2
8
1
2
1
2
1
1
5
3
2
Page 19 of 49
Pressure Ulcer Trends
The following line graph shows the number of Pressure Ulcers meeting SI Criteria
that have occurred each month since April 2013.
We can see that pressure ulcers that meet SI criteria are continuing to decline within SWBH.
Patient Fall Trends
The following line graph shows the number of Patient Falls meeting SI criteria that have occurred each month since
April 2013.
We can see that Patient Falls meeting SI criteria are levelling off once more, after a steady period of overall decline.
There are no wards/units experiencing significant trends within the last 6 months.
Page 20 of 49
Complaints Trends
The chart below shows the number and type of complaints and concerns received by the CCG about SWBH in the last
six months.
Type
Admissions, discharge and transfer arrangements
Personal records (including medical and/or complaints)
Others
Aids and appliances, equipment, premises (including access)
Communication/information to patients (written and oral)
Failure to follow agreed procedure
Appointments, delay/cancellation (out-patient)
Attitude of staff
All aspects of clinical treatment
Grand Total
Count
1
1
1
1
3
4
7
8
10
36
Integrated Quality Report Data (8th February 2016)
The number of complaints per month has increased since May 2015, but most of the complaints reported during this
period are first-time complaints, which suggests that good progress has been made by SWBH in regards to
complaints resolution. The % of responses to complaints that have exceeded the original agreed response date has
declined steadily since Nov 2014.
Page 21 of 49
CQRM Summary (February 8th 2016)
The following boxes contain summary information pertaining to areas of quality
featuring in the latest SWBH Quality Report.
Page 22 of 49
Commissioning for Quality and Innovation (CQUIN) Update
and continually improve how care is delivered and to achieve transparency and overall improvement in healthcare.
The Trust has agreed a number of CQUINs with the CCG. Each CQUIN scheme is summarised below.
SWBH CQUINs
Scheme
AKI
To improve the follow up and recovery for individuals who have sustained AKI, reducing the
risks of readmission, re-establishing medication for other long term condition and
improving follow up of episode of AKI, which is associated with increased cardiovasular risk
in the long term.
SEPSIS A
Providers are expected to screen for sepsis for all those patients for whom sepsis screening
is appropriate, and to rapidly initiate intravenous antibiotics within 1 hour of presentation,
for those patients who have suspected severe sepsis, Red Flag Sepsis or septic shock.
SEPSIS B
2b relies on administering intravenous antibiotics within 1 hour to all patients who present
with severe sepsis, Red Flag Sepsis or septic shock to emergency departments and other
units that directly admit emergencies.
DEMENTIA A:
i. The proportion of patients aged 75 years and over to whom case finding is applied
following an episode of emergency, unplanned care to either hospital or community
services;
ii. The proportion of those identified as potentially having dementia or delirium who are
appropriately assessed;
iii. The proportion of those identified, assessed and referred for further diagnostic advice in
line with local pathways agreed with commissioners, who have a written care plan on
discharge which is shared with the patient’s GP.
DEMENTIA B:
To ensure that appropriate dementia training is available to staff through a locally
determined training programme.
DEMENTIA C:
Ensure carers of people with Dementia and Delirium feel adequately supported.
A&E – MENTAL HEALTH DIAGNOSIS:
Improve Diagnosis recording in the A&E HES data set so that the proportion of records with
valid codes is at least 85%. For this purpose, codes 38 "Diagnosis not classifiable" and R69
"Unknown and unspecified causes of Morbidity" will be classed as invalid.
DIETETICS:
Effective referral management across community services, and ensuring robust pathways
are in place across community Dietetic teams, that communication with GPs is robust and
consistent. Ensuring teams undertake regular audit to improve patient care and outcome
when discharged into the community.
SAFEGUARDING:
There is a need to ensure safeguarding practices support the needs of vulnerable children
and adults. Therefore this indicator is aimed at ensuring that providers continue to embed
safeguarding into practice, implement lessons learnt following a safeguarding event, reflect
on practice and ensure that the voice of the child/adult is heard.
DEMENTIA MOVES:
The main benefit afforded by successful completion of this CQUIN will be a reduction in the
number of ward transfers experienced by patients who have been diagnosed with
dementia, which has been linked to better long term clinical outcomes for patients.
OUT OF HOURS TRANSFERS:
Reduction of Out-of-Hours transfers.
FALLS (Medication)
Q1
Q2
Q3
Q4
Comments
Partial payment. Trust failed
improvement payment.
Trajectory agreed with
SWBH.
Trajectory to be agreed with
SWBH.
Current highest score = 81%,
which equates to 90%
achievement of the total
CQUIN payment.
Legacy CQUIN. Achieved in
Q1.
‘Out of Hours’ period redefined as between 10pm
and 6am.
Data will be received in Q4
bundle.
Page 23 of 49
5. Black Country Partnerships Foundation Trust
Data contained in this report is accurate up to and including March 2016.
Serious Incident Update
The following chart shows all STEIS incidents reported by BCP in the last six months, with breakdowns of location
trends applied to the most common incident types.
Month/Type
Oct
Abuse/alleged abuse of adult patient by third party
Apparent/actual/suspected self-inflicted harm
Pending review (a category must be selected before closure)
Nov
Apparent/actual/suspected homicide
Dec
Apparent/actual/suspected self-inflicted harm
2016
Jan
Abscond
Unexpected Death of Community Patient (in receipt)
Feb
Count
4
1
1
1
1
4
1
1
1
1
7
2
1
1
2
1
4
1
1
1
1
1
1
Page 24 of 49
Complaints Trends
The chart below shows the number and type of complaints and concerns received by the CCG about BCP in the last
six months.
Complaint/Concern Type
All aspects of clinical treatment
Count
1
2
3
CQRM Summary (1st March 2016)
The following points of note were discussed at the last CQR Meeting, which occurred on Tuesday 1st March 2016.
BCP CQRM – March 2016 – Learning Disabilities
LD – Divisional Quality and Objective 1: We will nurture a culture which provides: safe, effective, caring, responsive and
Safety Report
well led services:
There has been an increase in reported incidents this month and overall since September the
number of incidents is higher than those reported last year. This appears to coincide with the
opening of The Larches where higher of acuity of patients are being admitted. One reported
unexpected death that was re- classified following coroner’s report identifying cause of death
was related to a deterioration of an existing medical condition. All other deaths were
community deaths which are not classed as BCPFTs deaths.
There has been an increase of physical interventions this has been evident since November
again coinciding with the opening of The Larches.
Objective 2: We will involve and listen to patients, carers and family’s experience to
continually improve services we provide:
Patient story included this month about an individual who has gained employment with BCPFT.
Four informal complaints received and actioned, no compliments have been recorded, staff are
reminded to record compliments on datix as anecdotally compliments have been given to the
service.
Objective 3: We will be a leading provider of specialist mental health, learning disability and
children’s services, proactively seeking opportunities to develop our services building
partnerships with others, to strengthen and expand the services we provide:
A number of local and national audits have been completed and detailed in the report. Action
plans to be completed, detailed on Pgs. 30 -33
The quality improvement priority for last year ‘Ward based communication for patients around
improving service user involvement – DOH positive and proactive care agenda’ is on track and
the QIP for this year is to be agreed by the quality and safety group.
Objective 4: Attract and retain a well-trained, diverse, flexible, empowered and valued
workforce:
Turnover is reported at 11.7% for January 2016, which remains within the Trust’s KPI of turnover
between 10-15%.
Long-term sickness makes up 3.8% and short-term sickness makes up 2.6% of the total sickness
(6.4%) in the Learning Disabilities Group for December 2015, seeing a small reduction in long
term absences, which we hope to see further reduce over the coming months despite their
complexities. LD Quality & Safety Report – January 2016 v1.4 Final Page 5 of 40
Agency costs have decreased this month.
Page 25 of 49
Objective 5: Resources will be used effectively, innovatively and in a sustainable manner:
The Specialist Epilepsy Nurse has contributed to a project called EpAID and has been successful
in a bid to purchase video equipment to support with assessment, monitoring and treatment of
patients with epilepsy.
SQPR
Exception Report:
KPI Ref
KPI Description
Findings of audit:
Increase of DNAs except in Period 2 where staffing
levels were more flexible, suggesting fewer DNAs
when the service was able to meet patient’s needs.
LQR13
EIS
More than 50% of
people experiencing a
first episode of
psychosis will be
treated with a NICE
approved care package
within two weeks of
referral
Inappropriate referrals increased in period 3 possibly
due to: i) A genuine increased in the number of
inappropriate referrals to the service, ii) Changes in
the assessment process (additional staff available in
Period 2; Introduction of new EIS Medical Team)
In order to further explore why DNA rates may be
increasing, the Sandwell Early Intervention Service
are collecting information about the reasons given
by clients for not attending appointments.
Unfortunately at the time of the audit conducted,
this information had only recently started to be
gathered and as such could not be compared across
time periods. This information will then be helpful to
continue to shape the service to meet client’s needs
and hopefully reduce DNA rates for initial
assessment appointments.
Page 26 of 49
Loss of two social care staff and 1 vacancy within the
team – leading to delay of assessments.
LQR15
EIS
Percentage of all
routine EIS referrals,
receive initial
assessment within 5
working days
LQR16
EIS
Percentage of EIS
caseload have crisis /
relapse prevention care
plan
LQR37
HCAIs
IPC training programme
adhered to as per
locally agreed plan for
each staff group.
Compliance to agreed
local plan. Quarterly
confirmation of
percentage of
compliance
LQR39
MEDS MGMT
Psychosis Medication
Review - Percentage
who have been
prescribed and
administered
antipsychotic
treatments for >12
Business case has been agreed which will lead to
recruitment of staff and increase capacity within the
team. The team are due to move to new premises
which will increase flexibilty in offering assessments
due to resources available at new premises.
Team continue to monitor DNA and explore reasons
given . DNA report has been compiled and any
findings will reviewed and acted upon to improve
performance
There appears to be an issue with OASIS which is
incorrectly reporting crisis/relapse plans as not being
updated. Staff have confirmed crisis/ relapse plans in
place for those clients identified. The revised figure
will be shared at CRM.
Team leader gained information on all clients
showing as not having crisis/relpase plans and
discussed with care co-ordinators. This brought to
light an issue with system recording which is
currently being reviewed as care co-ordinators were
reporting crisis/relapse plans in place.
Underperformance was highlighted during 2015. It
was identified that the performance and reporting
was against the Annual Mandatory Training Day,
rather than specifically infection prevention. As a
result, the reporting was based on all staff, rather
than a specific target audience of all clinical staff. A
Remedial Action Plan update report was produced in
December 2015 which outlined how the Trust would
reach the 95% target based on the correct target
audience of clinical staff. This was achieved for
December 2015
Agreed corrective action included the following:
1. Bookings were provided for all those out of date
within the target audience. 2. An on-line approach
for those non-attendees or those required to
complete infection prevention training by a certain
date. Moving forward, all those within the target
audience who do not attend the AMTD, or fall out of
compliance are forwarded the on-line approach in
order to ensure that they meet the infection
prevention compliance. For January 2016 the Trust
maintained over 95% for the specific target audience
of all clinical staff.
The Trust continues to be challenged with finding an
accurate mechanism for obtaining the information
for this Key Performance Indicator.
Page 27 of 49
months that have had
an antipsychotic
medications review in
the previous 12
months.
Service User Website
Development
Visits
Governance and
Assurance
CQUINs Q3
Domestic Homicide
Review
Clinical Supervision re:
Audit Findings
BCP are currently developing a service user website that will provide easy-to-read information
and allow for instant feedback on services.
So far, the trust have 1) Developed a Website Steering Group; 2) Appointed a Website Company;
3) The First phase of imagery and text are in place; 4) Easy-to-read information has been
uploaded.
Trust will demo software at the CQRM.
Abbey Ward – Absconsion
Visit to Abbey Ward at Hallam Street to look at absconsion procedures. No serious concerns
noted, save for out-of-date policy (Nov 2015).
Incident Reporting:
 Increased reporting in Q3, despite decline from Oct 15 to Dec 15
 Increased scrutiny of the severity assigned to all incidents reported to GAU before
submission to NRLS has impacted positively, with a 7% increase in recorded near misses and
a 5% increase in incident categorised as ‘Not Applicable’. Incident severity will continue to
be monitored closely by GAU in order to provide greater assurance that all teams report
severity accordingly.
 Physical assaults/aggression is the top rated staff incident category, though this is showing a
decrease between Oct and Dec 15.
 Slight decrease in Self Harm incidents in Q3 (107). Q2 (111)
 Record Keeping incidents reduced from 80 to 58 in Q3.
 Rise in falls in Q3 (82), compared to 68 in Q2.
 Medication incidents levelling off at around 130 per quarter.
 Absconsion numbers have remained level (approx. 30 per month) - Local Security
Management Specialist has been working closely with the police to build relationships
between the organisations and strengthen our partnership working. This work has helped
improve understanding of when and how the police will respond to incidents and the
responsibilities of both organisations when absconds/ AWOLs occur.
 Restraints rising in MH and LD
 41 uses of seclusion in Q3 (54 in Q2); only 3x were LD.
 No Never Events
 17x STEIS in Q; 26 YTD – Majority pertain to Unexpected Deaths, though 16 of the 26
reported were attributable to natural causes, with 7 under review; 2 suicides and 1 fall at
home.
 Failure of Trust for Q3 Quetiapine scheme. Solution to be discussed outside of the CQRM.
 Wolves still awaiting Training Plan for CQUIN 1a – Trust report that the training plan is not
actually required by staff.
It is proving difficult for 3 Trusts to satisfy the Domestic Homicide Review Standing Panel in the
completion of an action plan related to a DHR from 2011
Trust re-launched clinical supervision training in light of future audit for Jan 2017.
Page 28 of 49
Black Country Partnerships Foundation Trust CQUINs
Scheme
HEALTH EQUALITIES FRAMEWORK:
To implement use of the Health Equality Framework (HEF) using it to capture
salient outcome measures for people with learning disabilities using the service.
The tool will be implemented in phases to allow for training to be completed and
any necessary systems to be put in place.
IMPROVING PHYSICAL HEALTHCARE A:
To demonstrate full implementation of appropriate processes for assessing,
documenting and acting on cardio metabolic risk factors in inpatients and
community patients in early intervention teams.
IMPROVING PHYSICAL HEALTHCARE B:
90% of patients should have either an updated CPA i.e a care programme
approach acare plan or a comprehensive discharge summary shared with the GP.
A local audit of communications should be completed.
OPTIMISING THE USE OF QUETIAPINE WITHIN THE HEALTH ECONOMY:
To put in place clear guidance on antipsychotic choices within the trust. To
optimiser use of cost effective generic antipsychotics, and specifically to reduce
the use of slow relaease preparations of quetiapine both for new and exisiting
patients and those treated in the community.
HONOS – CA:
Health of the Nation Outcome Scales - Children & Adolescent Mental Health
HONOS-CA is nationally accepted as a measure on which to provide a minimum
basis of relevant clinical information for the measurement of outcomes
SHARED CARE ESCAS:
To ensure that patients on shared care drugs have an effective shared care
agreement (ESCA) in place and that there is a clear process and training
embedded on the use of ESCAs. The list of ESCAs will be based on all MH drugs
requiring an ESCA as shown by the trust’s formulary .
REDUCTION IN A&E MH RE-ADMISSIONS:
Reduce the rate of mental health re-attendances at A&E in 2015/1. The time
over which this applies will be agreed locally and will depend on how soon in the
reporting year data quality reaches an acceptable level.
Q1
Q2
Q3
Q4
Comments
Delay of EHR roll-out
affecting BCP ability to
deliver on this CQUIN.
CQUIN scheme ended in
Q2.
Delay in acquiring patient
list from GP Practices
affecting BCP ability to
deliver on this CQUIN.
A&E admissions data
shows strong progress in
this area.
Page 29 of 49
6. Birmingham & Solihull Mental Health Trust
Birmingham Cross City CCG is the Lead commissioner of services provided by
Birmingham & Solihull Mental Health Trust (BSMHT). Sandwell & West Birmingham CCG are significant stakeholders
and therefore send Quality Team representatives to the CQRM.
CQRM Summary (8th March 2016)
Item
SQPR
Details
Likely to miss target for Prevent Training by end of Q4. Position has
stayed the same since Q3, the Trust provided a report on the issues and
risks they have encountered in trying to ensure that their “Train the
Trainer” approach works. This is likely to be picked up through the
contract.
Incident Monthly Report
Health & Safety Report (
Inc. Patient Safety
Alerts)
Restraint Report
Quarterly Workforce
Report
Trust Board
Report
There is also low compliance with child safeguarding training level 2 and
level 3 and the increase in compliance has been low.
Incident reporting rates are slowing rising again throughout the trust. The
majority of all incidents have no or little harm and there are very few
incidents resulting in death.
There has been significant improvement in health and safety assessments
and audits. There were 10 sites with outstanding assessments and they
are now all complete. The majority of RIDDOR incidents relate to patient
to staff violence and aggression, some with serious harm.
Restraints in total are on a downward trend. There are still areas where
there are higher restraints than others. Thoughts have been shared by
the CCG in regards to the total time that service users are in restraints.
There has been some confusion by members of staff over how they time
the incidents. In relation to NICE Guidance, anything over 10 minutes
should be reported by exception. Less than 5% of the restraints reported
by the trust are for longer than 10 minutes.
Bank & Agency spend is still high but is reducing. The Trust is continuing
to try to recruit to positions to bring this down.
Quality Assaults – Our teams that have recorded high level of restraints and
Assaults such as Pacific, Meadowcroft, Eden PICU have all had high level
of clinical activity due to very unwell patients and new admissions
requiring seclusion.
Our Safewards pilot will be will be launched in February 2016,
commencing with Pacific and Magnolia. Both wards were in the list of
high incidents of assault on staff and patients in December’s data.
Absconcions - There were eight absconsions during December 2015 from
4 locations; Dan Mooney (2), Endeavour House (1), RAID UHB (1) and
Mary Seacole Ward 1(4). The absconscions review held in December
received very positive feedback from the clinicians in the room and the
actions will be monitored through the Clinical Governance Committee.
CPA - The quality audit has now commenced starting with all the teams in
the Northcroft site. This programme of audit will not be finished in
2015/16 and therefore continue into 2016/17.
Page 30 of 49
New Quality Goals have been set out in the report for 2016/17.
Corporate Risk Register
1. The Trust is currently reporting a total of 8 high level risks across the
organisation – high level risks are those with a score of 15 and above.
This is a reduction of 3 high level risks when compared to the November
2015 reporting position. The high level risks largely represent in-patient
bed capacity (with demand outweighing capacity), failure to comply with
the Mental Health Code of Practice, (particular reference to section 17
leave and consent), staffing levels within Forensic Services, the physical
environment at Reaside Clinic, inadequate physical monitoring during an
episode of rapid tranquilisation and the funding required to facilitate IT
software and licence updates.
2. Mitigating action plans are in place for all of the top risks. These are
attached electronically to enable Committee membership reference.
3. There are a number of risks which are currently attracting a risk score
of 12. The significant bulk of these risks relate to inadequate staffing
levels, challenges in the recruitment process and the high use of
temporary staffing. The weight and volume of these risks across a range
of risk registers has resulted in the Clinical Governance Committee
seeking assurance of a mitigating plan from the head of Human
Resources.
Incidents Summary
The following chart outlines all incidents and Serious Incidents involving Sandwell & West Birmingham Patients
reported within the last six months.
(P) BCC - Birmingham & Solihull Mental Health Trust
Appointments, Discharge & Transfers
Clinical Care (Assessment/Monitoring)
Diagnosis & Tests
Patient Falls, Injuries or Accidents
Records, Communication & Information
Safeguarding
Violence, Aggression & Self Harm
15
2
6
1
2
1
1
2
There have been no new concerns raised about against Birmingham and Solihull MHT FT in March 2016.
Page 31 of 49
7. West Midlands Ambulance Service
Data contained in this report is accurate up to and including March 2016.
STEIS Types & Status
The following chart shows all STEIS incidents reported by WMAS/NHS 111 in the last six months, with breakdowns of
subcategory trends applied to the most common incident types.
Month/Type
Oct
Nov
Dec
Unexpected / potentially avoidable injury requiring treatment to
Unexpected/ potentially avoidable death
2016
Jan
No recorded.
Feb
Sub-optimal care of the deteriorating patient
Surgical/invasive procedure
Treatment delay
Abuse/alleged abuse of child patient by staff
Unexpected / potentially avoidable injury causing serious harm
Mar
Count
3
3
1
1
2
1
1
4
2
2
6
1
1
1
1
1
1
1
1
Complaints Trends
The chart below shows the number and types of complaints and concerns against WMAS that were received by the
CCG in the last six months.
Type
Transport (ambulances and other)
Grand Total
Count
1
1
2
Page 32 of 49
CQRM Summary – 24th February 2016 (no March CQRM)
SQPR/Serious
Incidents
SQPR/Clinical Quality Performance Exceptions:
Indicator/Descriptor
CB_B15_02
Percentage of Category A
Red 2 ambulance calls
resulting in an emergency
response arriving within 8
minutes
LQR1
Ambulance Clinical QualityCategory A (Red 1) 95th
Centile Response Time
Comment
Currently 74.7% ↓, Target 75% (Annual)
There has been a slight reduction this month for this indicator,
but it is unlikely WMAS will fail the annual target of 75%, as the
YTD date figure is 76% with two months remaining.
LQR3 (See and Treat)
Ambulance re-contact rate
following discharge of care
Currently 14.8% ↑, Target = 12%
WMAS to investigate as part of the See and Treat report.
LQR7
Ambulance calls closed with
telephone advice
Currently 5.2% ↑- , Target =>7%
Values moving in the right direction, but too slow to meet the
target. CCG will contact NHS E to consider reviewing the
standards of this indicator.
LQR30
Following arrival at hospital,
patients should be handed
over from ambulance to Non
AE Hospital department,
within 15 minutes.
Currently 34.4%↑, Target <25%
Issue to be delegated to regional CCGs and local Acute Providers.
Currently 12.35% ↑, Target = <10
Most likely linked to seasonal demands of the service – higher
levels of service demand during the winter months. To look at
National Dataset.
CCGs to be informed to investigate handover times at a local
level with regional acute provider trusts.
WCCG to produce a report for outlining actions taken in relation
to handover times in Worcestershire.
SI Reporting
19x SIs during 2015/16
6x New STEIS Incidents reported in January 2016.
Investigation from recent SIs has revealed issues exist within the service regarding the experience levels of
staff. WMAS are working towards improving training and skill mix for DCAs, and are seeking to do this
through utilisation of Paramedic Skill Mix CQUIN, which will run in 2016/17.
Q3 CQUINs
Summary
All CQUIN milestones passed for Q3.
WMAS reported a minor issue with the EPR rollout, identifying hardware/software problems during the
Staffordshire pilot. This issue has been resolved but has pushed the project back 2-3 months. It was
agreed that is important to properly utilise the pilot period to identify and remedy any issues prior to the
whole-scale roll out.
Matters Arising
CQUINs 2016 -17:
Three CQUIN schemes identified: Continuation of EPR; Continuation of Paramedic Pathfinder (though the
name of this will change to avoid confusion with an existing franchise); and Paramedic Skill Set. Schemes
will be drafted by WMAS and sent to CCG for review.
Managing Airways:
A coroner’s report has recommended ambulance services update the training and equipment used in
Page 33 of 49
Endotracheal Tube Insertions. The implementation of this will have an impact on service resource, so
WMAS are submitting a business case for funds to the CCGs.
AQI Outcomes:
WMAS expressed concern that the risk of this indicator is held entirely by WMAS, though part of its
success is down to the Acute Trust. WMAS asked that CCG consider altering the indicator to reflect this.
National Red 2 Audit:
WMAS is involved with a national audit on the status and categorisation of Red 2 calls is currently being
conducted. The results of the audit will recommend changes to the classification pathway of Red 2 calls.
March WMAS Stakeholder Event
A stakeholder event was held in place of the March 2016 WMAS Clinical Quality Review Meeting. Most regional
CCGs were in attendance. Commissioning Intentions for 2016/17 and future measures for Quality were presented
and discussed.
Page 34 of 49
West Midlands Ambulance NHS Foundation Trust CQUINs
Scheme
REDUCED CONVEYANCE:
A reduction in the rate per 100,000 population of ambulance
999 calls that result in transportation to a type 1 or 2 AE Dept.
SEE AND TREAT RECONTACT RATES:
This CQUIN is designed to identify regional DOS gaps in Primary
Care service provision by conducting an analysis of all See &
Treat re-contacts made to the Trust.
ELECTRONIC PATIENT RECORD:
This CQUIN is designed to promote and support the timely
implementation of the EPR system within the Trust, which will
result in numerous quality improvements to the service.
PARAMEDIC PATHFINDER:
This scheme enables the care provider to identify a proactive
approach to individual care management needs but also
potential pathways, designed to provide care for specific
illnesses and long term conditions for all "Green" Activity, and
will support investment in technology for crews to electronically
access the DOS system via MiDOS
SAFEGUARDING:
There is a need to ensure safeguarding practices support the
needs of vulnerable children and adults. Therefore this indicator
is aimed at ensuring that providers continue to embed
safeguarding into practice, implement lessons learnt following a
safeguarding event, reflect on practice and ensure that the
voice of the child/adult is heard.
CLINICAL PATHWAYS HUB:
Introduction of HUB to assist necessary information is relayed
to HCPs to assist continued management of patient conditions
whilst EPR is not in place.
Q1
Q2
Q3
Q4
Comments
Page 35 of 49
8. Unplanned Care
The following chart outlines updates pertaining to the various Unplanned Care
centres/services commissioned by Sandwell & West Birmingham CCG during March 2016.
Some information for this section was supplied by Katie Hayes, Deb Howls and Hannah Askill.
Service
NHS 111
Vocare (NHS 111)
(Latest Update: December
2015)
Update
Activity Summary
KPI Performance
Page 36 of 49
Out of Hours GPs
Primecare
September
NQR 1 – Reporting to the PCT - Fully Compliant
NQR 2 – Consultation data to the practises by 8am the following morning –Fully Compliant (95.5%)
NQR 3 – System in place to encourage transfer of patient details - Fully Compliant
NQR 4 – Audit of Clinical Performance - Fully Compliant
NQR 5 – Audit a sample of Patient contacts - Fully Compliant
NQR 6 – Management of Complaints - Fully Compliant
NQR 7 – Match Capacity to Demand - Fully Compliant
NQR 10 – Face to Face Clinical Assessment (PCC)
Priority 1 PCC – Fully Compliant (100%)
Priority 2 PCC – Fully Compliant (97.2%)
Page 37 of 49
Priority 3 PCC – Fully Compliant (98.1%)
NQR 11 – Appropriate Consultation - Fully Compliant
NQR12 – Face to Face consultations (Home Visits)
Priority 1 Home Visits – Fully Compliant (97.8%)
CQC Visit
The CQC visit was mainly positive and Primecare were rated good in all areas but two. Recommendatio
from CQC were as follows:
The areas where the provider must make improvements are:
• Maintain an accurate audit trail for the location of medicines.
• Develop local arrangements and clear lines of accountability for the management of risks relating
specifically to the Birmingham branch. For example local trends in relation to incidents, audits, patient
feedback and complaints.
• Ensure consistent information is available and visible to patients who attend the primary care centres
relation to complaints.
• Ensure staff are aware of the importance of maintaining confidential patient information.
The areas where the provider should make improvements are:
• Ensure staff are aware who the safeguarding lead for the service is so that they know who contact fo
support and advice if needed.
• Implement systems to ensure all equipment requiring regular testing for electrical safety and calibrat
not missed, including emergency equipment checks.
• Improve signage for patients who need to access the out-of-hours s
Quality
Badger
No incidents reported to CCG in regards to Primecare.
There were no never events.
No duty of candour breaches
No safeguarding cases referred or reported.
Update to be supplied in future Quality Report.
Urgent Care Centres
Malling Health - Parsonage Street
Incidents
All incidents were reported in the relevant timeframe. All incidents reported to UHB through SWB CCG
have been responded too.
SQPR
SQPR Exception Report
RTT waits:
At Trust level all of the referral to treatment targets was achieved. The CCG-commissioned treatment
functions that did not achieve the unfinished target were Neurosurgery, Ophthalmology and General
Surgery. Remedial action plans including trajectories have been developed and plans to address
performance continue to be implemented.
A&E Clinical Quality - Total time spent in A&E - % waiting 4 hours or less:
In December 90.2% of patients left the Emergency Department within 4 hours compared to the target of
95%. The department continued to have significant number of attendances with an average of 300
attendances per day, 8.7% higher than December 2014.
The joint remedial action plan between the Trust and Birmingham CrossCity CCG to address the issues of
increased attendances, pathways for mental health patients and flow continues to be implemented. It
should however be noted that continued pressure has been seen to date in January.
Page 38 of 49
Cancer – 62 Day GP:
Performance against the Cancer 62 GP target in November was 78.3%. A significant improvement from
October performance of 70.5% and September performance of 66.9%. Performance is also in line with the
Trust’s recovery trajectory. Performance against the 62 day GP target for UHB-only pathways was above
target at 86.6%.
A more detailed update will be provided at February Contract Review Meeting.
Cancer 62 Day Screening:
Performance against the 62 day screening target fell in November to 80.0% against a target of 100%. This
indicator is subject to changes such as this due to the small number of patients. This performance equated
to 1.5 patients above tolerance, 1 of which was a late tertiary referral. The Trust expects to achieve this
target in December and the quarter as a whole.
Contract Performance Notice

Issued to UHB for underperformance in regards to finances
Workforce

Increased amounts of vacancies across departments and an increased spend on bank and agency staff
especially in nursing and HCA's. There are also increases across areas in sickness levels of staff
members.
High bank and agency spends.
Training for Hospital & Basic Life support has been under target all year.
Unannounced Visit



Generally positive response after the visit. Stroke ward and matrons were worth special mentions. No
concerns were raised.
Virgin - Summerfield
Incidents- No SIs, No Duty of Candour Breaches, No SG referrals, one incident (needle stick
injury)
Patient Experience – Service utilising a patient participation group to acquire feedback on
service provision; FFT has been implemented.
Activity – Patient numbers have decreased since last year – service has decreased capacity
without compromising patient care or waiting times.
Estates – Virgin meeting CCG estates manager to discuss issues with space.
CRM - Contract review meeting was held on 24 November and no quality issues raised.
Agreed to include an additional KPI of number of patients who leave before being seen into
monthly reporting.
Extended opening hours an key dates over Christmas and new year have been agreed.
Intermediate Care Centres – Q1 Audits
SWBH - Leasowes
No issues to report.
SWBH - Henderson
SWBH - Eliza Tinsley
Unannounced visit to Rowley planned for 15th Feb 2016, following patient complaint.
Unannounced visit completed and feedback session undertaken. Waiting for a response on
actions discussed at the feedback session.
SWBH - D47 Flexi Beds
Currently out to tender. Process to finish on 13th April.
SWBH - D43
Page 39 of 49
BUPA – Ryland View
BUPA - Waterside
Hall Green
Allerton
Manifoldia Grange
Own Bed Instead
Contract review meeting revealed concerns around the tender of the contract. BUPA are
concerned that they may be paying twice for GP cover.
Contract review meeting revealed concerns around the tender of the contract. BUPA are
concerned that they may be paying twice for GP cover.
No issues to report
No issues to report
No issues to report
Discussions about funding for 16/17 being undertaken currently. Birmingham has been costed as
more expensive than Sandwell and prices are being negotiated to ensure value for money.
Page 40 of 49
9. Dudley Group of Hospitals
CQRM Summary (1st March 2016)
Dudley CCG is the Lead commissioner of services provided by The Dudley Group (DGH). Sandwell & West
Birmingham CCG are significant stakeholders and therefore send Quality Team representatives to the CQRM.
Item
Detail
Speech and
Language
Therapy
Summary:
Following concerns raised about the waiting times for routine appointments, the report provides assurance that positive steps
continue to be taken to address the initial concerns raised and there has been no further decline in waiting times for routine
appointments. The overall number of patients waiting for a routine appointment has increased due to a combination of a significant
rise in the number of referrals received from the final week in January onwards and reduced SLT capacity.
It is predicted that due to the above, the impact upon waiting times and response times to urgent referrals will continue and waiting
times are likely to increase. This is likely to be exacerbated by the associated ongoing winter pressures.
The review of triage means that there is now greater assurance that urgent patients are being identified appropriately. The criteria
being used ensures the identification of vulnerable patients and timely access to the Service based upon individual clinical need. It is
acknowledged however, that the priority must remain improving and maintaining response times to urgent referrals within the local
standard of 2 weeks to ensure the benefits of this process are maximized and clinical outcomes and positive patient experience are
consistently achieved.
Despite the ongoing difficulties experienced by the Community SLT Service relating to capacity, the service continues to demonstrate
its commitment to further reduce waiting times whilst delivering high quality patient care.
Controlled
Drugs
Assurance
Report Summary:
The Accountable Officer (AO) for Controlled Drugs for the Trust during 2015-16 was Gideon Kotey, Chief Pharmacist. The CQC’s AO
website reflected this. The systems in place to ensure the appropriate management of controlled drugs are described. The processes
in place to ensure compliance with these systems are described. A variable level of compliance has been observed during 2015 and
as a result, the frequency of the assessment has been changed from twice a year to quarterly.
A summary of controlled drug-related incidents is presented. None gave rise to any concerns of misuse.
The Chief Pharmacist has attended all three Local Intelligence Network (LIN) meetings during 2015. Quarterly Occurrence Reports
have been submitted to the LIN, as required by the Local Area Team’s AO, in a timely manner.
Complaints
Report
Summary:
A detailed report was presented and discussed at the Internal Complaints Review Group chaired by the Chief Executive on the 12
January 2016. The key aspects from this report are:Complaints for Q3
There has been a 20% decrease in activity during Q3, as 72 [86] complaints were registered
100% [100%] of complaints received during Q3 were acknowledged within 3 working days
25% [44%] of complaints received and closed during Q3 were answered within 40 working days (in response to the Trust’s initiative
to offer more local resolution meetings before responses are drafted, complaints have responded favourably but this does mean the
responses are then not worked on until clarity of the complaint is obtained during these meeting, which does impact on the
achievement of an overall response within 40 days – NOTE this time is indicative only, as the 2009 regulations state that timescales
should be agreed with complainants. A local resolution meeting actually brings clarity and realism to these timescales.
51% [65%] of complaints received during earlier quarters and closed during Q3 were upheld/partially upheld
2 [1] complainants expressed dissatisfaction with their response (received and investigated)
28 [17] meetings held with complainants during Q3, plus several meetings still being arranged
Page 41 of 49
0 [5] Inquests held and closed during Q3
0 [0] rule 28 - reports on ‘Action to Prevent Future Deaths’ received from Senior Coroner in Q3
On reviewing the cases referred to the Ombudsman we have reviewed these to see if there was any common themes or issues
within these cases. Our analysis did not identify any areas for us to learn / modify our current processes.
Claims for Q3
5 [12] CNST claims closed, of which 80% [80%] had no settlements made
6 [2] Employer’s liability claim closed, of which 83% [0%] had no settlement costs attributed to Trust
2 [3] new Employer/Public liability claim received
15 [18] new CNST claims received
Workforce
Incidents Summary
(P) Dudley CCG - The Dudley Group (Russells Hall)
Diagnosis & Tests
Medication
Patient Falls, Injuries or Accidents
Pressure Sore
25
8
1
1
4
1
6
3
1
Complaints and Concerns
The following chart outlines all complaints and concerns involving Sandwell & West Birmingham Patients reported
within the last six months.
ID
Date
Type
No complaints/concerns received
Page 42 of 49
10. Birmingham Community Healthcare
CQRM Summary – 31st March 2016
Birmingham South and Central CCG is the Lead commissioner of services provided by Birmingham Community
Healthcare (BCHC). Sandwell & West Birmingham CCG are significant stakeholders and therefore send Quality Team
representatives to the CQRM.
Item
Detail
NHS Trust District
Nurse Vacancies
February 2016
In January 2016 there were 18 new starters: 8 Band 3 Health Care Assistants (HCA); 1
Band 4 Assistant Practitioner; 3 Band 5 Community Staff Nurses and 6 Band 6 District
Nurses.
In February 2016 there were 31 new starters: 8 Band 3 HCAs; 4 Band 4 Assistant
Practitioners; 13 Band 5 Community Staff Nurses; 4 Band 6 District Nurses and 2 Band
7 District Nurse Team Managers
In March 2016 there were 3 new starters: 1 Band 3 HCA; 1Band 4 Assistant
Practitioner and 1 Band 5 Community Staff Nurse
In the March recruitment event on 5th March 2016 there were a total of 20
candidates recruited: 7 Band 3 HCAs; 2 Band 4 Assistant Practitioners and 11 Band 5
Community Staff Nurses.
Please note that currently BCHC community service is going through a
transformational change project which will mean that there will be a number of
changes to the District Nursing teams/skill mix/caseloads so this picture may look
different as of the 1st April
Patient Experience
Report For Quarter 3,
2015/16
Report Summary
The Trust-wide Friends and Family Test (FFT) results for the quarter was 94.89. This
confirms 94.89% of respondents said they were extremely likely or likely to
recommend the service to another.
91.78% of respondents also said they considered the service to be excellent or very
good. This is from a total of 3133 patients who responded to the FFT question and
2955 who responded to questions about how they would rate the service.
DNA Rates per service
(by exception)
Page 43 of 49
Quality Priorities
2016/17
Incidents Summary
(P) BSC - Birmingham Community Healthcare Services
Diagnosis & Tests
Medication
8
1
3
1
1
2
The chart below shows complaints or concerns that have been received about this provider during the past six
months.
ID
1352
1231
1450
Date
17/02/2016
07/12/2015
24/3/2016
Type
Attitude of staff
Page 44 of 49
11. Birmingham Childrens Hospital NHS FT
Incidents Summary
(P) BSC - Birmingham Childrens Hospital
5
2
1
2
months.
ID
Date
Type
No complaints/concerns received
Page 45 of 49
12. University Hospital Birmingham NHS FT
Incidents Summary
(P) BCC - University Hospitals Birmingham
Medication
Pressure Sore
6
1
1
1
1
2
months.
ID
1137
Date
20/10/2015
Type
Appointments, delay/cancellation (in-patient
1209
18/11/2015
Page 46 of 49
13. Smaller Provider Contracts
Data contained in this report is accurate up to and including 31st March 2016.
Incidents Summary
Minor Contracts
(P) BCC - Royal Orthopaedic Hospital
Diagnosis & Tests
(P) BSC - Birmingham Womens Hospital
(P) Solihull CCG - Heart of England
Medication
(P) Walsall CCG - Walsall Healthcare NHS Trust
Infection Control
(P) Wolves CCG - Royal Wolverhampton Hospitals NHS Trust
Pressure Sore
3rd Sector & Private Contracts
(CCG) (Private) Air Products - Home Oxygen Service
Equipment
(CCG) (Private) BMI Healthcare (Edgbaston Hospital)
(CCG) (Private) Camino Healthcare (Mental Health) - Oak House
(CCG) (Private) HealthHarmonie
Diagnosis & Tests
Significant Event
(CCG) (Private) Nutricia Homeward
Medication
(CCG) (Private) Optegra Birmingham Eye Hospital
Theatres
(CCG) (Private) Out of Hours GP Service - Primecare
Medication
Significant Event
(CCG) (Private) Ultra Sound (Health Harmonie)
3
1
1
1
3
2
1
4
2
2
2
1
1
2
1
1
2
2
2
2
2
2
20
3
1
7
8
1
1
1
2
1
1
3
2
1
13
4
Page 47 of 49
Diagnosis & Tests
Workforce
(CCG) (Private) West Midlands Hospital
(CCG) (Private) Lymphcare UK CIC
(CCG) (Private) Notespace (Off Site File Storage Company)
(CCG) (3rd Sector) Marie Stopes International
(CCG) (Private) InHealth Ltd
6
2
1
1
1
1
1
2
2
1
1
1
1
Issues/Trends
Health Harmonie
Health Harmonie now have the capacity to respond to incidents directly via the Datix Incident Reporting system.
Page 48 of 49
14. Local Authority - Nursing/Care Homes
Data contained in this report is accurate up to and including 31st March 2016.
Incidents
There have been 174 incidents reported against Nursing/Care Homes since September 2014.
Incidents Summary – February 2016
Reported
18/03/2016
09/03/2016
03/03/2016
Severity
Minor
Moderate
Minor
Type
Significant Event
Pressure Sore
Medication
There have been no complaints and concerns pertaining to Nursing/Residential Care Homes this month.
ID
Date
Type
Page 49 of 49
GOVERNING BODY/FINANCE & PERFORMANCE COMMITTEE
Report Title:
Report author and Title:
Financial & Activity Report
(as at 31st March 2016)
James Green, CFO
David Hughes, Deputy CFO
Date of Governing Body/ Committee:
Wednesday 4th May 2016
Contact Details:
[email protected]
[email protected]
Agenda No: 7.2
Sign off from Chief Officers: (Before the report is presented to the Governing Body
any implications relating to Finance, Quality and Commissioning must be agreed and
signed by the Chief Officer. (see guidance note) Without this information the report
will not be taken to the Governing Body)
Chief Finance Officer: Agreed
Chief Officer for Quality: NA
Chief Officer for Operations: NA
Chief Officer for Partnership: NA
Supporting Documents/further Reading: (Highlight any documents or further
reading for members which supports this report)
None
Previous Decision (Inform the Governing Body/Committee if the paper has been
reviewed or monitored by another committee and their recommendation or decision)
The purpose of this report is to provide an update to the Finance & Performance
Committee and Governing Body in respect of the CCG’s financial position for
2015/16. The key points are:
Sandwell and West Birmingham CCG’s overall Revenue Resource Limit (annual
budget) is £746m.

The CCG has delivered a surplus of £12m for the financial year 2015/16.

The CCG’s QIPP target for 2015/16 remains at £8.4m and has been delivered for
2015/16.

The CCG has operated within its Running Cost Allowance.

All Better Payment Practice Code metrics have been achieved.
Recommendations:
Members of the Finance and Performance Committee are asked to:
 Discuss the content of the report;
 Approve the content of the report and the year-end position.
Action
Approve
Assurance
Decision
Conflict noted, conflicted party can participate in clinical discussion
but not decision
circumstances only)
Quality & Safety
Partnership
Implications:
Financial
Assurance Framework
Consultation: X
Patients
Staff
Committees
Public
Partners
Sponsored By: (Chief Officer or James Green, CFO
Committee Chair)
Date Report received for Governing
Body/Committee
X
X
X
Finance and Performance Committee
Report Topic:
Finance and Activity Report as at 31st March 2016 (Month 12/Year-end)
Report From:
James Green – Chief Finance Officer
Date:
Monday 25th April 2016
Purpose of the Report
To provide information to the committee on the financial performance of the CCG for the 2015/16 financial
year-end.
Key Issues Summary

Sandwell and West Birmingham CCG’s overall Revenue Resource Limit (annual budget) is £746m.


The CCG’s QIPP target for 2015/16 was £8.4m. This target has been delivered for 2015/16.

The CCG has operated within its Running Cost Allowance.

Recommendations
1. Discuss the content of the report;
2. Approve the content of the report and the year-end position.
Executive Summary – CCG Assurance
Commentary
Financial Performance
No. Indicator
1 Underlying Recurrent Surplus
Self
Assessment
2.3%
Surplus - Year to Date Performance 2
Variance
0.5%
3 Surplus - Full Year Forecast - Variance
0.5%
4
Management of 2% NR Funds Within
Agreed Processes
5 QIPP - Year to Date Delivery
6 QIPP - Full Year Forecast
Clear Identification of Risks Against
Financial Delivery & Mitigations
Overall: All Primary Indicators Are Green

The underlying surplus is calculated by taking the forecast financial
position, adjusting for the full year effect of expenditure
commitments/savings and removing non-recurrent items.
The
underlying surplus (as submitted in our latest update to NHSE in
respect of March 2016) is 2.3% of total expenditure. This attracts a
green rating.

The outturn surplus (£12m) is rated as green. This is £3.2m higher
than the surplus originally planned at the beginning of the year.

Full achievement of £8.4m QIPP target has been secured.

The CCG’s Running Costs Allowance expenditure has been delivered
at £10.9m for 2015/16, within the adjusted Running Cost Allowance
ceiling of £12.3m. The CCG’s running cost ceiling has increased inyear following the receipt of a non-recurrent quality premium
allocation (£0.9m) in December 2015.
100%
100%
8 Activity Trends - Full Year Forecast
10
The table opposite is similar to the CCG assurance framework used
by NHS England to assess the financial performance of CCGs. The
overall performance is rated as green.
Yes
7 Activity Trends - Year to Date
9 Running Costs

88%
Indicator Met In
Full
Green
1. Financial Position
Commentary
 The CCG’s Revenue Resource Limit for 2015/16 is £746m.

The CCG’s year-end surplus is £12m.

The CCG’s running costs have delivered a total under spend of £1.5m.
This includes the quality premium allocation of £869k for which costs are
sitting in programme expenditure.

A more detailed breakdown of the financial position can be found in
Appendix 1 of this document.
Surplus Analysis (in £000s)
£14,000
£12,000
£10,000
£8,000
£6,000
£4,000
£2,000
£0
Plan
Actual
2. Revenue Resource Limit
The CCG’s Revenue Resource Limit (income) for 2015/16 is £746m. This is significantly higher than previous years and reflects the
additional allocations received in respect of primary care co-commissioning and the Better Care Fund. The CCG’s Revenue Resource
Limit has increased by £491k since last month. An overview of the allocation increases are shown below:-
Revenue Resource Limit at Month 11
Third Sector contract adjustments
Vanguards: Rapid Test Site - Modality
Vanguards: Vitality / Modality - National Support package
Revenue Resource Limit at Month 12
746,269
345
72
74
746,760
3. Contract Finance
The table below details the CCG’s higher value contracts. The main contracts to note are SWBH and Dudley Group. The SWBH and Dudley
Group contracts are analysed later in this report.
ACUTE:
Sandwell & West Birmingham Hospitals NHST
Dudley Group of Hospitals NHS FT
University Hospitals Birmingham NHS FT
Birmingham Children's Hospital NHS FT
Heart of England NHS FT
Walsall Healthcare NHST
Birmingham Women's Hospital NHS FT
Royal Orthopaedic Hospital NHS FT
Royal Wolverhampton Hospitals NHST
West Midlands Ambulance Service
Extended Choice
COMMUNITY:
Sandwell & West Birmingham Hospitals NHST
Birmingham Community Healthcare NHST
MENTAL HEALTH:
Black Country Partnership NHSFT
Birmingham & Solihull MH NHSFT
Dudley & Walsall MH Partnership NHST
Annual
Budget
£000
233,011
30,153
21,086
9,530
8,518
7,295
5,027
4,669
1,914
17,238
2,441
Annual
Budget
£000
26,685
19,695
Annual
Budget
£000
34,238
747
1,878
YTD
Budget
£000
233,011
30,153
21,086
9,530
8,518
7,295
5,027
4,669
1,914
17,238
2,441
YTD
Budget
£000
26,685
19,695
YTD
Budget
£000
34,238
747
1,878
YTD
Actual
£000
228,661
32,238
21,379
9,146
8,464
7,406
5,198
5,329
1,979
16,961
2,936
YTD
Actual
£000
26,839
19,801
YTD
Actual
£000
34,203
807
1,878
YTD
Surplus/
(Deficit)
£000
4,350
(2,085)
(293)
384
54
(111)
(171)
(660)
(65)
277
(495)
YTD
Surplus/
(Deficit)
£000
(154)
(106)
YTD
Surplus/
(Deficit)
£000
35
(60)
0
Forecast
Outturn
£000
228,661
32,238
21,379
9,146
8,464
7,406
5,198
5,329
1,979
16,961
2,936
Forecast
Outturn
£000
26,839
19,801
Forecast
Outturn
£000
34,203
807
1,878
Forecast
Surplus/
(Deficit)
£000
4,350
(2,085)
(293)
384
54
(111)
(171)
(660)
(65)
277
(495)
Forecast
Surplus/
(Deficit)
£000
(154)
(106)
Forecast
Surplus/
(Deficit)
£000
35
(60)
0
4. Sandwell and West Birmingham Hospital
The tables below summarise the contract monitoring information provided by Sandwell and West Birmingham Hospital (SWBH) for the
period April to February 2016. A full a final settlement for the contract (and other related non-contractual items) has been agreed at
£255.5m. The monitoring information provided SWBH can be summarised as follows:YTD M11
Activity
A&E
Elective
Emergency
Outpatients (New)
Outpatients (review)
Total
Cost
A&E
Elective
Emergency
Outpatients (New)
Outpatients (Review)
Community
Other
Total
Plan
143,221
63,374
47,886
101,279
240,291
596,051
YTD M11
Actual
142,711
63,135
47,356
104,137
230,195
587,534
YTD M11
YTD M11
Plan
£000
Actual
£000
14,495
38,248
62,060
14,846
18,983
23,862
64,395
236,889
13,861
34,036
63,364
15,048
17,805
23,995
65,520
233,629
YTD M11
Full year
Variance Below/(Above)
Plan
Plan
510
155,236
239
70,087
530
52,626
(2,858)
111,227
10,096
265,461
8,517
654,637
YTD M11
Full Year
Variance Below/(Above)
Plan
£000
£000
634
4,212
(1,304)
(202)
1,178
(133)
(1,125)
3,260
15,711
42,157
68,152
16,304
20,972
26,537
68,984
258,817
5. Dudley Group Hospitals
The tables below summarise the contract monitoring information provided by Dudley Group of Hospitals for the period April to February
2016. This information has been used when reporting the CCG’s financial position and grossed up to month 12 in the financial tables of this
report. The monitoring information provided DGOH can be summarised as follows:-
Activity
A&E
Elective
Emergency
Outpatients (New)
Other
Total
Cost
A&E
Elective
Emergency
Outpatients (New)
Community
Other
Total
YTD M11
Plan
12,892
10,604
6,956
13,801
33,734
60,594
138,581
YTD M11
Plan
£000
1,579
5,719
11,238
1,830
2,223
367
4,997
27,953
YTD M11
Actual
15,657
11,345
9,887
14,729
33,476
67,223
152,317
YTD M11
Actual
£000
1,909
5,946
12,356
2,061
2,222
367
5,087
29,948
YTD M11
Variance
(2,765)
(741)
(2,931)
(928)
258
(6,629)
(13,736)
YTD M11
Variance
£000
(330)
(227)
(1,117)
(232)
1
0
(90)
(1,995)
Full year
Plan
14,119
12,683
9,677
15,062
36,870
66,948
155,359
Full Year
Plan
£000
1,729
6,243
12,305
1,997
2,427
401
5,460
30,563
Non-elective – The trust is experiencing significantly higher levels of activity when compared to last year. A&E – The plan for A&E was
reduced for 2015/16 due to the Dudley Urgent Care Centre opening in April 2015. However, the DUCC is not achieving the activity levels
predicted; hence A&E is slightly higher than expected. There has been a significant reduction in the lower HRG/tariff activity levels with an
increase in the higher level tariff activity. Daycase – The trust is increasing activity to ensure RTT targets are achieved.
6. Prescribing Performance
Commentary
Prescribing - Outturn
•
The prescribing budget for 2015/16 is £87.8m,
with expenditure of £88.9m.
•
Information from the Prescription Pricing
Authority has been received for the period
April to February 2016.
•
The graph below shows a comparison of
prescribing expenditure over the financial
years 2013/14 to 2015/16.
Actual £000's
Budget £000's
87,000
87,500
88,000
88,500
89,000
89,500
Prescribing - Expenditure
£7,400,000
£7,200,000
£7,000,000
2013/14
£6,800,000
2014/15
£6,600,000
£6,400,000
£6,200,000
£6,000,000
2015/16
7. Quality Innovation Price Productivity (QIPP)
Commentary
 The CCG’s overall QIPP target for the year was £8.4m.
 The outturn is full achievement of the planned £8.4m. However, there are a number of schemes (inc. readmissions, displaced
activity, etc.) that have not delivered the originally planned savings.
 The shortfall against these schemes has been replaced by recurrent underspends identified through in-year budgetary reviews.
QIPP Schemes
Category
Phasing
Transactional
Readmissions
Community Prescribing
Mental Health Services
Acute Services
October to March
Primary Care ServicesApril to March
Acute Services
April to March
Total Transactional schemes
Year to Date
Actual
Variance
£'000
£'000
Plan
£'000
Annual Plan
£'000
Forecast
Actual
£'000
Variance
£'000
419
1,230
1,200
0
1,230
1,200
(419)
0
0
419
1,230
1,200
0
1,230
1,200
(419)
0
0
2,849
2,430
(419)
2,849
2,430
(419)
Transformational
Push Site NEL scheme
Contract Review
SWBH Displaced Activity
Acute Services
October to March
Programme Services October to March
Acute Services
April to March
409
262
3,000
409
262
0
0
0
(3,000)
409
262
3,000
409
262
0
0
0
(3,000)
Running Costs
Running
1,870
1,500
(370)
1,870
1,500
(370)
5,541
2,171
(3,370)
5,541
2,171
(3,370)
Total Other Schemes
0
0
0
0
0
0
In Year Commentary Schemes - Transactional
Other
In Year Commentary Schemes - Transformational
Other
In Year Commentary Schemes - Other (Net Budget Variances)
Other
0
0
0
0
0
3,789
0
0
3,789
0
0
0
0
0
3,789
0
0
3,789
8,390
8,390
0
8,390
8,390
0
Total Transformation schemes
Total QIPP Schemes
April to March
8. Statement of Financial Position
31 March 2016
Non-Current Assets
Total Non-Current Assets
Current Assets
Inventory
Trade and Other Receivables
Accrued Income and Prepayments
VAT
Bad Debt Provision
Cash and Cash Equivalents
Commentary
£'000
0
0
0
3,137
3,088
9
(1,026)
337
Total Current Assets
5,545
Total Assets
5,545
Current Liabilities
Trade and Other Payables
Accrued Expenditure and Deferred Income
Prescribing
Provisions
Tax and Social Security
(16,473)
(11,038)
(13,798)
(3,570)
(195)
Total Current Liabilities
(45,074)
Non-Current Assets plus/less Net Current
Assets/Liabilities
(39,529)
Non-Current Liabilities
Trade and Other Payables
Provisions
Total Non-Current Liabilities
0
0
0
Assets Less liabilities
(39,529)
Financed by Taxpayers' Equity
General Fund
Revaluation Reserve
Charitable Reserves
Total Taxpayers' Equity
(39,529)
0
0
(39,529)
 The balance sheet cash book balance
was £337k at the end of March, with a
further £69k timing adjustment.
 Trade and other receivables include
£1.8m of debts that are less than one
month overdue.
 The accrued income and prepayments
figure includes £2.129m in respect of
maternity pathways prepayments.
9. Cash Efficiency
Commentary
The CCG has a bank balance of £268k at the end of March. This balance was within the 1.25% ceiling set by NHSE. (Note: This
excludes the impact of the CCG’s pooled budgets.)
The CCG has a bank balance of £287k at the end of November 2015. This balance was within the 1.25% ceiling set by NHSE.
10. Better Payment Practice Code
2015-16 Year to Date
2014-15 (April 2014 to
(April to March 2016)
March 2015)
31-Mar-16
31-Mar-16 31-Mar-15 31-Mar-15
Number
£'000
Number
£'000
Non-NHS Payables: CCG
Total Non-NHS trade invoices paid in the year
Total Non-NHS trade invoices paid within target
Percentage of CCG non-NHS trade invoices paid within
target
NHS Payables: CCG
Total NHS trade invoices paid in the year
Total NHS trade invoices paid within target
Percentage of CCG NHS trade invoices paid within
target
14,919
14,285
108,833
104,653
11,249
10,835
62,643
57,475
95.75%
96.16%
96.32%
91.75%
3,568
3,441
488,083
486,158
3,446
3,226
498,195
489,548
96.44%
99.61%
93.62%
98.26%
Commentary
The CCG is required to pay 95% of all valid invoices
within 30 days.
In Month
During March, 2,037 invoices were registered with a
combined value of £57.3m.
Better Payment Practice Code performance for March
showed that 96% of Non NHS invoices were paid within
30 days (with 96% in value terms) paid on time.
Better Payment Practice Code performance for March
showed that 96% of NHS invoices were paid within 30
days (with 99% in value terms) paid on time.
102.00%
100.00%
98.00%
96.00%
94.00%
92.00%
90.00%
88.00%
Invoices Paid
Overall Performance
% Passed
The annual performance is above the required target of
95%.
% Amount
Passed
95.7% of Non NHS invoices have been paid within 30
days.
% Target
96.4% of NHS invoices have been paid within 30 days.
11. Conclusion
In conclusion, the key points to note from this report are:
Sandwell and West Birmingham CCG’s overall Revenue Resource Limit (annual budget) is £746m.


The CCG’s QIPP target for 2015/16 remains at £8.4m and has been delivered for 2015/16.

The CCG has operated within its running cost allowance.

12. Recommendations


Discuss the content of the report;
Approve the content of the report and the year-end position.
Contact Officers
James Green – Chief Finance Officer – [email protected] - Tel: 0121 612 1568
David Hughes - Deputy Chief Finance Officer – [email protected] – Tel: 07872055022
Appendix One
Annual Budget
YTD Budget
YTD Actual
£000
£000
£000
YTD
Surplus/(Deflicit)
£000
Forecast Outturn
£000
Forecast
Surplus/(Deflicit)
£000
SOURCES OF FUNDING
Confirmed Allocations - Commissioning
Confirmed Allocations - Primary Care Co-Commissioning
(672,777)
(73,983)
(672,777)
(73,983)
(672,777)
(73,983)
0
0
(672,777)
(73,983)
0
0
Total Revenue Resource Limit
(746,760)
(746,760)
(746,760)
0
(746,760)
0
NHS Acute Services
Sandwell and West Bham NHS Trust
University Hospitals Birmingham NHS FT
Walsall Hospitals NHS Trust
Heart of England NHS FT
Birmingham Womens Hospital NHS FT
Birmingham Childrens Hospital NHS FT
Royal Orthopaedic Hospital NHS FT
Royal Wolverhampton Hosps NHS Trust
West Midlands Ambulance Services NHS Trust
Worcester Acute Hospitals NHS Trust
University Hospitals of North Midlands NFT
233,011
21,085
30,153
7,295
8,518
5,027
9,530
4,669
1,956
17,238
344
196
233,011
21,085
30,153
7,295
8,518
5,027
9,530
4,669
1,956
17,238
344
196
228,651
21,121
32,477
7,380
8,487
5,243
9,198
5,340
2,052
17,130
402
198
4,361
(36)
(2,325)
(85)
31
(216)
331
(671)
(96)
109
(58)
(2)
228,651
21,121
32,477
7,380
8,487
5,243
9,198
5,340
2,052
17,130
402
198
4,361
(36)
(2,325)
(85)
31
(216)
331
(671)
(96)
109
(58)
(2)
Total NHS Acute Services
339,022
339,022
337,679
1,343
337,679
1,343
3,445
108
2,441
137
3,445
108
2,441
137
3,850
1
2,957
529
(405)
107
(516)
(392)
3,850
1
2,957
529
(405)
107
(516)
(392)
APPLICATIONS - PROGRAMME
Acute Services
Acute Services Other
Non Contracted Activity & Out of Area
Individual Funding Requests
Extended Choice Contracts
Other Acute Services
Total Acute Services Other
6,131
6,131
7,337
(1,206)
7,337
(1,206)
345,152
345,152
345,015
137
345,015
137
26,685
19,696
253
144
411
0
47,189
26,685
19,696
253
144
411
0
47,189
26,839
19,866
253
147
416
0
47,522
(153)
(170)
(0)
(3)
(6)
0
(333)
26,839
19,866
253
147
416
0
47,522
(153)
(170)
(0)
(3)
(6)
0
(333)
Community Assessment
NHS 111
Clinical Assessment & Urgent Care Centres
2,287
3,313
2,287
3,313
2,442
2,907
(155)
407
2,442
2,907
(155)
407
Total Community Assessment
5,600
5,600
5,348
252
5,348
252
Continuing Healthcare
Continuing Healthcare - Physical Disabilities
Continuing Healthcare - Children
Continuing Healthcare - Staffing
Continuing Healthcare - Joint Funded
Personal Health Budgets
Funded Nursing Care
Looked After Children
Birmingham Children's Hospital - Complex Care
8,933
369
1,661
0
330
5,962
1,517
650
8,933
369
1,661
0
330
5,962
1,517
650
11,766
365
1,539
0
309
4,485
1,047
586
(2,833)
5
121
0
22
1,477
470
64
11,766
365
1,539
0
309
4,485
1,047
586
(2,833)
5
121
0
22
1,477
470
64
Total Acute Services
Commissioned Community Services
NHS Community Services
Sandwell & West Birmingham Hospitals
Birmingham Community Healthcare Trust
Walsall Hospitals NHS Trust
Royal Wolverhampton Hosp NHS Trust
Birmingham Community Health Care Trust - Non Contracted
Total NHS Community Services
Total Continuing Healthcare
19,423
19,423
20,097
(675)
20,097
(675)
Other Community Services
Interpreting Services
Reablement
Safeguarding (Programme)
Carers
Hospices
Pallative Care
Intermediate Care
Push Site Investments
Joint Equipment Stores
Patient Transport
Non NHS Community Contracts
791
347
827
756
1,138
905
2,073
3,752
0
438
6,609
791
347
827
756
1,138
905
2,073
3,752
0
438
6,609
875
295
931
531
1,174
643
1,803
3,718
3
525
6,225
(85)
52
(104)
224
(36)
262
270
34
(3)
(87)
384
875
295
931
531
1,174
643
1,803
3,718
3
525
6,225
(85)
52
(104)
224
(36)
262
270
34
(3)
(87)
384
Total Other Community Services
17,636
17,636
16,723
913
16,723
913
Property Costs
NHS Property Costs
3,230
3,230
5,185
(1,955)
5,185
(1,955)
Total Property Costs
3,230
3,230
5,185
(1,955)
5,185
(1,955)
93,078
93,078
94,876
(1,798)
94,876
(1,798)
Total Community Services
Total Mental Health & Learning Disabilities
89,480
89,480
90,529
(1,049)
90,529
(1,049)
Winter Pressure Schemes
Winter Pressures - West Midlands Ambulance Service
1,829
2,031
1,829
2,031
1,847
2,031
(18)
0
1,847
2,031
(18)
0
Total Mental Health & Learning Disabilities
3,860
3,860
3,878
(18)
3,878
(18)
GP Commissioning (Delegated)
Local Incentive Schemes
Out of Hours
GP IT
CCG Primary Care Investment
73,983
999
3,165
1,942
213
2,239
73,983
999
3,165
1,942
213
2,239
73,983
924
3,455
1,778
348
1,220
0
75
(290)
164
(135)
1,019
73,983
924
3,455
1,778
348
1,220
0
75
(290)
164
(135)
1,019
Total Primary Care
82,541
82,541
81,707
833
81,707
833
Prescribing Practice Budgets
Prescribing Other
Home Oxygen
Medicines Management Clinical
82,441
3,641
931
764
82,441
3,641
931
764
82,559
4,935
924
548
(118)
(1,294)
6
216
82,559
4,935
924
548
(118)
(1,294)
6
216
Total Prescribing
87,777
87,777
88,967
(1,190)
88,967
(1,190)
Better Care Fund
18,061
18,061
18,060
1
18,060
1
Total Better Care Fund
18,061
18,061
18,060
1
18,060
1
Reserves, Contingency & QIPP
Quality Premium
5,684
0
5,684
0
0
869
5,684
(869)
0
869
5,684
(869)
Total Reserves
5,684
5,684
869
4,815
869
4,815
725,633
725,633
723,902
1,731
723,902
1,731
9,016
2,283
940
110
9,016
2,283
940
110
7,470
2,280
956
146
1,546
3
(16)
(36)
7,470
2,280
956
146
1,546
3
(16)
(36)
Winter Pressures
Primary Care
Prescribing
Better Care Fund
Reserves, Contingency & QIPP
TOTAL PROGRAMME EXPENDITURE
APPLICATIONS - RUNNING COSTS
CCG Running Costs
CCG Running Costs - CSU
CCG Running Costs - Primary Care Co Commissioning
CCG Running Costs - NHS 111
TOTAL RUNNING COSTS
TOTAL EXPENDITURE
SURPLUS
12,349
12,349
10,853
1,496
10,853
1,496
737,982
737,982
734,754
3,228
734,754
3,228
8,778
8,778
12,006
3,228
12,006
3,228
Report Topic:
Key Indicators Performance Report – data up to March
2016
Report From:
James Green – Chief Finance Officer
Date
25th April 2016
Aim of Report
To provide information to the Board on the
performance of the CCG against key indicators for the
2014/15 and 2015/16 financial years.
Discussion Points
- Planning Round 2016/17
- Exception Reports
- Outcomes Measures
- A&E
- Cancer waits
- Ambulance Red 2 incidents
- IAPT
Members of the Committee are asked to:
RECOMMENDATIONS
1. Discuss the contents of the report
2. Approve the contents of the report
Contents
Section
Page
Key Messages
2
Outcomes Domain 1
3
Outcomes Domain 2
4
Outcomes Domain 3
5
Outcomes Domain 5
6
The Forward View into action - Annex B Measures
7
Legend
17
1
Key Messages
Summary:
Summary Continued:
Our lead roles and responsibilities:
Planning Round
The final submission of the CCG Monthly Activity Template for 16/17 plans was made
on 18th April 16. This included plans for the constitution indicators plus WMAS,
activity, IAPT , Dementia and LD plans. A copy of the template is attached at the end
of the report for information.
Cancer Waits
In February, the CCG failed to meet the 31 day targets for subsequent surgery and anticancer drug. 4 patients in total waited over 31 days, 2 due to capacity reasons and 2
admin errors. The CCG also failed to meet the 62 day urgent referral to first treatment
standard. 11 patients in total waited over 62 days, 6 for medical reasons, 3 late tertiary
referrals, 1 patient choice and 1 capacity.
In 2014/15 Sandwell and West Birmingham Clinical Commissioning
Group (SWB CCG) is the lead commissioner on;
Exception Reports
We are trying to embed a process for the timely turnaround of exception reports from
SWBHT. The CCG Performance Strategy specifies a 5 day turnaround for returning
completed exception reports, but this timeline is not always adhered to. In future we
will report the turnaround dates of exception reports through the monthly Contract
Review Meetings with SWBHT.
Outcomes Measures
There have been a few updates to the outcomes measures namely smoking at
delivery, dementia, emergency re-admissions, IAPT, MRSA & Cdiff.
Accident & Emergency (A&E)
Performance continues to fall below the 95% 4 hour A&E standard, as in previous
months. In addition, the Easter bank holiday weekend fell early this year, at the end of
March. This weekend and the days following it are typically a busy period for urgent
care services with increased attendances. The majority of ED breaches relate to delays
in clinical decision making, ED cubicles being full and awaiting beds in MAU. Staffing
issues are still present with heavy reliance on agency and locum staff and a number of
unfilled shifts each day
It is still not clear whether the Trust have signed up to the Strategic Transformation
Fund. The CCG plans submitted on 18th April, which included a Trust wide A&E plan,
reflect the Trust’s STF trajectory and are below the national 95% target.
Ambulance Red 2 incidents
Red 2 incidents for WMAS as a whole failed to meet the national target for the second
month in a row. Although Red 2 performance is projected to achieve the national
target at the end of the year, if performance continues to fall in M12 at the same rate,
it is likely that Red 2 performance will not be achieved. This will be discussed with the
provider at the Contracts Review Meeting. For Sandwell and West Birmingham CCG,
performance against Red 1, 2 and 19 exceeded the Trust-wide average and the forecast
is that all national targets will be exceeded.
IAPT
National data has been published for December. The CCG achieved both entering
treatment and moving to recovery, although moving to recovery was only just above
target again at 50.7%. National data for Q3 will not be published until later in April.
Progress has been made on the Birmingham side with the reconciliation process. On
the Sandwell side a new IT system has been put into place from 1st April.
NHS 111 across the West Midlands.
WMAS across the West Midlands
Home Oxygen across the West Midlands.
Urgent care for the Black Country
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Hea
Sandwell and West Birmingham CCG is leading the reconfiguration of
Stroke services across Birmingham and the Black Country on behalf
of all commissioners.
Stroke
Our significant CCG redesign projects are;
Community Nursing
Diabetes
Right care right here – As part of the partnership programme an on-going
process of redesigning services with a stronger Community focus.
2
Outcomes Domain 1. Preventing people from dying prematurely
Data
Quality
Previous Year
Indicator
Target
Statistic
Basis
A
M
J
J
A
S
O
N
Current Monitoring Year
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Reducing deaths in babies and young children
High
Antenatal assessments <13 weeks
Increase
%
CCG



High
Maternity smoking at delivery
Reduce
%
SWBHT





High
Breast feeding prevalence at 6-8 weeks
Increase
%
SWBHT






Q3 14-15
129.42%
117.90%
Q2 15-16
10.00%
10.24%
Q1 15-16
33.42%
33.42%
No new data since last report
Antenatal assessments - Again this quarter we have an improper percentage. 2146 patients having an assessment within 13 weeks out of 1898 patients in total. The only way this could be correct is if it is to do with the timing of the assessments crossing over between months. Three
other CCGs in the local area also had percentages over 100.
Updated
Performance remained at a similar level in Q2, although the number of maternities was up to over 2000 compared to 1631 in Q1. SWBCCG continue to sit in the middle across the local patch with Birmingham Cross City CCG having the lowest rate of 8.2% and Dudley CCG the highest
at 14.5%. There is no national or regional average published to compare against.
Breastfeeding Prevalence - Breastfeeding prevalence at Q1 remained just over 30%, still the lowest on the local patch and more than 10% lower than the England average.
Performance for these indicators will be raised with the commissioning programme lead in due course through the performance strategy process.
3
Outcomes Domain 2. Improving quality of life for people with long-term conditions
Data
Quality
Previous Year
Indicator
Target
Statistic
Basis
Increase
67%
CCG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J










F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Enhancing quality life for people with dementia
High
Estimated diagnosis rate of people with
dementia

Jan-16
66.09%
R
Updated
Diagnosis may have reduced in Primary Care due to General Practitioners no longer being incentivised. Further, there is a lack of service provision locally once a patient has received a diagnosis. The CCG are working with local partners, specifically neighbouring CCGs (BXC) to put in
place Dementia Navigators to provide post diagnostic support and negotiating with the Local Authority for funding through the Better Care Fund.
4
Outcomes Domain 3. Helping people to recover from episodes of ill health or following injury
Data
Quality
Previous Year
Indicator
Target
Statistic
Basis
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Overarching Indicators
High
Emergency admissions for acute
conditions that should not usually require
hospital admission
Reduce
DSR
CCG




High
Emergency readmissions within 30 days of
discharge from hospital
Reduce
%
CCG




1813.30
Q4 14-15











Feb-16
8.23%
9.47%
R
G
Emergency admissions that should not usually require admission
Data for Q4 shows an increase again in the DSR. Increases were also seen in all 6 CCGs across the local patch and for England as a whole (1272.4).
Updated
Emergency re-admissions within 30 days
There was a very slight reduction in re-admissions in January. Overall though, year to date a similar position to last year. It is not clear from the technical guidance what the baseline for this indicator is and therefore the directional arrows show improvement from the previous data
period. National publications are out of date with the latest being 2012. A benchmarking exercise against 4 local CCGs shows SWB is still marginally higher, with Birmingham Cross City being the next highest with 7.13%.
Improving recovery from mental health conditions
High
IAPT - People entering treatment
>=15%
%
CCG






Q2 15-16
3.96%
7.79%
G
High
IAPT - Moving to recovery
>=50%
%
CCG






Q2 15-16
50.66%
49.31%
G
High
IAPT - Moving to recovery
>=50%
%
BCPFT






Q2 15-16
48.65%
48.18%
R
Updated
CCG
No new data is shown in the report however, monthly data has been received for December and is reported in the words below.
The latest national data published for December shows the numbers entering treatment are running above the planned level with some headroom for the remainder of the year.
The December moving to recovery percentage was almost the same as November at 50.7%. Q3 data is due to be published with the January data on 20th April. Until then we won’t know if we have met the national target for Q3, but it is expected to be very close.
There have been further discussions with the Birmingham Joint Commissioning team around the discrepancies between local and national data on the West Birmingham side and this is being addressed through a reconciliation process between the CSU, BSMHT and The Birmingham
MH Consortium. Initial findings are that both trusts have incorrectly completed the appointment type field in the national submission. We should start to see the results of this in their data from 1st April 16.
A New IT system called PCMIS has been put into place for the Sandwell side of IAPT for all providers from 1st April 2016. This will enable commissioners and CSU to directly see where there are any performance issues including DNA’s, how quickly people are seen, where any bottle
necks are etc. The previous system did not allow for this. Kulbinder Thandi (Senior Commissioning Manager) has worked with the CSU team, to draw off reports whenever required. The reports will be live as opposed to relying on the provider giving us their local data and then us
comparing it to national data which was sometimes way out. The data entry has to be done in each field in order to move onto the next info requirement, therefore allowing for less inaccuracies and need for ‘cleaning data’ at the end of the period.
We have agreed to move to cost and volume for our IAPT contracts and have advised present providers. Good practice model information has been received from NHSE IAPT national team so work will commence on this shortly. BCPFT are in agreement to move forward. We have
also informed BSMHT via the joint commissioning team in Birmingham that we want to move to cost and volume but with 3 parts to the tariff to promote reaching the targets. At present BSMHFT are on a cost and volume contract but on entering treatment they get the full payment.
BCPFT are on a block contract and the 3rd sector providers are on a block contract too.
BCPFT
Performance against the moving to recovery target for BCPFT improved in the three months of Q3 which were all above the 50% target.. The contracting arrangements for BCPFT are not on a host CCG basis but are held and monitored separately by SWBCCG and Wolverhampton
CCG.
5
Outcomes Domain 5. Treating and caring for people in a safe environment and protecting them from avoidable harm
Target
Data
Quality
Indicator
Previous Year
Green
Amber
Statistic
Basis
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Improvement Areas
Reducing the indidence of avoidable harm
High
MRSA
Zero
0
Number
CCG
0
1
2
2
2
3
3
3
3
5
6
7
1
1
2
2
2
2
3
4
4
4
5
Feb-16
1
5
R
High
MRSA
Zero
0
Number
SWBHT
0
0
0
0
0
1
1
1
1
1
1
2
0
0
1
1
1
1
2
2
2
2
2
Feb-16
0
2
R
High
Cdiff
Reduce
109
Number
CCG
12
19
27
42
51
62
74
79
88
95
107
124
7
14
23
39
46
55
66
76
88
94
103
Feb-16
9
103
G
High
Cdiff
Reduce
37
Number
SWBHT
3
5
7
9
13
17
19
20
20
20
24
29
2
4
8
10
13
14
16
17
20
23
26
Feb-16
3
26
G
Updated
MRSA
CCG - There were 1 non-acute infection for the CCG in February at SWBHT. Year to date the CCG has had 5 infections.
SWBHT - There were 0 infections for SWBHT in February. Year to date there has been 2 infections.
Cdiff
CCG - There were 9 infections in February, 2 acute at SWBHT and 7 non-acute, 6 at SWBHT and 1 at UHB. The CCG are within the 109 year to date target.
SWBHT - There were 3 infections for the Trust in February. The Trust remains within their YTD target of 37.
6
The Forward View into action - Annex B Measures
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
92%
87%
%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
92.07%
G
SWBHT























Feb-16
92.00%
G
    


   


    

  

Feb-16
5
A
     


  


  
 
Feb-16
3
A
Incomplete Referral to Treatment pathways
High
High
% of incomplete pathways within 18
weeks
Number of 52 week Referral to Treatment
Pathways - Incomplete
CCG
0
10
Number
SWBHT
RTT - Incomplete - CCG

95.0%
90.00%
90.0%
85.00%
85.0%
80.00%
80.0%
75.00%
75.0%
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
100.0%
95.00%
% < 18 wks
National Target
Amber Threshold
% < 18 wks
RTT - Incomplete > 52 wks - CCG
8
National Target
Amber Threshold
RTT- Incomplete >52 wks - SWBH
4
3
3
2
2
1
1
0
6
4
2
0
Number > 52 wks
National Target



CCG - Updated
Overall the CCG were meeting the target. 2278 out of 28730 patients waited over 18 weeks.
RTT Incomplete - SWBH
100.00%

5 patients waited over 52 weeks, 2 at SWBHT, 1 in Cardiology & 1 in Dermatology, exception reports have been
requested. 3 were at ROH, the latest report from the Clinical Quality Contract Review Group (CQCRG) is as follows:
All patients are spinal deformity bar one. There are still problems with BCH, unavailability PICU beds has been an issue
in the last few months. ROH are almost all the way through the Cromwell exercise, so 30 patients will have been
treated at Cromwell in the next 2 weeks.
The backlog at Horton is also being dealt with.
We are looking at all patients going to the Cromwell next year. The Cromwell works well but is expensive as well as a
long trip for our patients. It has been a challenge getting patients to go despite having this signed off. 33 patients in
total have agreed to attend.
There is a meeting in the pipeline with specialised commissioners about the extra activity as part of contract
discussions from last year. We have been asked to provide them with information about what capacity would be
required to get below 52 weeks etc. This was looking at BCH patients whilst doing a similar exercise with our own
patients on this site to provide them with that narrative. Patients are transferred back to the ward at ROH depending
on their length of stay. Our anaesthetists are carrying out the procedures, so we are only using Cromwell’s theatres
and PICU beds. The length of stay is approximately 4 or 5 days.
SWBHT - Updated
Incomplete - Overall the Trust met the national target with 92.00%. 2421 patients out of 30281 waited over 18 weeks,
635 waited over 26 weeks. 3 patients waited over 52 weeks - 1 each in Dermatology, ENT & Cardiology. Thoracic
Medicine, Cardiology and T&O failed to meet the speciality target.
Number > 52 wks
National Target
7
The Forward View into action - Annex B Measures Cont…
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
1%
6%
%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
0.54%
0.68%
G
SWBHT























Feb-16
0.50%
0.27%
G
Diagnostic test waiting times
Monthly Actual
National Target
National Target
SWBHT - Updated
The Trust incurred 34 over 6 week breaches for February out of 6820 patients. This was within 1% target with 0.54%,
32 patients in Echocardiography, 1 in Flexi-sygmoidoscopy, 1 in colonoscopy. An exception report from January on the
increased number of echocardiography patients waiting over 6 weeks is still outstanding from SWBHT.
Mar-16
Jan-16
Feb-16
Dec-15
Oct-15
CCG - Updated
There were 40 over 6 week waits in February out of 7362 patients. This was within 1% target with 0.54%. 37 patients
waited 6-13 weeks (20 of which were at SWBHT) with 3 waiting 13+weeks at DGFT, Children's and University College
London.
Nov-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Jan-15
Monthly Actual
Amber Threshold
Feb-15
Dec-14
0.0%
Oct-14
2.0%
0.0%
Nov-14
4.0%
2.0%
Sep-14
6.0%
4.0%
Apr-14
6.0%
Jun-14
Diagnostic Test Waiting Times - SWBH
8.0%
May-14
Diagnostic Test Waiting Times - CCG
8.0%
Jul-14
% waiting 6 weeks or more for a diagnostic
test
Aug-14
High
Amber Threshold
A & E Waiting Times < 4 hours
High
High
% of patients who spend 4 hours or less in
A&E
Total number of patients who have waited
over 12 hours in A&E from decision to
admit to admission
95%
0
%
SWBHT
























Mar-16
88.57%
92.54%
R
Number
SWBHT
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mar-16
0
0
G
90%
Updated
% < 4hrs in A&E - SWBH
Performance continues to fall below the 95% 4 hour A&E standard, as in previous months. In addition, the Easter bank holiday
weekend fell early this year, at the end of March. This weekend and the days following it are typically a busy period for urgent care
services with increased attendances. The majority of ED breaches relate to delays in clinical decision making, ED cubicles being full and
awaiting beds in MAU. Staffing issues are still present with heavy reliance on agency and locum staff and a number of unfilled shifts
each day
100%
95%
90%
85%
80%
Final agreement of an improvement trajectory for 2016/17 is in progress.
75%
Monthly Actual
National Target
Amber Threshold
8
The Forward View into action - Annex B Measures Cont…
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
93%
88%
%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
96.03%
94.11%
G
SWBHT























Feb-16
95.52%
93.75%
G
CCG























Feb-16
97.38%
97.24%
G
SWBHT























Feb-16
97.40%
98.21%
G
Cancer - 2 week wait
High
High
All cancer two week wait
93%
Two week wait for breast symptoms
88%
%
All cancer 2 week waits - CCG
All Cancer 2 week waits - SWBH
100.0%
100.0%
95.0%
95.0%
90.0%
90.0%
85.0%
85.0%
80.0%
80.0%
75.0%
75.0%
Updated
CCG
All cancer two week wait - overall the CCG were meeting the target in-month. 43 out of 1084 patients waited over two
weeks in February. 35 of these were at SWBHT, the majority (21) were through patient choice, 6 were listed as 'no
reason given'.
Breast - Overall the CCG were meeting the target in-month. 5 patients out of 191 waited over two weeks. All at
SWBHT, 4 through patient choice, 1 'no reason given'.
Exception reports will be sent regarding the breaches with no reason given.
Monthly Actual
National Target
Amber Threshold
Monthly Actual
National Target
Amber Threshold
SWBHT
Both categories were within target in February.
9
The Forward View into action - Annex B Measures cont…
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
% receiving first definitive treatment
within one month
96%
91%
%
31-day standard for subsequent cancer
treatments-surgery
94%
treatments-anti cancer drug
98%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
97.81%
97.24%
G
SWBHT























Feb-16
100.00%
98.21%
G
CCG


















  


Feb-16
88.00%
92.70%
R
    
Feb-16
100.00%
99.21%
G
           
Feb-16
97.37%
99.69%
A
                      
Feb-16
100.00%
100.00%
G
   
Feb-16
98.00%
97.55%
G
Cancer - 31 day waits
High
High
High
High
treatments-radiotherapy
89%
%
SWBHT
CCG
93%
CCG
89%
         

%
SWBHT
94%
                 


  














%
This service is not provided at SWBHT
SWBHT
Updated
Cancer 31 day waits - CCG
Cancer 31 Day Waits - SWBH
100.0%
100.0%
95.0%
95.0%
90.0%
90.0%
85.0%
85.0%
80.0%
80.0%
75.0%
75.0%
Monthly Actual
National Target
Amber Threshold
CCG
31 day first treatment - Overall the CCG were meeting the target. 3 patients out of 137 waited over 31 days, 2 at UHB
due to capacity. 1 at Guy's and St Thomas' due to medical reasons. Breaches are reported to both the contracting
team and the commissioning lead for cancer.
31 day subsequent surgery - Overall the CCG failed to meet the target with 88.00%. 3 out of 25 patients waited over
31 days. All at UHB, 2 due to capacity and one admin error . UHB as a total trust failed this target.
31 day sub anti-cancer drug - Overall the CCG failed to meet the target with 97.37%. 1 patient out of 38 waited over
31 days at Burton Hospitals due to an administrative delay.
Monthly Actual
National Target
Amber Threshold
31 day sub radiotherapy - Overall the CCG met the target this month with 98.00%. 1 out of 50 patients waited over 31
days at UHB due to equipment failure.
SWBHT
The Trust were meeting the 31 day targets.
10
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
80%
%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
84.29%
84.35%
A
SWBHT























Feb-16
86.01%
86.30%
G
CCG
    






  



  
  
Feb-16
100.00%
95.42%
G
SWBHT
    






  



  
  
Feb-16
100.00%
97.26%
G
CCG


  




    









Feb-16
81.82%
88.05%
SWBHT


  


  





  

Feb-16
88.64%
91.35%
Cancer - 62 day waits
High
All cancer two month urgent referral to
first treatment wait
85%
High
62-day wait for first treatment following
referral from an NHS cancer screening
service
90%
High
62-day wait for first treatment for cancer
following a consultants decision to
upgrade the patient's priority
85%
No
Operational
Standard
%
%




Updated
Cancer 62 day waits - CCG
CCG
62 day first treatment - The CCG failed to meet the target with 84.29%. 11 patients out of 70 waited over 62 days. 5
were at SWBHT - 2 due to medical reasons, 2 tertiarys (from UHB on days 55 and 59, but originally referred to UHB
from SWBHT) and 1 patient delayed through patient choice. 3 patients waited at UHB - 2 for medical reasons and 1
through late tertiary (from SWBHT day 111). 2 at Wolverhampton - 1 medical and 1 capacity. 1 at Dudley - Medical.
Cancer 62 day waits - SWBH
100.0%
100.0%
95.0%
95.0%
90.0%
85.0%
85.0%
80.0%
80.0%
75.0%
75.0%
62 day screening - The CCG met the national target 100%.
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
90.0%
Monthly Actual
National Target
Amber Threshold
Monthly Actual
National Target
Amber Threshold
62 day consultant upgrade – 4 patients out of 22 waited over 62 days. 1 at SWBHT for medical reasons. 2 at UHB - 1
patient declined and 1 capacity issues. 1 at HEFT - reason given late tertiary from SWBHT, although first seen provider
is recorded as HEFT.
Attached for information is the UHB remedial action plan which covers the general issue of late tertiary referrals
across our local providers.
SWBHT
The Trust met all 62 day targets.
11
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
Category A red 1 incidents within 8
minutes.
75%
70%
%
Category A red 2 incidents within 8
minutes.
75%
Category A calls resulting in an ambulance
arriving within 19 minutes.
95%
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG























Feb-16
84.06%
86.23%
G
WMAS























Feb-16
75.53%
78.79%
G
CCG























Feb-16
74.67%
78.16%
G
WMAS























Feb-16
70.70%
75.48%
A
CCG























Feb-16
98.74%
99.08%
G
WMAS























Feb-16
96.46%
97.26%
G
Response Times
High
High
High
70%
%
90%
%
Ambulance Red 1 Response Time - CCG
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Ambulance Red 1 Response Time - WMAS
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Monthly Actual
Target (%)
Amber Threshold
Ambulance Red 2 Response Time - CCG
80.0%
80.0%
60.0%
60.0%
40.0%
40.0%
20.0%
20.0%
0.0%
0.0%
National Target
Amber Threshold
Amber Threshold
At Month11 (Feb2016), WMAS responded to 82,247 assigned incidents across all dispositions compared to 87,662 in M10. The
number of assigned incidents exceeded the contracted volume of 77,678 assigned incidents, resulting in an over-performance of
5.88%. At a CCG Level, for Sandwell, the Trust responded to 7,844 assigned incidents against a contracted level of 7,709 incidents, an
over-performance of 1.75% for the period. Forecast outturn for 2015-16 at Trust and Sandwell CCG levels at M11 is projected to be 0.89% and -2.09% respectively. YTD, Hear and Treat dispositions for Sandwell and West Birmingham CCG is 5.7% above the Trust
average of 4.7%. However See and Treat and See and Convey are above the Trust average at 33.8% and 60.4% respectively compared
to Trust-wide performance of 35.2% and 60%.
Ambulance System Performance
Trust-wide performance against Red 1 and Red 19 at M11 exceeded the national targets of 75% and 95% respectively. Actual
performance was 75.5% and 96.5% respectively. Red 2 performance fell further to 70.7% at M11 compared to 74.7% at M10.
Although Red 2 performance is projected to achieve the national target at the end of the year, if performance continues to fall in M12
at the same rate, it is likely that Red 2 performance will not be achieved. This will be discussed with the provider at the Contracts
Review Meeting. For Sandwell and West Birmingham CCG, performance against Red 1, 2 and 19 exceeded the Trust-wide average and
the forecast is that all national targets will be exceeded.
Actual
Ambulance A 19 min Response Time - CCG
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
National Target
Ambulance Red 2 Response Time - WMAS
100.0%
Monthly Actual
Activity Performance
Actual
100.0%
Updated
National Target
Amber Threshold
Ambulance A 19 min Response Time - WMAS
Green 2 performance Trust-wide at M11 was 84.8% compared to the national target of 90%. Performance for Sandwell and West
Birmingham CCG was 82%. Forecast outturn for 2015-16 is 90.2%. Green 4 performance has remained consistently at 99% throughout
2015-16, exceeding the target of 90%.
Handover breaches reported during M11 were 2,596 and 236 between 30 and 60 minutes and over 60 minutes respectively. The
main hotspots were the University Hospital Coventry Warwick, Worcestershire Royal, Royal Shrewsbury, Princess Royal and Hereford
County hospitals. Crew Clear breaches during the same period were 62 and 3 between 30 and 60 minutes and over 60 minutes
respectively.
100.0%
95.0%
90.0%
85.0%
Monthly Actual
National Target
Amber Threshold
Monthly Actual
National Target
Amber Threshold
12
The Forward View into action - Annex B Supporting Measures cont…
Target
Data
Quality
Indicator
Green
Amber
2014-15
Basis
Statistic
2015-16
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Handover Times
Number
SWBHT























Feb-16
100
1157
R
Number
WMAS























Feb-16
2596
23551
R
Number
SWBHT























Feb-16
6
53
R
Number
WMAS























Feb-16
236
1404
R
Handovers of over 30 minutes
High
Zero
Handovers of over 1 hour
Ambulance Handover Delays - SWBH
Ambulance Handover Delays - WMAS
3500
3000
2500
2000
1500
1000
500
0
200
150
100
50
0
Mar-15 Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16
Monthly Actual > 30 mins
Monthly Actual > 1 hour
Feb-16 Mar-16
National Target
National Target
Crew Clear Times - Local measure
Number
SWBHT























Feb-16
5
112
R
Number
WMAS























Feb-16
62
798
R
Number
SWBHT























Feb-16
0
9
G
Number
WMAS























Feb-16
3
60
R
Crew clear delays of over 30 minutes
High
Zero
Crew clear delays of over 1 hour
Ambulance Crew Clear Delays - WMAS
Ambulance Crew Clear Delays - SWBH
180
160
140
120
100
80
60
40
20
0
25
20
15
10
5
0
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
National Target
Feb-16
Mar-16
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
National Target
13
Target
Data
Quality
Indicator
2014-15
Green
Amber
Statistic
0
<10
Number
0
<10
Number
Basis
2015-16
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
CCG
32
37
8
3
0
0
8
0
1
1
1
1
0
1
0
0
2
2
0
0
0
2
0
Feb-16
0
7
G
SWBHT
36
43
14
3
0
0
7
0
2
0
0
0
0
0
0
0
2
0
0
0
0
0
0
Feb-16
0
2
G
Q3 15-16
0.00%
0.31%
G
0
1
Mixed Sex Accomodation Breaches
High
High
Number of mixed sex accommodation
(MSA) Breaches
Number of mixed sex accommodation
(MSA) Breaches
MSA Breaches - CCG
Updated
MSA Breaches - SWBH
CCG
There were no breaches for the CCG in February.
Monthly Actual
National Target
Amber Threshold
National Target
SWBHT
There were no breaches at SWBHT in February.
Mar-16
Jan-16
Feb-16
Dec-15
Oct-15
Nov-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Jan-15
Monthly Actual
Feb-15
Dec-14
Oct-14
Nov-14
Sep-14
Apr-14
0
Jul-14
10
Aug-14
20
Jun-14
50
40
30
20
10
0
30
May-14
40
Amber Threshold
Cancelled Operations
High
% of cancelled operations offered another
binding date within 28 days
Reduce from
previous year
%

SWBHT






Cancelled Operations offered another binding date within 28 days - SWBH
Cancelled Operations SWBHT- 0 patient out of 116 waited over 28 days after a cancelled elective operation.
1.20%
1.00%
0.80%
0.60%
Monthly Actual
0.40%
National Target
0.20%
0.00%
Q1
14/15
Q2
14/15
Q3
14/15
Q4
14/15
Q1
15/16
Q2
15/16
Q3
15/16
Q4
15/16
Urgent operations cancelled for a second time
High
Reduce from
previous year
operations cancelled for a second time
Number
0
SWBHT
1
1
1
0
0
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
Feb-16
Updated
Operations cancelled for a second time
15
SWBHT had 0 urgent operations cancelled for the second time in February.
10
5
0
Apr-15
May-15
SWBHT
Jun-15
Jul-15
DGFT
Aug-15
Sep-15
ROH
Oct-15
Nov-15
Royal Wolves
Dec-15
Jan-16
UHB
Feb-16
Mar-16
Walsall
14
Target
Data
Quality
Indicator
Green
Amber
2014-15
Basis
Statistic
A
M
J
J
A
S
O
2015-16
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Care Programme Approach (CPA)
High
>=95%
Follow-up within 7 days
High
High
Follow-up within 7 days
CCG







Q3 15-16
97.38%
96.83%
G
BCPFT







Q3 15-16
97.10%
0.00%
G
Feb-16
100.00%
96.51%
G
%
>=95%
SWBCCG
BCPFT
%
 







 
Updated
Care Programme Approach (CPA) - CCG
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
CPA - The CCG & BCPFT were both within target for Q3 15/16.
There is no one CCG lead for the contract for BCPFT, contracts are held with both SWBCCG and Wolverhampton CCG.
Monthly Actual
National Target
Q1
14/15
Q2
14/15
Q3
14/15
Q4
14/15
Q1
15/16
Q2
15/16
Q3
15/16
The new third line of monitoring this month shows CPA performance for SWBCCG with BCPFT as per the contract. This
is taken from the locally reported Service Quality Performance Report (SQPR) which is received monthly.
Q4
15/16
15
The Forward View into action - Annex F Measures
Target
Data
Quality
Indicator
Green
Amber
2014-15
Statistic
Basis
A
M
J
J
A
S
O
2015-16
N
D
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
Data
Period
Actual
Mth/Qtr/
YTD
Annual
FOT
RAG
Vaccination Coverage
CCG







Q3 15-16
91.99%
90.90%
R
%
CCG







Q3 15-16
39.27%
38.94%
R
%
CCG







Q3 15-16
92.05%
90.93%
R
High
Dtap/IPV/Hib (1 year old)
94.7%
%
High
MenC (1 year old)
93.9%
High
PCV (1 year old)
94.2%
Updated
Data for these indicators is now published nationally through the Unify system. None of the three vaccinations for one year olds achieved the national target. Dtap/IPV/Hib and PCV were just below but MenC is still some way off.
High
Dtap/IPV/Hib (2 year old)
96.1%
%
CCG







Q3 15-16
94.37%
93.66%
R
High
PCV Booster (2 years old)
91.5%
%
CCG







Q3 15-16
90.90%
89.30%
R
High
Hib/MenC Booster (2 years old)
92.3%
%
CCG







Q3 15-16
90.59%
89.02%
R
CCG







Q3 15-16
90.34%
89.12%
R
High
MMR for One Dose (2 years old)
91.2%
%
Updated
Data for these indicators is now published nationally through the Unify system. None of the four vaccinations to two year olds reached the national targets.
High
MMR for One Dose (5 years old)
92.9%
%
CCG







Q3 15-16
93.81%
93.82%
G
High
MMR for Two Doses (5 years old)
86%
%
CCG







Q3 15-16
86.33%
85.62%
G
High
Hib/MenC booster (5 years old)
88.6%
%
CCG







Q3 15-16
92.32%
88.95%
G
Updated
Data for these indicators is now published nationally through the Unify system. All three vaccinations to 5 year olds achieved the national targets in Q3.
Vaccination Coverage Cont…
High
Percentage of Babies Registered within
the Local Authority area both at Birth and
at the Time of Report who are Eligible for
Newborn Blood Spot Screening
95%
CCG




Q4 14-15
97.09%
97.57%
G
High
Percentage of Babies Eligible for Newborn
Hearing Screening for whom the Screening
Process is Complete within 4 Weeks
Corrected Age
95%
CCG




Q4 14-15
98.95%
98.88%
G
16
Legend
Data Quality
High
Medium
Low
National data source
Local but reliable data source
Local data source
Basis
CCG
SWBHT
BCPFT
WMAS
Sandwell & West Birmingham Hospital Foundation Trust
Black Country Partnership Foundation Trust
Statistic
DSR
ISR
Direct Standardised Rate
Indirect Standardised Rate
FOT RAG
G
A
R
Green - forecast to achieve target
Amber - some uncertainty but may achieve target
Red - unlikely to achieve target
Directional Arrows



Improvement in data since last data point
Decline in data since last data point
No change in data since last data point
17
Planning 16/17 - CCG Monthly Activity and Other Requirements
(functional)
V2.1
Planning 16/17 - CCG Monthly Activity and Other Requirements-(functional)-V2.1
Please choose your organisation:
Code:
Name:
05L
NHS Sa ndwel l a nd Wes t Bi rmi ngha m CCG
Getting a Unify2 account:
In order to upload a template for a CCG, colleagues will need a Unify2 account for their CCG/CSU
To reques t a new a ccount
- pl ea s e go to the Uni fy2 homepa ge
http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx
- under ‘Sys tem Li nks ’ cl i ck ‘Reques t a Uni fy a ccount’,
- s el ect doma i n ‘Knowl edge a nd Intel l i gence’, a nd
- s el ect Orga ni s a ti on Type ‘CLINICAL COMMISSIONING GROUP' or 'COMMISSIONING SUPPORT UNIT' a s requi red
Completing the template:
BEFORE COMPLETING THIS TEMPLATE PLEASE READ:
“Delivering the Forward View: NHS planning guidance for 2016/17 – 2020/21”
and
“Annex 1 to the Technical Guidance Activity Plan, Contract Tracker and SRG Operational Resilience Template Guidance”
Enter data into each of the tabs in this spreadsheet. Cells are shaded as follows to indicate which are needed to be completed:
Validations and Warnings will prevent upload of the template to Unify2
To mi ni mi s e da ta entry errors thi s templ a te ha s Da ta Va l i da ti on Tes ts a nd Da ta Wa rni ng Al erts . If a ny Da ta Va l i da ti on Tes ts fa i l or Da ta Va l i da ti on Wa rni ngs a re a cti va ted, Cel l B7 i n the Da ta Va l i da ti ons a nd Wa rni ngs ta b wi l l di s pl a y "No". Pl ea s e revi ew the s umma ry i n the Da ta Va l i da ti ons a nd Wa rni ngs ta b fol l owi ng the i ns tructi ons gi ven. Pl ea s e note tha t:
Da ta Va l i da ti on Tes ts hi ghl i ght errors i n the da ta entered i n the templ a te. If a ny of the Da ta Va l i da ti on Tes ts fa i l , thi s wi l l prevent upl oa d of the templ a te to Uni fy2. A s umma ry of thes e a re gi ven i n the Da ta Va l i da ti ons a nd Wa rni ngs ta b.
Da ta Wa rni ng Al erts hi ghl i ght pos s i bl e probl ems i n the da ta entered i n the templ a te. If a ny of the Da ta Wa rni ng Al erts a re a cti va ted, thi s wi l l prevent upl oa d of the templ a te to Uni fy2. If on checki ng the da ta you a re s a ti s fi ed i t i s correct you ca n de-a cti va te the Da ta Wa rni ng Al erts i n the Da ta Va l i da ti ons a nd Wa rni ngs ta b.
Once Cel l B7 i n the Da ta Va l i da ti ons a nd Wa rni ngs ta b di s pl a ys “Yes ” you ca n s ubmi t your compl eted templ a te to the Uni fy2 s ys tem.
How to upload this template:
Once you ha ve compl eted the workbook a nd s a ved i t onto your ha rd dri ve, pl ea s e upl oa d your da ta i nto Uni fy 2.
To do thi s , l ogi n to Uni fy2 http://nww.uni fy2.dh.nhs .uk/uni fy/i nterfa ce/homepa ge.a s px
[If you are a CSU acting on behalf of a CCG and have logged in using a CSU account, at this point you will need to follow an extra step before continuing - see CSU Guidance. If logged in as a CCG, continue to
step below]
Once logged in click on ‘Data collection & management’
…..then ‘NON DCT Home Page’
...and select the Upload option for the return ‘PlanAMC’
Then click 'Browse' and select (or drill down to) the location of the completed workbook on your hard drive (the file path will be displayed below)
T:\SWB Meetings\Finance and Performance Committee\Meetings 2016 - 2017\(1) April 2016\[1. Planning 16-17 - CCG Monthly Activity and Other Requirements - (functional) V2.1 18.04.16.xls]
...now ti ck "Auto Si gn Off" a nd then cl i ck "Upl oa d".
Viewing Data in Unify following Upload
Once you ha ve upl oa ded you wi l l then be a bl e to vi ew your da ta through the Extra cti on Vi ewer menu i n Uni fy. Pl ea s e be a wa re tha t i t ca n ta ke a few hours for your da ta to a ppea r i n Extra cti on Vi ewer fol l owi ng upl oa d.
CSU Guidance:
If you are a CSU acting on behalf of a CCG and have logged in using a CSU account you will first need to ‘impersonate’ the CCG for whom you are uploading the template
• In the top ri ght corner of the s creen, cl i ck where i s rea ds
‘You a re s i gned i n a s xxx a s XXX COMMISSIONING SUPPORT UNIT’
• Sel ect the correct CCG from the orga ni s a ti on dropdown l i s t
• Cl i ck ‘Impers ona te’
• Fol l ow the rema i ni ng s teps a bove, from ‘Once l ogged i n cl i ck on Da ta col l ecti on a nd ma na gement'
Further Information:
For queries related to this Template and its submission to Unify2 please email [email protected]
Planning 16/17 - CCG Monthly Activity and Other Requirements-(functional)-V2.1
Are all Data Validations Tests and Data Warning Alerts passed (see below):
Yes
0
If No the template will not upload: please check the red boxes below to resolve
0
Data Validation Tests highlight errors in the data entered template. If any of the Data Validation Tests fail, this will prevent upload of the template to Unify2. A summary of these are given in the table below.
Data Warning Alerts highlight possible problems in the data entered in the template. If any of the Data Warning Alerts are activated, this will prevent upload of the template to Unify2. If on checking the data you
are satisfied it is correct you can de-activate the Data Warning Alerts in the table below.
Once Cell B7 in the Data Validations and Warnings tab displays “Yes” you can submit your completed template to the Unify2 system.
Summary of Validations and Warnings:
Measure
Data Validation Tests
Ensure all Validation Tests have passed (highlighted by change from red to green)
Constitution Sheet
RTT - Incomplete - E.B.3
Diagnostics - E.B.4
Diagnostics - E.B.4
Cancer Waiting Times - 2 week wait - E.B.6
Cancer Waiting Times - 2 week (breast symptoms) - E.B.7
Cancer Waiting Times - 31 Day First Treatment - E.B.8
Cancer Waiting Times - 31 Day Surgery - E.B.9
Cancer Waiting Times = 31 Day Drugs - E.B.10
Cancer Waiting Times - 31 Day Radiotherapy - E.B.11
Cancer Waiting Times - 62 Day GP Referral - E.B.12
Cancer Waiting Times - 62 Day Screening - E.B.13
Cancer Waiting Times - 62 Day Upgrade - E.B.14
Constitution - Ambulance Sheet
Ambulance Performance - E.B.15.i
Ambulance Performance - E.B.15.ii
Ambulance Performance - E.B.16
Constitution - A&E Sheet
A&E Performance Provider 1
Activity Sheet
Total Referrals (All Specialties) - E.M.1
Consultant Led First Outpatient Attendances (Total activity) - E.M.2
Consultant Led First Outpatient Attendances (Total activity) - E.M.2
Consultant Led Follow-Up Outpatient Attendances (Total activity) - E.M.3
Consultant Led Follow-Up Outpatient Attendances (Total activity) - E.M.3
Total Elective Admissions (Spells) (Total activity) - E.M.4
Total Elective Admissions (Spells) (Total activity) - E.M.4
Total Non-Elective Admissions (Spells) (Total activity) - E.M.5
Total Non-Elective Admissions (Spells) (Total activity) - E.M.5
Total A&E Attendances - E.M.6
Total A&E Attendances - E.M.6
Total Referrals (G&A) - E.M.7
Consultant Led First Outpatient Attendances (Specific Acute) - E.M.8
Consultant Led Follow-Up Outpatient Attendances (Specific Acute) - E.M.9
Total Elective Admissions (Spells) (Specific Acute) - E.M.10
Total Non-Elective Admissions (Spells) (Specific Acute) - E.M.11
Total A&E Attendances excluding planned follow ups - E.M.12
Endoscopy Activity - E.M.13
Diagnostic Activity excluding Endoscopy - E.M.14
Cancer two week wait referrals - E.M.16
Cancer 62 day treatments following an urgent GP referral - E.M.17
Number of completed admitted RTT pathways - E.M.18
Number of completed non-admitted RTT pathways - E.M.19
Activity Waterfall Sheet
Other Commitments Sheet
C.Difficile - E.A.S.5
Dementia - E.A.S.1
Dementia - E.A.S.1
IAPT Access - E.A.3
IAPT Access - E.A.3
IAPT Recovery - E.A.S.2
Mental Health Access - 6 Weeks - E.H.1 - A1
LD Patient Projections
Learning Disability Inpatient Trajectories
Data Validation Test
VALIDATION PASSED
VALIDATION PASSED - ALL DATA ENTERED (BLUE CELLS)
VALIDATION PASSED - ALL VALUES BELOW 100% (GREY CELLS)
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED - ALL DATA ENTERED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
VALIDATION PASSED
Data Warning Alerts
Where a Data Warning Alert is activated, indicated by a red cell in Column E below, check data entered in the template, and either correct for
errors or de-activate the Warning Alert by selecting Yes in Column F below
Measure
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Diagnostics - E.B.4 i
Diagnostics - E.B.4 i
Dementia - E.A.S.1
Dementia - E.A.S.1
IAPT Access - E.A.3
IAPT Access - E.A.3
Data Warning Alert
YES - VALIDATIONS PASSED
YES - DATA MANUALLY CHECKED
If row labelled as red. Is data checked
and approved? (manually select
Yes/No)
Yes
Pre-populated historic actual data used from the following times, subsequent revisions will not be recorded.
Total Referrals (All Specialties)
Consultant Led First Outpatient Attendances (Total Activity)
Consultant Led Follow-Up Outpatient Attendances (Total Activity)
Total Elective Admissions (Spells) (Total Activity) [Ordinary Electives + Daycases]
Total Non-Elective Admissions (Spells) (Total Activity)
Total A&E Attendances
Total Referrals (G&A)
Consultant Led First Outpatient Attendances (Specific Acute)
Consultant Led Follow-Up Outpatient Attendances (Specific Acute)
Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases]
Total Non-Elective Admissions (Spells) (Specific Acute)
Total A&E Attendances excluding planned follow ups
Endoscopy Activity
Diagnostic Activity excluding Endoscopy
Cancer Two Week Wait Referrals
Cancer 62 Day Treatments following an Urgent GP Referral
Number of Completed Admitted RTT Pathways
Number of Completed Non-Admitted RTT Pathways
RTT - Incomplete
Diagnostics
Cancer Waiting Times - 2 week wait
Cancer Waiting Times - 2 week (breast symptoms)
Cancer Waiting Times - 31 Day First Treatment
Cancer Waiting Times - 31 Day Surgery
Cancer Waiting Times - 31 Day Drugs
Cancer Waiting Times - 31 Day Radiotherapy
Cancer Waiting Times - 62 Day GP Referral
Cancer Waiting Times - 62 Day Upgrade
Cancer Waiting Times - 62 Day Screening
Ambulance Performance Red 1 Cat A calls
Ambulance Performance Red 2 Cat A calls
Ambulance Performance Cat A 19 calls
C.Difficile
Dementia
IAPT Access
IAPT Recovery
Mental Health Access - 18 Weeks
Mental Health Access - 6 Weeks
Learning Disabilities
QAR; Unify; 22/01/2016
SUS; temporary National Repository (tNR),
23/03/2016
MAR; Unify; 21/01/2016
SUS; temporary National Repository (tNR),
23/03/2016
Monthly Diagnostics Waiting Times and
Activity; Unify2, 21/01/2016
Monthly Cancer Waiting Times statistics;
Open Exeter, 08/01/16
Consultant-led Referral to Treatment
Waiting Times; Unify2, 21/01/16
Monthly Diagnostics Waiting Times and
Activity; Unify2, 21/01/2016
Monthly Cancer Waiting Times statistics;
Open Exeter, 08/01/16
Ambulance Quality Indicators; Unify2,
10/12/2016
A&E Attendances and Emergency
Admissionns Monthly Return; Unify2,
08/01/2016
HSCIC, 06/01/16
na
Monthly IAPT return; Unify2, 20/01/16
na
CCG Code:
CCG Name:
05L
NHS Sandwell and West
Birmingham CCG
All Validations and Warnings for Worksheet Passed?
YES
All cells only have whole numbers entered?
YES
and
E.B.3
National Standard
92%
Monthly Diff Tolerance >>
10%
Incomplete Pathways < 18 weeks
Total Incomplete Pathways
%
%
APRIL
26,236
28,186
93.1%
26,755
28,200
94.9%
MAY
27,449
29,599
92.7%
28,684
30,106
95.3%
JUNE
28,250
30,325
93.2%
29,204
30,700
95.1%
JULY
28,124
30,168
93.2%
28,797
30,549
94.3%
AUGUST
27,930
29,940
93.3%
29,595
31,549
93.8%
SEPTEMBER
27,262
29,352
92.9%
28,948
31,111
93.0%
OCTOBER
26,618
28,804
92.4%
28,272
30,519
92.6%
NOVEMBER
26,846
28,589
93.9%
DECEMBER
25,872
27,431
94.3%
JANUARY
25,603
27,197
94.1%
FEBRUARY
25,371
26,762
94.8%
MARCH
25,732
27,126
94.9%
26878
28695
29261
29118
30071
29653
29089
28658
27366
27533
27383
26900
2014-15
RTT - The percentage of incomplete pathways
within 18 weeks for patients on incomplete
pathways at the end of the period.
2015-16
2016/17 Plan
%
E.B.4
FEBRUARY
53
9,075
0.6%
MARCH
72
9,455
0.8%
Number waiting > 6 weeks
92
97
104
106
102
109
95
84
82
75
76
102
9259
9768
10527
10671
10296
11026
9560
8490
8318
7588
7627
10353
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
1.0%
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
Total Number waiting
National Standard
93%
10%
896
1,016
879
1,206
856
954
1,073
892
969
980
845
999
815
932
1,268
93.8%
93.9%
94.7%
94.5%
93.3%
94.0%
93.6%
94.3%
94.1%
94.3%
95.1%
Number seen < 2 weeks
848
903
1,071
1,033
1,041
998
994
Total number seen
900
967
1,142
1,099
1,113
1,054
1,062
94.2%
93.4%
93.8%
94.0%
93.5%
94.7%
93.6%
867
932
1101
1060
1073
1016
1023
1071
1151
766
1007
1369
Total number seen
National Standard
93%
10%
Total number seen
%
Total number seen
%
2016/17 Plan
Total number seen
%
904
921
791
942
767
932
1002
1183
1139
1153
1092
1100
1151
1237
823
1082
1472
93.0%
93.0%
93.1%
93.1%
93.1%
93.0%
93.0%
93.0%
93.0%
93.1%
93.1%
93.0%
APRIL
121
129
93.8%
MAY
88
95
92.6%
JUNE
105
111
94.6%
JULY
171
179
95.5%
AUGUST
108
114
94.7%
SEPTEMBER
131
141
92.9%
OCTOBER
118
123
95.9%
NOVEMBER
176
187
94.1%
DECEMBER
136
145
93.8%
JANUARY
80
85
94.1%
FEBRUARY
189
202
93.6%
MARCH
81
85
95.3%
185
161
146
271
114
156
144
206
207
183
179
150
215
211
192
182
197
96.0%
95.8%
98.1%
95.3%
98.4%
96.4%
158
145
208
204
186
176
190
169
155
223
219
199
189
204
198
173
156
291
122
93.5%
93.5%
93.3%
93.2%
93.5%
93.1%
93.1%
93.4%
93.1%
93.6%
93.1%
93.4%
MAY
160
161
99.4%
103
106
97.2%
JUNE
148
152
97.4%
137
145
94.5%
JULY
135
140
96.4%
133
134
99.3%
AUGUST
122
124
98.4%
118
121
97.5%
SEPTEMBER
156
164
95.1%
127
129
98.4%
OCTOBER
151
153
98.7%
113
114
99.1%
NOVEMBER
149
151
98.7%
DECEMBER
147
153
96.1%
JANUARY
149
155
96.1%
FEBRUARY
130
136
95.6%
MARCH
131
138
94.9%
Number treated < 31 days
123
106
144
134
120
129
114
134
141
128
117
119
128
96.1%
110
96.4%
150
96.0%
139
96.4%
125
96.0%
134
96.3%
118
96.6%
139
96.4%
146
96.6%
133
96.2%
121
96.7%
123
96.7%
94%
10%
Total number treated
%
%
APRIL
21
22
95.5%
24
27
88.9%
MAY
18
19
94.7%
31
33
93.9%
JUNE
16
18
88.9%
17
20
85.0%
JULY
16
21
76.2%
11
12
91.7%
AUGUST
20
21
95.2%
13
14
92.9%
SEPTEMBER
21
25
84.0%
21
22
95.5%
OCTOBER
27
31
87.1%
23
23
100.0%
NOVEMBER
16
16
100.0%
DECEMBER
17
19
89.5%
JANUARY
21
22
95.5%
FEBRUARY
18
21
85.7%
MARCH
35
37
94.6%
27
32
20
12
15
22
23
16
20
21
20
35
28
34
21
12
15
23
24
17
21
22
21
37
96.4%
94.1%
95.2%
100.0%
100.0%
95.7%
95.8%
94.1%
95.2%
95.5%
95.2%
94.6%
APRIL
43
43
100.0%
31
31
100.0%
MAY
32
32
100.0%
12
12
100.0%
JUNE
31
31
100.0%
42
42
100.0%
JULY
26
26
100.0%
36
36
100.0%
AUGUST
26
26
100.0%
35
35
100.0%
SEPTEMBER
30
30
100.0%
26
26
100.0%
OCTOBER
29
29
100.0%
27
27
100.0%
NOVEMBER
24
24
100.0%
DECEMBER
25
25
100.0%
JANUARY
24
25
96.0%
FEBRUARY
25
25
100.0%
MARCH
30
30
100.0%
2015-16
2016/17 Plan
%
National Standard
98%
10%
%
%
2014-15
2015-16
2016/17 Plan
%
12
44
37
36
27
28
32
25
26
26
31
12
100.0%
44
100.0%
37
100.0%
36
100.0%
27
100.0%
28
100.0%
32
100.0%
25
100.0%
26
100.0%
26
100.0%
31
100.0%
94%
10%
%
%
APRIL
51
51
100.0%
72
73
98.6%
MAY
48
48
100.0%
46
47
97.9%
JUNE
55
55
100.0%
59
59
100.0%
JULY
61
63
96.8%
60
61
98.4%
AUGUST
51
53
96.2%
56
58
96.6%
SEPTEMBER
52
55
94.5%
56
59
94.9%
OCTOBER
73
73
100.0%
51
51
100.0%
NOVEMBER
60
60
100.0%
DECEMBER
54
55
98.2%
JANUARY
56
57
98.2%
FEBRUARY
54
54
100.0%
MARCH
69
69
100.0%
72
47
58
60
57
58
50
54
38
58
52
66
76
49
61
63
60
61
53
57
40
61
55
70
94.7%
95.9%
95.1%
95.2%
95.0%
95.1%
94.3%
94.7%
95.0%
95.1%
94.5%
94.3%
2016/17 Plan
%
85%
10%
%
%
APRIL
51
57
89.5%
57
67
85.1%
MAY
66
73
90.4%
35
46
76.1%
JUNE
68
81
84.0%
66
80
82.5%
JULY
58
67
86.6%
61
71
85.9%
AUGUST
46
50
92.0%
50
64
78.1%
SEPTEMBER
64
75
85.3%
65
75
86.7%
OCTOBER
57
68
83.8%
49
59
83.1%
NOVEMBER
70
76
92.1%
DECEMBER
58
67
86.6%
JANUARY
54
68
79.4%
FEBRUARY
59
70
84.3%
MARCH
64
73
87.7%
59
41
54
63
57
67
52
48
61
48
57
58
2015-16
2016/17 Plan
%
69
48
63
74
66
78
61
56
71
56
66
68
85.5%
85.4%
85.7%
85.1%
86.4%
85.9%
85.2%
85.7%
85.9%
85.7%
86.4%
85.3%
90%
10%
%
%
APRIL
10
10
100.0%
8
8
100.0%
MAY
14
14
100.0%
6
8
75.0%
JUNE
6
6
100.0%
9
10
90.0%
JULY
9
9
100.0%
10
10
100.0%
AUGUST
18
19
94.7%
7
8
87.5%
SEPTEMBER
16
19
84.2%
15
15
100.0%
OCTOBER
16
17
94.1%
12
12
100.0%
NOVEMBER
24
24
100.0%
DECEMBER
14
15
93.3%
JANUARY
18
19
94.7%
FEBRUARY
13
13
100.0%
MARCH
7
7
100.0%
8
8
9
9
8
15
11
14
16
17
9
5
2015-16
2016/17 Plan
%
8
8
10
10
8
16
12
15
17
18
10
5
100.0%
100.0%
90.0%
90.0%
100.0%
93.8%
91.7%
93.3%
94.1%
94.4%
90.0%
100.0%
None
10%
%
%
APRIL
15
16
93.8%
9
9
100.0%
MAY
12
13
92.3%
19
24
79.2%
JUNE
19
19
100.0%
18
20
90.0%
JULY
16
16
100.0%
15
17
88.2%
AUGUST
10
12
83.3%
19
20
95.0%
SEPTEMBER
14
16
87.5%
18
19
94.7%
OCTOBER
20
22
90.9%
14
14
100.0%
NOVEMBER
19
20
95.0%
DECEMBER
14
16
87.5%
JANUARY
24
24
100.0%
FEBRUARY
17
17
100.0%
MARCH
25
25
100.0%
9
23
20
17
20
19
14
31
26
22
20
28
9
25
21
18
21
20
15
33
28
23
21
30
100.0%
92.0%
95.2%
94.4%
95.2%
95.0%
93.3%
93.9%
92.9%
95.7%
95.2%
93.3%
2015-16
2016/17 Plan
%
Note: V1.2 of this template onwards correctly describes each of the cancer lines as either 'seen' or 'treated' rather than 'waiting'.
VALIDATION PASSED - ALL VALUES
BELOW 100% (GREY CELLS)
VALIDATION PASSED - MONTHLY %
CHANGE WITHIN TOLERANCE (GREY
CELLS)
MEETS NATIONAL STANDARD (GREY
CELLS)
VALIDATION PASSED - ALL DATA
ENTERED (BLUE CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
TRUE
National Standard
2014-15
TRUE
National Standard
2014-15
CELLS)
TRUE
National Standard
2014-15
CELLS)
TRUE
32
32
100.0%
2015-16
TRUE
National Standard
2014-15
TRUE
National Standard
2014-15
CELLS)
TRUE
APRIL
124
127
97.6%
113
124
91.1%
CELLS)
190
163
95.7%
10%
%
%
2015-16
TRUE
96%
%
Cancer - 62 day wait for first treatment for cancer
following a consultant's decision to upgrade the
patients priority
843
National Standard
2016/17 Plan
E.B.14
803
2014-15
Cancer - 62 day wait for first treatment following
referral from an NHS cancer screening service
880
MAY
932
%
2015-16
APRIL
Data Warning Alerts
Check data entered and either correct for errors or de-activate Warning Alert in the Data Validations and
Warnings tab
TRUE
94.4%
Total number seen
E.B.13
92.0%
JANUARY
87
8,362
1.0%
2014-15
Cancer - All cancer 62 day urgent referral to first
treatment wait
29239
92.0%
DECEMBER
43
8,494
0.5%
%
E.B.12
29764
92.0%
NOVEMBER
93
9,151
1.0%
Cancer - 31 Day standard for subsequent cancer
treatments - radiotherapy
29927
92.0%
OCTOBER
178
9,568
1.9%
35
9,288
0.4%
2016/17 Plan
E.B.11
29745
92.0%
SEPTEMBER
140
8,347
1.7%
62
10,644
0.6%
Cancer- All Cancer two week wait
treatments -anti cancer drug regimens
31149
92.0%
AUGUST
63
8,044
0.8%
86
9,938
0.9%
2015-16
E.B.10
31618
92.0%
JULY
79
8,355
0.9%
107
10,300
1.0%
%
treatments -surgery
32231
JUNE
98
8,612
1.1%
69
10,161
0.7%
E.B.9
32685
92.0%
MAY
158
8,414
1.9%
79
9,429
0.8%
2014-15
Cancer - Percentage of patients receiving first
definitive treatment within 31 days of a cancer
diagnosis.
31649
92.0%
APRIL
101
8,052
1.3%
87
8,937
1.0%
%
E.B.8
31805
92.0%
10%
%
%
2016/17 Plan
Cancer - Two week wait for breast symptoms
(where cancer not initially suspected)
31190
92.0%
1%
2015-16
E.B.7
29215
92.0%
Diagnostics Test Waiting Times
E.B.6
Ensure all Validation Tests have passed (highlighted by change from red to green text)
National Standard
2014-15
TRUE
TRUE
CCG Code:
CCG Name:
05L
NHS Sandwell and West Birmingham
CCG
YES
All cells only have whole numbers entered?
YES
and
Note: Plans are to be submitted by lead commissioners of Ambulance Trusts.
Ambulance Trust (if lead
commissioner)
West Midlands Ambulance Service NHS Foundation Trust
RYA
E.B.15i
National Standard
75%
10%
2014-15
Ambulance Clinical
Quality - Category A
(Red 1)
2015-16
2016/17 Plan
E.B.15ii
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
558
524
618
551
1352
1431
1657
1569
1377
1574
Total responses from incidents
701
668
690
674
753
664
1763
1832
2276
2085
1789
2010
%
Response arriving at scene < 8 mins
%
80.6%
1513
1864
81.2%
82.0%
1474
1888
78.1%
80.9%
1516
1901
79.7%
77.7%
1534
1933
79.4%
82.1%
1437
1782
80.6%
83.0%
1503
1913
78.6%
76.7%
1675
2113
79.3%
78.1%
72.8%
75.3%
77.0%
78.3%
1423
1441
1455
1479
1364
1464
1617
1446
1738
1617
1467
1541
%
1897
75.0%
1921
75.0%
1939
75.0%
1972
75.0%
1818
75.0%
1951
75.0%
2155
75.0%
1927
75.0%
2317
75.0%
2156
75.0%
1955
75.0%
2054
75.0%
10%
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
23470
24823
23375
23579
23352
23103
23403
22844
24348
23501
20747
23694
30466
31939
31080
31776
30825
30537
31991
31493
35523
31761
28374
31570
%
77.0%
77.7%
75.2%
74.2%
75.8%
75.7%
73.2%
72.5%
68.5%
74.0%
73.1%
75.1%
23060
24212
22837
23957
24102
22962
24888
30019
31523
30339
31513
31639
30589
32270
%
76.8%
76.8%
75.3%
76.0%
76.2%
75.1%
77.1%
22946
24099
23204
24102
24201
23396
24683
24302
26309
26296
24690
25043
30594
32131
30938
32135
32267
31194
32910
32402
35078
35061
32919
33389
%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
75.0%
2015-16
95%
10%
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
Number of ambulance arrivals within 19 minutes
30296
31704
30836
31363
30681
30361
32704
32199
36166
32788
29089
32665
Total number Category A incidents
31167
32607
31770
32450
31578
31201
33754
33325
37799
33846
30163
33580
%
97.2%
97.2%
97.1%
96.7%
97.2%
97.3%
96.9%
96.6%
95.7%
96.9%
96.4%
97.3%
31131
32601
31415
32582
32543
31501
33442
31883
33411
32240
33446
33421
32502
34383
%
97.6%
97.6%
97.4%
97.4%
97.4%
96.9%
97.3%
30867
32350
31234
32402
32380
31488
33313
32613
35526
35358
33132
33774
32491
34052
32877
34107
34084
33145
35066
34329
37395
37218
34875
35551
%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
2016/17 Plan
Data Warning Alerts
Check data entered and either correct for errors or de-activate Warning Alert in the Data Validations and
Warnings tab
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
CELLS)
TRUE
National Standard
2015-16
TRUE
75%
2014-15
Ambulance Clinical
Quality- Category A
19 minutes
JUNE
548
2016/17 Plan
E.B.16
MAY
565
National Standard
2014-15
Ambulance Clinical
Quality - Category A
(Red 2)
APRIL
TRUE
YES
All cell values only have whole numbers entered?
YES
05L
CCG Code:
CCG Name:
05L
CCG
and
2
E.B.5
1
A&E Waiting times - Total time in the A&E department
Note: Plans are to be submitted by lead commissioners of Type 1 Trusts. Plan submitted should be for all attendances to A&E.
RXK
Provider 1
National Standard
95%
Quarterly Diff Tolerance >>
10%
Only monthly actuals have been provided below.
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
1,037
18,979
1,086
18,648
741
17,801
1,138
18,187
1,106
19,110
94.2%
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
Number waiting > 4 hours
SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS
TRUST
2014-15
Total Attendances
SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS
TRUST
2015-16
% < 4 hours
Total Attendances
TRUE
94.5%
94.2%
95.8%
93.7%
1380
1310
1260
1260
1120
1120
1120
1120
1380
1380
1380
1380
Total Attendances
% < 4 hours
18500
92.5%
19000
93.1%
19000
93.4%
19000
93.4%
18000
93.8%
18000
93.8%
18000
93.8%
18000
93.8%
18500
92.5%
18500
92.5%
18500
92.5%
18500
92.5%
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
Total Attendances
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
% < 4 hours
RXK
2016/17 Plan
National Standard
95%
10%
Data Warning Alerts
Check data entered and either correct for errors or de-activate Warning Alert in the Data Validations
and Warnings tab
VALIDATION PASSED - MANUALLY
VALIDATION PASSED - ALL DATA ENTERED VALIDATION PASSED - ALL VALUES BELOW 100%
(GREY CELLS)
CHANGE WITHIN TOLERANCE (GREY CELLS)
CHECKED
(BLUE CELLS)
2014-15
Total Attendances
% < 4 hours
2015-16
Provider 2
% < 4 hours
TRUE
2016/17 Plan
(BLUE CELLS)
Total Attendances
VALIDATION PASSED - ALL VALUES BELOW 100%
(GREY CELLS)
Not applicable
CELLS)
VALIDATION PASSED - ALL VALUES BELOW 100%
(GREY CELLS)
Not applicable
CELLS)
% < 4 hours
National Standard
95%
10%
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
Total Attendances
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
2014-15
Total Attendances
% < 4 hours
2015-16
Provider 3
% < 4 hours
`
2016/17 Plan
Total Attendances
% < 4 hours
TRUE
(BLUE CELLS)
CCG Code:
CCG Name:
05L
NHS Sandwell and West Birmingham CCG
YES
YES
and
16/17 Annual Plan
Forecast Growth in 16/17
on FOT 15/16
224154
232223
3.6%
ENTERED
NHS England
Produced
259,563
268907
3.6%
ENTERED
VALIDATION PASSED
258,981
NHS England
Produced
344,491
356893
3.6%
ENTERED
VALIDATION PASSED
15/16 Month 1-9
from SUS
31,558
NHS England
Produced
41,820
42573
1.8%
ENTERED
VALIDATION PASSED
Total Non-Elective Admissions (Spells) (Total
Activity)
15/16 Month 1-9
from SUS
55,939
NHS England
Produced
74,690
76184
2.0%
ENTERED
VALIDATION PASSED
E.M.6
15/16 Month 1-9
from SUS
168,214
NHS England
Produced
222,717
228062
2.4%
ENTERED
VALIDATION PASSED
Code
Activity Line
16/17 Annual Plan
Forecast Growth in 16/17
on FOT 15/16
April
May
June
July
August
September
October
November
December
January
February
March
E.M.7
Total Referrals (G&A)
15/16 YTD from
MAR
(Month 1-6)
95,823
To be entered by
CCG
192015
198,928
3.6%
15600
15219
17926
17422
15363
17346
17032
16835
15607
16182
16604
17792
TRUE
E.M.8
Consultant Led First Outpatient Attendances
(Specific Acute)
15/16 Month 1-9
from SUS
178,495
NHS England
Produced
236,723
245,248
3.6%
19232
18763
22100
21479
18940
21385
20998
20755
19241
19950
20470
21935
TRUE
ENTERED
E.M.9
Consultant Led Follow-Up Outpatient
Attendances (Specific Acute)
15/16 Month 1-9
from SUS
219,597
NHS England
Produced
292,238
302,760
3.6%
23742
23163
27283
26515
23382
26400
25922
25622
23753
24628
25271
27079
TRUE
ENTERED
E.M.10
Total Elective Admissions (Spells) (Specific
Acute) [Ordinary Electives + Daycases]
15/16 Month 1-9
from SUS
31,497
NHS England
Produced
41,747
42,499
1.8%
3333
3251
3830
3722
3282
3705
3639
3597
3335
3457
3547
3801
E.M.10.a Total Ordinary Elective Admissions (Spells)
(Specific Acute)
15/16 Month 1-9
from SUS
6,332
NHS England
Produced
8,308
8,457
1.8%
663
647
762
741
653
737
724
716
664
688
706
756
TRUE
E.M.10.b Total Day Case Elective Admissions (Spells)
(Specific Acute)
15/16 Month 1-9
from SUS
25,165
NHS England
Produced
33,439
34,042
1.8%
2670
2604
3068
2981
2629
2968
2915
2881
2671
2769
2841
3045
TRUE
Code
Activity Line
E.M.1
Total Referrals (All Specialties)
15/16 YTD from
QAR (Q1 & Q2)
112,077
To be entered by
CCG
E.M.2
Consultant Led First Outpatient Attendances
(Total Activity)
15/16 Month 1-9
from SUS
195,704
E.M.3
Consultant Led Follow-Up Outpatient
Attendances (Total Activity)
15/16 Month 1-9
from SUS
E.M.4
Total Elective Admissions (Spells) (Total
Activity) [Ordinary Electives + Daycases]
E.M.5
15/16 YTD Actuals
15/16 YTD Actuals
CCG 15/16 Forecast outturn
CCG 15/16 Forecast outturn
VALIDATION PASSED
TRUE
VALIDATION PASSED
Profiled Monthly 16/17 Plan
Ensure all Validation Tests have
passed (highlighted by change
from red to green text)
ENTERED
ENTERED
E.M.11
Total Non-Elective Admissions (Spells)
(Specific Acute)
15/16 Month 1-9
from SUS
45,940
NHS England
Produced
61,467
62,698
2.0%
4917
4797
5650
5491
4842
5467
5368
5306
4919
5100
5233
5608
TRUE
ENTERED
E.M.12
Total A&E Attendances excluding planned
follow ups
15/16 Month 1-9
from SUS
166,209
NHS England
Produced
220,082
225,362
2.4%
17673
17241
20308
19737
17405
19651
19295
19072
17681
18332
18811
20156
TRUE
ENTERED
E.M.13
Endoscopy Activity
4,683
To be entered by
CCG
9366
9,702
3.6%
761
742
874
850
749
846
831
821
761
789
810
868
TRUE
ENTERED
E.M.14
Diagnostic Activity excluding Endoscopy
67,727
To be entered by
CCG
135434
140,309
3.6%
11003
10734
12644
12288
10836
12235
12013
11874
11008
11414
11711
12549
TRUE
ENTERED
E.M.16
Cancer Two Week Wait Referrals Seen
6,275
To be entered by
CCG
12901
13,366
3.6%
932
1002
1183
1139
1153
1092
1100
1151
1237
823
1082
1472
TRUE
ENTERED
E.M.17
Cancer 62 Day Treatments following an Urgent
GP Referral
403
To be entered by
CCG
750
776
3.5%
69
48
63
74
66
78
61
56
71
56
66
68
E.M.18
Number of Completed Admitted RTT Pathways
16,119
To be entered by
CCG
32395
33,558
3.6%
2577
2617
2935
2930
2668
2973
3016
2737
2745
2740
2848
2772
TRUE
ENTERED
E.M.19
Number of Completed Non-Admitted RTT
Pathways
47,278
To be entered by
CCG
99581
103,156
3.6%
7479
6989
8687
8968
7613
9241
9305
9498
8914
8812
9129
8521
TRUE
ENTERED
15/16 YTD from
DM01
(Month 1-6)
15/16 YTD from
DM01
(Month 1-6)
15/16 YTD from
Open Exeter
(Month 1-6)
15/16 YTD from
Open Exeter
(Month 1-6)
15/16 YTD from RTT
Unify return
(Month 1-6)
15/16 YTD from RTT
Unify return
(Month 1-6)
ENTERED
CCG Code:
CCG Name:
All Validations and Warnings For Worksheet Passed?
05L
CCG
YES
YES
and
“Annex 1 to the Technical Guidance Activity Plan, Contract Tracker and SRG Operational Resilience
Template Guidance”
Enter as a + or - figure to add or subtract activity from the 15/16 FOT to get to the 16/17 plan.
Absolute values to be entered here and not percentages.
Policy Changes are calculated. That is, Column H = Column I - (Column D + Column E + Column F + Column G)
Non-recurrent activity
changes
CCG 15/16 Forecast
outturn
Underlying trend and
demographic growth
To capture the effect of for
To capture any additional
example, changing definitions, activity as a result of changes
boundaries, reporting
in population and underlying
standards.
changes in trend
0
Transformational change
Apply the impact of
transformation / allocative
efficiency. To include for
example: NCMs, UEC,
RightCare, Prevention, Self
care and procedures of
limited clinical value.
Policy changes
To capture the impact of new 16/17 Annual Plan
policies, for example hospital
7 day services; primary care
access, Cancer, Mental Health.
E.M.2
E.M.3
E.M.4
E.M.5
E.M.6
Consultant Led First Outpatient Attendances (Total Activity)
Consultant Led Follow-Up Outpatient Attendances (Total Activity)
Total Elective Admissions (Spells) (Total Activity) [Ordinary Electives + Daycases ]
Total Non-Elective Admissions (Spells) (Total Activity)
259,563
344,491
41,820
74,690
222,717
0
0
0
0
0
9344
12402
753
1494
5345
0
0
0
0
0
0
0
0
0
0
268,907
356,893
42,573
76,184
228,062
E.M.8
E.M.9
E.M.10
E.M.11
E.M.12
Consultant Led First Outpatient Attendances (Specific Acute)
Consultant Led Follow-Up Outpatient Attendances (Specific Acute)
Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases ]
Total Non-Elective Admissions (Spells) (Specific Acute)
Total A&E Attendances excluding planned follow ups
236,723
292,238
41,747
61,467
220,082
0
0
0
0
0
8525
10522
752
1231
5280
0
0
0
0
0
0
0
0
0
0
245,248
302,760
42,499
62,698
225,362
YES
CCG Code:
CCG Name:
05L
CCG
YES
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
MAY
7
7
9
JUNE
8
9
9
JULY
15
16
9
AUGUST
9
7
9
SEPTEMBER
11
9
9
OCTOBER
12
11
9
NOVEMBER
5
10
9
DECEMBER
9
JANUARY
7
FEBRUARY
12
MARCH
17
9
9
9
9
and
National Standard
E.A.S.5
HCAI measure (C.Difficile
infections)
E.A.S.1
Dementia - Estimated diagnosis
rate
None
10
2014-15
2015-16
2016-17 Plan
APRIL
12
7
10
National Standard
66.7%
10%
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
Number of People diagnosed (65+)
2840
2840
2840
2840
2840
2840
2840
2840
2840
2840
2840
2840
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
4,257
66.71%
2016-17 Plan
Estimated dementia prevalence (65+ Only
(CFAS II))
%
Total
124
76
109
TRUE
2016-17 Objective
109
Ensure all Validation Tests have passed (highlighted by
change from red to green text)
Data Warning Alerts
Check data entered and either correct for errors or de-activate Warning Alert in the Data Validations and Warnings tab
(BLUE CELLS)
VALIDATION PASSED - MONTHLY CHANGE
WITHIN TOLERANCE
VALIDATION PASSED - C-DIFF PLAN EQUAL TO OBJECTIVE
Data Warning Alerts
Check data entered and either correct for errors or de-activate Warning Alert in the Data Validations and Warnings tab
VALIDATION PASSED - ALL DATA ENTERED VALIDATION PASSED - ALL VALUES
(BLUE CELLS)
VALIDATION PASSED - MONTHLY % MEETS
NATIONAL STANDARD (GREY CELLS)
TRUE
E.A.3
National Standard
3.75%
5%
The number of people who receive
psychological therapies
2014-15
The number of people who have depression
and/or anxiety disorders (local estimate based
on Adult Psychiatric Morbidity Survey 2000).
% per quarter (e.g. 3.75%)
IAPT Access - Roll Out
2015-16
2016-17 Plan
E.A.S.2
on Adult Psychiatric Morbidity Survey 2000).
Quarter 1
Quarter 2
Quarter 3
Quarter 4
2,705
3,025
2,385
2,670
54,406
54,406
54,406
54,406
4.97%
5.56%
4.38%
4.91%
2,085
2,155
-
-
54,406
54,406
3.83%
3.96%
2041
2041
2041
2041
54406
54406
54406
54406
3.75%
3.75%
3.75%
3.75%
Quarter 1
Quarter 2
Quarter 3
Quarter 4
300
265
305
410
National Standard
50%
20%
The number of people who have completed
treatement having attended at least two
treatment contacts and are moving to
recovery (those who at initial assessment
achieved 'caseness' and at final session did
not)
VALIDATION PASSED - QUARTERLY %
(BLUE CELLS)
VALIDATION PASSED - QUARTERLY % MEETS
TRUE
2014-15
The number of people who finish treatement
having attended at least two treatment
contacts and coded as discharged) minus (The
number of people who finish treatment not at
clinical caseness at initial assessment)
%
The number of people who have completed
treatement having attended at least two
treatment contacts and are moving to
recovery (those who at initial assessment
achieved 'caseness' and at final session did
not)
IAPT Recovery Rate
775
640
725
825
38.71%
41.41%
42.07%
49.70%
500
580
2015-16
1,035
1,145
%
48.3%
50.7%
-
-
518
568
543
543
contacts and are moving to recovery (those
who at initial assessment achieved 'caseness'
and at final session did not)
2016-17 Plan
1035
1135
1085
1085
%
50.0%
50.0%
50.0%
50.0%
Quarter 1
Quarter 2
Quarter 3
Quarter 4
825
893
859
859
course of treatment in the reporting period.1
1100
1190
1145
1145
%
75.0%
75.0%
75.0%
75.0%
Quarter 1
Quarter 2
Quarter 3
Quarter 4
1045
1131
1088
1088
course of treatment in the reporting period.1
1,100
1,190
1,145
1,145
%
95.0%
95.0%
95.0%
95.0%
(BLUE CELLS)
TRUE
Mental Health Access
E.H.1 - A1
The proportion of people that
wait 6 weeks or less from
referral to entering a course of
IAPT treatment against the
number of people who finish a
course of treatment in the
reporting period.
E.H.2 - A2
The proportion of people that
wait 18 weeks or less from
referral to entering a course of
IAPT treatment against the
number of people who finish a
course of treatment in the
reporting period.
National Standard
75%
10%
The number of ended referrals that finish a
course of treatment in the reporting period
who received their first treatment
appointment within 6 weeks of referral
2016-17 Plan
National Standard
95%
10%
course of treatment in the reporting period
who received their first treatment
appointment within 18 weeks of referral
2016-17 Plan
(BLUE CELLS)
TRUE
(BLUE CELLS)
The number of ended referrals who finish a
1. The denominators in measures E.H.1 - A1 and E.H.2 - A2 are identical. Given this, the values entered for E.H.1 - A1 are automatically used to populate the denominator in E.H.2 - A2.
TRUE
YES
YES
GUIDANCE: Learning Disability Inpatient Trajectories
Who's Included in the trajectories? (inclusion criteria are as defined by the Assuring Transformation Collection: http://www.hscic.gov.uk/assuringtransformation )
A person in an in-patient bed for mental and/or behavioural healthcare needs and has learning disabilities or autistic spectrum disorder (including Asperger’s syndrome) of any age or security type.
Quarterly Trajectories over 1 Year (No. of Learning Disability Inpatients at the end of each quarter)
The trajectories are aiming to capture the total number of people with a learning disability and/or autism in inpatient care at the end of each quarter, in a specialist hospital bed (either MH or LD). Measured on a CCG of origin basis, so patients whose care is
commissioned by NHS England Specialised Commissioning Teams are reported against their 'home' CCG (Quarterly Learning Disability Inpatient figures should not be on the basis of who pays for care). The inpatient trajectories must be on a Transforming Care
Partnership (TCP) basis and should be submitted by the nominated CCG for that TCP.
Nominated Submitting CCG:
Submitting CCG
Submitting on behalf of Transforming Care Partnership (TCP):
GP Registered Population of Transforming Care Partnership (18+ only):
Black Country
1,086,358
CCGs within the Transforming Care Partnership (TCP)
BNHS WALSALL CCG
BNHS DUDLEY CCG
BNHS SANDWELL AND WEST BIRMINGHAM CCG
BNHS WOLVERHAMPTON CCG
B
#N/A
B
#N/A
B
#N/A
B
#N/A
B
#N/A
B
#N/A
B
#N/A
B
#N/A
Transforming Care Partnership Learning Disability Inpatient Projections (including all patients originating from within the TCP, both NHS England- and CCG- commissioned)
2016/17
E.K.1
End of Q1
30/06/16
End of Q2
30/09/16
End of Q3
31/12/16
End of Q4
31/03/17
Total No. of Inpatients with learning disabilities* (TCP level; and by TCP of origin)**
GP Registered Population of Transforming Care Partnership (18+ only)
Learning Disability Inpatient Rate per Million GP Registered Population ***
104
1,086,358
95.73
99
1,086,358
91.13
97
1,086,358
89.29
93
1,086,358
85.61
Ensure all Validation Tests have passed (highlighted by change from
red to green text)
TRUE
* People in an in-patient bed for mental and/or behavioural healthcare needs and has learning disabilities or autistic spectrum disorder (including Asperger’s syndrome) of any age or security type.
** Quarterly projected figures are not on the basis of who pays, but on the basis of the Transforming Care Partnership the patient originates from.
*** The national plan "Building the Right Support" published on 30 October 2015 sets out a planning assumption that each TCP will reduce reliance on inpatient care, and where they are currently above this level, will plan to reach an inpatient rate within the range
30 - 40 inpatients per million population by March 2019.
Closed actions
UHB CANCER ACTION PLAN
NAME OF PROVIDER
University Hospitals Birmingham NHS Foundation Trust
Key Performance Indicator
62 day GP referral to treatment target
Lead Officer
Joanne Robson,
Deputy Chief Operating Officer
TARGET
Cancer – 62 day GP referral to treatment
Executive Director
Cherry West,
Chief Operating Officer
JANUARY PERFORMANCE
JANUARY TRAJECTORY
RESOLUTION DATE
75.6%
71.1%
(see trajectory detailed below)
WHY IS CURRENT/PROJECTED PERFORMANCE NOT ON TARGET?
Briefly explain the reasons, listing the most significant first. Be clear and up-front.
You may wish to mention targets, resources, environment, change, or other issues impacting upon performance.
1 Late tertiary referrals
2 Backlog of patients on 62 day pathway
3 Complex diagnostic pathway for colorectal surgery and Head & Neck - many and complex diagnostics
1|Page
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
Develop inter hospital referral
Cancer Services
protocol for all referrals on the basis Manager
of those introduced in East Anglia,
Manchester and London. – 62 day
targets only.
4
A summary report of late referrals
will be submitted on a monthly
basis to the CCG and SCN
Local late referral protocol to be
developed via SRG cancer sub
group.
CCG Lead Rachel
O’Connor
Target
Completion
Date of
Action
(RAG)
Ongoing
How & why this action will make a
positive difference? What risks are
associated with this action?
To reduce the number of 62 day breaches.
On hold and
await
National
review and
further
guidance at
the end of
August 15
December 15
To reduce the number of 62 day breaches
Status (including actual
completion date of
action)
On-going, as this relies
on a system wide
Network agreed
approach the Trust in
the interim will report
and notify all referring
Trusts of the impact of
late tertiary referrals.
Further work is being
done with referrers
whilst a national steer is
being discussed
National workshop held
10/12/15 – potential for
38 day cut off. Further
guidance expected
2|Page
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
CCG Clinical Lead
Dr P. Ingham and
Dr W. Taylor
Target
Completion
Date of
Action
(RAG)
completion date of
action)
CCG will update the referrals form to
include a checklist to ensure patients are
aware they are on a 2w referral pathway,
and that the GP has explained this to them
and the importance of attended an
appointment in the 2 week period. The CCG
will also feedback to GPs where patients
have declined appointments in the 2 week
period so they can review processes
internally to ensure patients are aware at
referral of the importance of taking up
offered appointments. Breach analysis by
GP Practice to be shared from UHB to
commissioners. Commissioners will then
share with LCNs to feedback on rates by
practice and agree comms and education
plan. This will increased number of patients
attending for appointment within 2 week of
referral.
10/6 Following a
meeting with
Birmingham Cross City
CCG the date has been
moved to January 2016
pending further
discussion and a detailed
communication plan.
A project group has
been established to
manage the roll out
3|Page
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
Engage with regional review of
current provision of Hep Bil
Services.
Director of
Partnerships
Pathway redesign workshop for
colorectal surgery
Deputy Chief
Operating
Officer/Dr Mark
Cook
Target
Completion
Date of
Action
(RAG)
Ongoing
completion date of
action)
Proposal to reduce to 2 centres: UHB and
Stoke with UHB working on 2 sites: QEHB
and UHCW. Potential to redirect
appropriate geographical referrals to Stoke.
CEAG / BOD approval
required.
UHB internal scoping
meeting held in March
2015.
Awaiting confirmation of
specialised
commissioner proposal
in relation to this,
however important to
note that current
capacity would not be
able to support
additional demand
Twice weekly tracking
meetings in place since
April 15. Workshop set
up for October 15,
pathway redesign initial
meeting’s commenced
in Sept 15.
Feb 16 -New pathway
internally agreed,
commencement date &
pathway to be agreed at
SRG sub group
7
8.
Pathway redesign meeting
scheduled for all MDT members in
October to bring improvements in
streamlining and efficiency. Actions
implemented from November
onwards. Reduce delays within the
diagnostics phase for colonoscopy
January 2016
-Completed
Weekly enhanced tracking in place for
colorectal patients. Pathway redesign
meeting scheduled for all MDT members
October 2015
Patients diagnosed and treated within 62
days/ reduction in breached pts. Impact on
improvement trajectory from November
onwards to enable performance delivery by
January.
4|Page
62V1 March 16
Closed actions
Action
Trial for pooling oncology capacity
11
Executive Lead/
Operational Lead
Head of Cancer
Services/Dr Ford
Target
Completion
Date of
Action
(RAG)
September
2015
Commence
January 2016pilot ongoing
completion date of
action)
The Urology workshop highlighted potential
delays might occur if waiting for a specific
named oncologist. Given the number of
oncologist in the speciality the proposal is to
trial pooling of all referrals to manage the
demand more proactively.
Pilot being discussed and
will commence in Sept
15. Pilot commenced
evaluation to take place
& review other
specialities. Review in
March 16
5|Page
62V1 March 16
Closed actions
Action
Regional Pathway development and
timed pathway to be agreed
18
Executive Lead/
Operational Lead
SRG CCG Rachel
O’Connor
Target
Completion
Date of
Action
(RAG)
Subgroup to
be
established in
October.
Work plan
agreed to
inform key
milestones of
actions
completion date of
action)
SRG have agreed to establish a system wide
cancer sub-group to lead on impact
assessment of new NICE guidelines against
baseline position, agreement and develop
revised timed system pathways, impact
assessment of those changes,
implementation plans, communication and
education plans and contract changes
required. The group will also lead on local
modelling and action plans for any system
operation issues arising and modelling and
preparing for national campaigns i.e. blood
in pee (March Campaign).
To be agreed with the
subgroup re the phasing
days/ reduction in breached patients
/reduction in late referrals. Impacts on
planning for a sustaining performance from
implementation and into 2016.
6|Page
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
CLOSED ACTIONS
3
Review of all MDT working to
provide assurance to the Cancer
Steering Group that robust
processes are in place.
Head of Cancer
Services /Dr Mark
Cook UHBFT
Cancer Clinical
Lead
Additional capacity put in place for
endoscopy , urology, via improved
efficiencies i.e. straight to test and
one stop clinics, increased capacity
in colorectal with 2 additional
consultants recruited,
commissioning of additional growth
in contracts following Specialty
Equilibrium Modelling. Trust is now
ensuring all capacity is fully utilise
Head of
Performance &
Trust Senior
Manager for
Strategy &
Planning and Dr
Mark Cook UHBFT
Cancer Clinical
Lead
Target
Completion
Date of
Action
(RAG)
May 2015
July 2015
25th Sept
2015
completion date of
action)
Provide assurance and highlight any areas of Reviews commenced
concern ahead of Peer Review.
Feb 2015.
Report to be submitted
to Cancer Steering
days/ reduction in breached pts. Impacts on Group May 2015. The
improvement trajectory from September.
feedback will be
discussed at the steering
group July 15- scheduled
for Sept 25th
Modelling completed
days/ reduction in breached pts. The
March 15.
additional capacity contributes to the
Capacity expansion and
trajectory from October as all planned
backlog reduction Dec
additional capacity is then in place.
14 to Dec 15. All planned
additional capacity now
2weekly monitoring of backlog
in place.
Monthly monitoring of performance and
activity.
7|Page
62V1 March 16
Closed actions
Action
UHBFT and CCG Implement roll out
of E-Referral and Choose & Book for
all 2week waits.
Review and refine the 2 week
referral process.
6
Executive Lead/
Operational Lead
Deputy Chief
Operating
Officer/Director
of Patient
Services UHBFT
Target
Completion
Date of
Action
(RAG)
July 2015
November
2015
January 2016
Implemented
completion date of
action)
To ensure that Birmingham Cross City CCG
GP’s can offer appointments to patients via
choose & book on the day to improve the
percentage of patients accessing their
appointment within two weeks.
A scoping process is
currently in place with
the Divisions to ensure
that there is a
centralised process in
place for all specialities
via the booking team
and sufficient capacity is
in place to meet
demand. A roll out
programme including
communication to all
end users will be
communicated at the
beginning of May 15
Capacity and clinic
requirements currently
being reviewed to
ensure there is sufficient
capacity.
Implementation &
communication plan to
be agreed with CCG
discussion and a detailed
communication plan. A
project group has been
established to manage
the roll out
8|Page
62V1 March 16
Closed actions
Action
All Cancer Service staff to receive
training on the new access policy
2
Executive Lead/
Operational Lead
Cancer Services
Manager
Target
Completion
Date of
Action
(RAG)
End of Dec
2014
April 2015
November
2015
Completed
To ensure full compliance with cancer
access standards
completion date of
action)
To be completed once
new policy agreed.
23/3/15-training will be
rolled out once the
policy has been ratified
& agreed with CCG.
Linked to item 1, training
cannot be rolled out
until the policy has been
agreed. All staff are
currently trained and
when the new policy is
implemented staff will
be updated
9|Page
62V1 March 16
Closed actions
Action
Develop a Trust Cancer specific
Access Policy to provide guidance
for the management of patient on
cancer pathways for sign off
approval with commissioners.
1
Executive Lead/
Operational Lead
Director of
Partnerships
Target
Completion
Date of
Action
(RAG)
Nov 2014
March 2015
April 2015
June 2015
November
2015
To ensure full compliance with cancer
access standards
completion date of
action)
Draft cancer access
policy in development.
AM to discuss with BK.
Final version submitted
to CCG on 5th March
2015 for discussion at
the Clinical
Commissioning Policy
Approval sub-group of
the CCG on the 12th
March 2015. 23/3/15 CCG has rescheduled the
meeting for 9th April 15.
CCG have rescheduled
meeting to 11th June
2015.
It has been agreed with
the CCG to implement ereferrals and a new
access policy with the
introduction of choose
and book for 2 wk waits
for 1st January 2016
(linked to Action 6)
10 | P a g e
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
Pathway milestone review for
colorectal patients.
Deputy Chief
Operating Officer
12
Introduction of a results clinic for
prostate patients
Director of
Operations
Division D
Target
Completion
Date of
Action
(RAG)
End of
September
2015
November
2015
9.
completion date of
action)
A sample of patients will be reviewed
against the current pathway and critical
milestones. This will highlight the average
time in the pathway and flag areas of
improvement. This will then help to inform
workshop in October and patients can then
be tracked against key milestones
Patient’s will be given a date to return to
OPD for their results to ensure there are no
delays in the pathway
Initial review of patients
to be undertaken by the
end of Sept
Completed presenting at
workshop 19/10/15
Initial meeting have
taken to commence in
November
Patients will have a results clinic date when
they attend for a diagnostic
Urology patients.
14
Deputy Chief
Operating Officer
End of
November
2015January 2016
milestones. This will provide assurance that
the current pathway has been embedded
and continued performance of the target
will be sustained
end of October 15 .
Initial review undertaken
to be reviewed against
current PTL and represented in January
2016 completed
11 | P a g e
62V1 March 16
Closed actions
Action
Executive Lead/
Operational Lead
Target
Completion
Date of
Action
(RAG)
September
2015 to
January 2016
62 day Backlog Management
(number of patients on a pathway
over 62 days)
DCOO
Review weekly PTL and escalation
meetings with Cancer and Divisional
teams.
DCOO/Dr Mark
Cook UHBFT
Cancer Clinical
Lead
On-going
Deputy Chief
Operating Officer
/Dr Mark Cook
February
2016
17
16
Pathway redesign workshop for
Head & Neck
10
Analysis of Backlog Patients and actions
required for each patient identified.
Actions undertaken to reduce backlog from
251 in April 15 bi-monthly reporting of
progress with backlog in terms of
classification, planned TCI date, date of
breach.
Weekly assurance meeting in place from
September 14. Twice weekly enhanced
tracking meetings commenced April 2015
Reduction in breaches and improved
management of the PTL. Total patients on
the PTL Tumour sites has reduced by 50%.
Weekly enhanced tracking in place for Head
& Neck patients which includes oncology,
radiology and pathology. Pathway redesign
meeting scheduled for all MDT members
October 2015
completion date of
action)
Breast recovery date
November; Colorectal
recovery date January
16; Head and Neck
recovery date
January 16; Urology
recovery date
September; Hep B
recovery date
September
Ongoing and weekly
monitoring.
Workshop set up for
October 15, pathway
redesign initial meeting’s
commenced in Sept 15.
Scheduled for 3rd Feb
12 | P a g e
62V1 March 16
Closed actions
Action
Pathway milestone review for Head
& Neck patients.
Executive Lead/
Operational Lead
Deputy Chief
Operating Officer
13
Haematology patients.
15
Deputy Chief
Operating Officer
Target
Completion
Date of
Action
(RAG)
End of
November
2015
Rescheduled
to February
2016
End of
November
2015
January 2016
completion date of
action)
end of October
Presenting at workshop
12/11/15
Actions agreed at
workshop 3rd Feb
to be undertaken in
October 15. Agreed to
be presented in January
2016 -
13 | P a g e
62V1 March 16
Closed actions
Action
To review all tumour site pathways
to ensure that all complex
diagnostic and treatment pathways
are streamlined ensuring that they
are efficient and meet the
operational standards
5
A sample of patients will be
reviewed against the current
pathway and critical milestones.
This will highlight the average time
in the pathway and flag areas of
improvement. This will then help to
inform a workshop in October and
patients can then be tracked against
key milestones.
Executive Lead/
Operational Lead
Cancer Service
Manager/ Dr
Mark Cook UHBFT
Cancer Clinical
Lead
Target
Completion
Date of
Action
(RAG)
Ongoing
See specific
tumour sites
below (in
action plan)
To ensure that patients are treated within
the operational standards and services and
pathways are patient centred
Impact on improvement trajectory from
November onwards to enable a
performance delivery by January.
completion date of
action)
This will commence in
March 2015. 23/3/15 Urology pathway
meeting with all
consultants to sign off
UHB pathway arranged
for May 15. Urology
workshop held on 2th
May and key actions
agreed. Further
workshop to review
progress being arranged
for end of
June/beginning of July
15. Head & Neck/ HEPB
and Colorectal
workshops to be set up
in Aug/Sept
14 | P a g e
62V1 March 16
Closed actions
PREDICTED PERFORMANCE TRAJECTORY
2015/16
Trajectory
%
Actual
%
68.8%
April
Treatments
88
Breaches
27.5
May
68
30
66.9%
June
91.5
38
58.5%
July
99.5
26.5
70% (25 Breaches)
73.4%
August
84.5
28
72% (25 Breaches)
75.1%
86
28.5
63% (30 breaches)
66.9%
October
88.5
26
72 % (25 breaches)
70.6%
November
80.5
17.5
76% (20 Breaches)
78.3%
December
94
14.5
81% (15 Breaches)
84.6%
January
101
25
71.1% (26 breaches)
75.6%
September
February
March
71.1% (26 breaches)
80% (18 Breaches)
15 | P a g e
62V1 March 16
Closed actions
Trajectory Submitted to Monitor :62 Day Cancer – Birmingham Cross City CCG
Baseline Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Total patients treated
Total waiting over 62 days
% performance
90
92
71
94
104
86
89
89
87
95
103
76
89
18
18
14
19
21
17
13
13
13
14
15
11
13
80.00
80.43
80.28
79.79
79.81
80.23
85.39
85.39
85.06
85.26
85.44
85.53
85.39
WHAT ARE THE RISKS AND OPPORTUNITIES?
What issues/factors may adversely impact on performance and stop the target from being achieved? What is being done to manage these risks?
Failure to agree a system of reallocation for late tertiary referrals.
Significant increase in cancer referrals to individual service or overall.
Emergency pressures may lead to the cancellation of elective admissions.
Referring Trust clearing backlog & increased in late referrals after day 38
SIGN OFF
Lead Officer
Jo Williams -Deputy Chief Operating
Officer
Executive Director
Signature
J Williams
Signature
Date
1st Sept 2015
Date
If you have any queries regarding the completion of this Report please contact either of the two leads above
16 | P a g e
62V1 March 16
GOVERNING BODY/COMMITTEE
Report Title: Partnership Report
Report Author and Title:
Sharon Liggins, Chief Officer
Partnerships
Contact Details:
4th May 2016
[email protected]
0121 612 2833
Agenda item: 7.4
Sign off from Chief Officers: produced by Chief Officer signed off by Partnership
Committee Chair
Supporting Documents/further Reading: Appendices 1 & 2
The report provides Governing Body with an overview of the Partnership Committee meetings held on the 3rd
and 15th March 2016 and asks the Governing Body to approve the refreshed committee Terms of Reference.
Recommendations:
The Governing Body are asked to note the report and approve the attached Terms of Reference.
Governing Body/Committee are requested to: X
Decision
Assurance
Action
Approve
X
Previous Decision (Inform the Governing Body/Committee if the paper has been reviewed or monitored by
another committee and their recommendation or decision)
Summary of Strategic Priorities:
Quality & Safety
Partnership
Implications:
Financial
Assurance Framework
X
Risks and legal obligations
Consultation : X
Patients
Staff
Committees
Sponsored By: (Chief Officer or Committee Chair)
Strategic Commissioning & Redesign
State any financial implications for the CCG
The Partnership portfolio supports the following
Assurance Framework domains:
Domain 3 - Patient and public engagement,
including members, HWBs, LAs and other
Domain 4 - Partnership working with other
CCGs, NHS Trusts, LAs, NHS England to effectively
commission key local services,
N/A
N/A
N/A
none
Public
Partners
1
Date Received for Committee:
27th April 2016
Partnership Committee Report
1. INTRODUCTION
1.1
Since the last Governing Body report the Partnership Committee has met twice; firstly
on the 3rd March to action the CW Audit recommendation for the committee to review
its terms of reference, and again on the 15th March to discuss the following items:
 Terms of Reference (TOR)
 Partnership Committee Framework
 Sustainability Transformation Plans
 BCF Planning
2. DETAIL OF REPORT
2.1
On the 3rd March the Partnership Committee with Paul Capener in attendance
reviewed and refreshed its TOR.
The discussions focused on the committees’
responsibility for monitoring the health status of key partnerships, the connectivity
with other CCG committees and the importance of monitoring the relationship and
views of CCG members.
2.2
The TOR (Appendix 1) were amended slightly to strengthen its role membership
engagement
2.3
Following the discussions, the Partnership Framework (Appendix 2) was amended to
reflect the key partnerships/strategic relationships, the partnership interface and
where the general reporting responsibility sits within the organisation.
2.4
On the 15th March, the committee received an update on the development of the
Sustainability Transformation Plans (STP). Sandwell and West Birmingham CCG is
entirely reported within the Black Country STP. Andy Williams (Accountable Officer
for Sandwell and West Birmingham CCG) has been selected to be the Chair of the Black
Country STP and Paula Clarke (Chief Executive Dudley Group NHS Foundation Trust) is
the Vice Chair.
2.5
The Black Country STP membership includes all health and social care organisations in
the area; NHSEs as specialised commissioners, the 4 acute community providers, 2
mental health trusts, 5 Local Authorities (including Birmingham as an Associate
Member) and 4 CCGs, West Midlands Ambulance Service and Birmingham Community
Health Care Trust through their partnership with Black Country Partnership.
2.6
The west Birmingham component of the Birmingham and Solihull STP will report
through the Black Country STP, therefore associate commissioner arrangements will be
required between the Black Country and the Birmingham and Solihull STPs. The
details of the arrangements will be agreed in the near future.
2
2.7
The Birmingham and Solihull STP will be Chaired by Mark Rogers (CEO for Birmingham
City Council), the membership will consist of Sandwell and West Birmingham CCG (as
an associate commissioner), Birmingham Cross City CCG, Birmingham South Central
CCG, Solihull CCG, Birmingham City Council, Solihull Council and the main health care
providers with the exception of Sandwell and West Birmingham NHS Trust.
2.8
The STPs are within their early stages of development but their initial priority is to
agree the immediate way forward and develop a transformation plan for submission in
June. The emerging themes include mental health, urgent care, health and social care
integration and children/maternity.
2.9
STPs are not statutory bodies and therefore it is imperative that the agreements made
at these partnership forums are taken through the relevant CCG governance; e.g.
reported via the local Systems Resilience Group and then through the CCG Strategic
Commissioning and Redesign Committee.
The Partnership Committee will keep
abreast of the STP development and associated engagement.
3.0
The committee noted the future potential to align STPs with the Combined Authority,
particularly in terms of the role health plays in supporting local regeneration and
economic development.
3.1
The committee received an update on the Better Care Programmes and were assured
that the plans were being developed in partnership and would be submitted in line
with planning guidance.
3.2
It was noted by the committee that Sandwell Metropolitan Borough Council have
indicated that a number of community support services are risk due to budget cuts.
Through the Health and Social Care Integration Board, the CCG has agreed to review
the current BCF expenditure plan during 2016/17 to determine if additional efficiencies
can be delivered.
3. RECOMMENDATIONS
3.1 Members of the Governing Body are asked to:
 Note the contents of the report and approve the amended TOR.
Contact Officer with contact telephone number
Sharon Liggins, Chief Officer, 0121 612 2833
3
Appendix 2
Clinical Commissioning Group Governing Body
Partnership Committee
Terms of Reference
Document Amendment History
Version Number
Date
Comment
Full history
Version 1.15
03/03/2016
02/02/2016
Appendix 1
Author Sharon Liggins: reviewed and amended by the
committee in response to the CW Audit.
Clinical Commissioning Group Governing Body
Partnership Committee
Terms of Reference (Version 1.15)
1 Introduction
1.1
Sandwell and West Birmingham Clinical Commissioning Group is an
organisation committed to working in partnership. Its mission Healthcare
without Boundaries cannot be delivered without effective and productive
partnership working.
1.2
The Partnership Committee is established in accordance with Sandwell and
West Birmingham Clinical Commissioning Group’s (Governing Body)
constitution, standing orders and scheme of delegation.
1.3
These terms of reference set out the membership, remit responsibilities and
reporting arrangements of the committee and shall have effect as if
incorporated into the Clinical Commissioning Group’s constitution and
standing orders.
4
1.4
For the purpose of this committee the term partner is defined as including NHS
England, Local Authorities, other CCGs, member practices.
1.5
For the purposes of this committee the term stakeholders is defined as
including patients, public, Healthwatch, regulators, health and social care
providers, voluntary and community sector organisations.
2 Membership
2.1
CCG Core voting members (designation and/or job title)




GP Clinical Lead for Partnerships (Chair)
Independent Committee Member (Vice Chair)
CCG Accountable Officer
Chief Officer Partnerships
3 In attendance
3.1
In attendance
The following may be invited to attend:










3.2
Clinical leads for relevant work programmes
Senior Commissioning Managers for relevant portfolios
Contracting and Performance leads for relevant portfolios
Right Care Right Here Programme
LCG Clinical representatives
Representation from health and social care providers
Neighbouring CCGs
Local Authorities including Health and Wellbeing Boards, Public Health
NHS England
Other drawn from our stakeholders
Invitations may be extended to any appropriate personnel to attend and
provide evidence, information or expert advice to the Committee.
4 Secretary
4.1
The committee Chairman and the Chief Officer (Partnerships) will be
responsible for steering and setting the Committee agenda.
4.2
The Committee’s secretary will be responsible for
 Preparation of the agenda in conjunction with the Chairman and the Chief
Officer (Partnerships)
 Minuting the proceedings and resolutions of all meetings of the
Committee, including recording the names of those present and in
attendance. Minutes shall be circulated promptly to all members of the
Committee
 Keeping a record of matters arising and issues to be carried forward
5

Advising the Committee on pertinent areas.
6
5 Quorum
5.1
The Committee will be considered quorate when, the Chair or the Vice Chair
(ICM), the Accountable Officer or the Chief Officer Partnerships.
5.2
If a quorate member of the Committee should be required to leave prior to the
conclusion of the meeting, the chair should confirm that the meeting is still
quorate or not. If the meeting is no longer quorate, it may continue but
decisions will have to be ratified at the next meeting.
5.3
A duly convened meeting of the Committee at which a quorum is present shall
be competent to exercise all or any of the authorities, powers and discretions
vested in or exercisable by the Committee.
5.4
The Committee may on occasion take a decision by email provided that:
 The decision taken is by quorum of the committee as laid down in its
Terms of Reference
 If the decision is one which requires a vote, it shall be at the discretion of
the Chair to decide whether use of email is appropriate
 The decision is reported to the next meeting and is minuted
 The e-mails reflecting the decision are copied to all members of the
committee, are printed, appended to the minutes and are retained on file.
6 Frequency and notice of meetings
6.1
The Committee shall meet a minimum of four occasions per financial year.
Additional formal or informal meetings may be arranged and convened by the
Chair.
6.2
Meeting papers must be issued 5 working days in advance of the meeting.
.
7 Remit and responsibilities of the committee
7.1
The Committee will provide assurance that appropriate arrangements are in
place to deliver and effectively manage collaborative, joint and pooled
arrangements with partners.
7.2
The Committee will provide assurance that the organisation is actively
engaging with external partners and stakeholders to deliver the CCGs
commissioning strategy, wider strategies and plans.
7.3
The Committee will share intelligence relating to partnership working,
associated risks, potential opportunities and challenges, keeping abreast of
relevant national, regional and local policy changes with the Governing Body
and any relevant committee.
7.4
The Committee will ensure appropriate arrangements are in place for
engaging its members.
7
7.5
Issues raised by members within the remit of other committees will be referred
appropriately e.g. issues relating to finance and performance will be
redirected.
7.6
The Committee will foster positive relationships with potential new members,
ensuring they are fully informed and welcomed into the CCG.
8 Relationship with the Governing Body
8.1
The Committee will be directly accountable to the Governing Body.
8.2
The Committee Chair shall report formally to the Governing Body on the key
points arising from its proceedings after each meeting.
8.3
The Committee shall make whatever recommendations it deems appropriate
on any area within its remit where action or improvement is needed.
8.4
The Committee minutes shall be formally recorded and submitted to the next
appropriate Governing Body once ratified.
8.5
The Committee shall make available in the form of a report, suitable
information on partnership policy, practices and undertakings for publication in
the Governing Body annual reports.
8.6
The Committee will work closely with the Governing Body’s Committees,
receiving regular reports pertinent to the partnership agenda from the Strategic
Commissioning and Redesign Committee, Quality and Safety Committee and
when relevant from other committees or associated subcommittees.
9 Policy and best practice
9.1
The Committee will use best practice and policy guidance to inform the
partnership strategy and to deliver its business.
9.2
The Committee is authorised to seek any information it requires from any
employee or Governing Body member in order to perform its duties.
10 Conduct of the Committee
10.1
Conflicts of interests will be managed in accordance with the CCG Conflicts of
Interest Policy.
10.2
All members must adhere to the CCGs Standards of Business Conduct.
Review Date: March 2017
8
Appendix 1
Document Amendment History
Version Number
Date
Draft V1
Draft V1.1
20/6/2012
Authors: Mohammed Khalil, Chris Gibbs
27/06/2012 Comments from Andy Williams, changed membership
added annex 1
20/08/2012 Author: Manjinder Palak, Amended following
comments made from the Partnership Committee
17/08/2012
10/10/2012 Author: Manjinder Palak, Membership updated to
include the details of the Chief Executives for
Birmingham Council of the Voluntary Sector and
Sandwell Council of the Voluntary Sector
19/11/2012 Author: Manjinder Palak, Updated following committee
meeting on 21st October 2012
11/08/2013 Author Sharon Liggins, revised following review of
Partnership Committee purpose and structure
05/09/13
Author Sharon Liggins, amended following Governing
Body comments.
15/10/13
Author Sharon Liggins, amended following comments
received from committee members Tracey-O’Brian,
Janette Rawlinson
10/03/14
Author Sharon Liggins, amended following CCG refocus
22/04/14
Author Sharon Liggins, amended membership following
discussion at the Partnership Committee meeting in
March.
29/07/14
Author Paul Capener: amended following governance
review
2./10/14
Author Sharon Liggins: amended to include a review
date
22/01/15
Author Paul Capener: amended to reflect delegated
primary care commissioning
28/01/15
Author Sharon Liggins: amended following members
away session (agreed by Committee but not submitted
to Governing Body for ratification)
20/04/15
Author Sharon Liggins: amended to reflect the
proposed remit of the Committee. Presented to the
Governing Body on the 6th May.
15/09/15
Author Sharon Liggins: amended the core membership
and the quoracy to reflect the recent changes following
the Governing Body agreed CCG refocus.
Draft V1.2
Draft V1.2
Draft V1.3
Version 1.4
Version 1.5
Version 1.6
Version 1.7
Version 1.8
Version 1.9
Version 1.10
Version 1.11
Version 1.12
Version 1.13
Version 1.14
Comment
9
Appendix 2
Sandwell and West Birmingham CCG
Partnership and Stakeholder Framework
Updated March 2016
1
The aims of the Partnership Framework
We know that working in partnership brings a number of benefits such as; sharing
limited resources for greater gain, attracting external investment, and improved
patient experience through better coordination and integration of services. However,
partnership working can be difficult to do well and costly if not properly managed.
This document draws the distinction between our key partnerships and our general
stakeholders. It outlines CCG departments responsible for building and maintaining
key partnership relationship.
2
Partnership Values and Principles
We value:




being the type of organisation that listens to and engages its patients, its staff,
its member Practices and its external partners
a transparent, open and supportive culture that ensures everyone is well
informed and communication is meaningful, purposeful and effective at all
times.
inclusivity and shared leadership, with delegated responsibilities.
going the extra mile for our population, staff, member Practices and partners.
Partnership Principles:

Patients come first in everything we do.

Patients, staff, families, carers, communities, and professionals inside and
outside the organisation are engaged.

The needs of patients and communities are put before organisational
boundaries.

Decisions are made in a clear and transparent way, so that the public can
understand how services are planned and delivered. We are honest and
open about our point of view and what we can and cannot do.

Work with partners to continuously improve the quality of healthcare includes
improvements to the safety, effectiveness and experience of services. We
10
insist on quality and strive to get the basics of quality of care – safety,
effectiveness and patient experience – right every time.

Improving health of our population and the quality of services provided drives
our partnership agenda.

Adopt and share best practice.

Actively working in partnership to address the variations in health outcomes
for our diverse community.

Show real clinical leadership and development across the health economy –
not just within our group but in partnership with others particularly the local
authorities, clinical networks and those who contribute to health and wellbeing
for our patients

Develop commission partnerships which provide the best outcomes in the
most effective and efficient way.

Lead by example, delivering on our promises and listening to our patients, the
public and wider stakeholders.

Be effective in communications within our organisation, our partners and with
the people we serve – sharing what we know is working for our patients and
keeping everyone informed about what our priorities are and how they can
shape health.

Be ready and willing to lead work in partnership to manage the health and
social care as a system.

Collaborative commissioning arrangements will be entered into when a
service is most effectively commissioned beyond our boundary and where
they will derive tangible benefits for patients, for example, where services
need to be commissioned across a wider geography or where skilled
management expertise can be shared..
Table 1 below outlines the current CCG partners, what we are hoping to achieve
from the relationship and the responsible CCG directorate.
11
Table 1
Strategic Partnership (Relationship) Analysis
Partners
Partnership Interface
Directorate Responsibility
 Committees
and Partnerships
subgroups
 LCG forums
 Practice visits
Sandwell Metropolitan  Health and Wellbeing Partnerships
Borough
Council
Board and its work
(including public health)
streams
Member practices
 Health and Social Care Partnerships/Strategic
Commissioning
Integration Board
 Joint Partnership Board
Partnerships/Strategic
Commissioning
 Safeguarding - adults
Quality
and children
Birmingham
City  Health and Wellbeing Partnerships
Council (including public
Board
health)
Partnerships
 BCF Executive/Board
 Safeguarding - adults
Quality
and children
Mental Health Trusts
(Birmingham
and
Solihull Mental Health
Trust, Black Country
Partnership)
Acute Providers
Sandwell and West
Birmingham
 Right Care Right Here Strategic Commissioning
Programme
 New Models of Care
development
Programme
development
Strategic Commissioning
 Via associate
commissioner
arrangements
Acute Providers
Dudley
UHB
HEFT
Community Providers
Birmingham Community
Programme
Health Care Trust
Sandwell and West
development
Birmingham Hospitals
12
Trust
NHS England
STP CCG’s
Voluntary
Organisations
(BVSO, SCVO)
 Co-commissioning
arrangements
 Specialised
commissioning
 STP Board
Sector  Right Care Right Here
Programme
development
 Better
Care
Fund
Programme
Primary Care Commissioning
Committee
Accountable Officer
Partnerships/Strategic
Commissioning
13
14
GOVERNING BODY
Report Title: Audit and Governance Report Author and Title: Alison Hodgson,
Committee
Date of Governing Body: 4th May 2016
[email protected]
Agenda No: 7.6
the Governing Body)
members which supports this report) NHS England Managing conflict of Interest: Revised
Statutory Guidance for CCGs, Draft discussion.
Minutes of the meeting
(Highlight key points you wish to bring to the attention of members)
The aim of the report is to provide the Governing Body of the issues discussed at the Audit
and Governance Committee held on 21st April 2016
Recommendations:


To appoint the Chair of the Audit and Governance Committee as the Conflict
of Interest Guardian
To highlight the Head of Internal Audit Opinion
Action
Approve
Assurance
Decision
x
x
x
not decision
circumstances only)
Quality & Safety
x
x
Partnership
x
x
x
x
x
Implications:
Financial
State any financial implications for the CCG
Assurance Framework
The Audit and Governance Committee have
delegated responsibility to review the Assurance
Framework and provide assurance to the Governing
Body
The Audit and Governance Committee Review the
corporate risk register on behalf of the Governing
Body.
Detail any further implications including resources
and training
Consultation: X
Patients
Staff
Committees
Public
Partners
Sponsored By: (Chief Officer or Committee Julie Jasper, Lay Member and Audit Chair
Chair)
26th April 2016
SANDWELL AND WEST BIRMINGHAM CLINICAL COMMISSIONING GROUP
Report to the Governing Body
Subject: Audit and Governance Committee
Date: 4th May 2016
Author: Alison Hodgson, Deputy Chief Officer, Quality
Remit of Subcommittee
The Audit and Governance Committee is a committee of the SWBCCG Governing Body.
The Committee will inform the Governing Body of its deliberations formally by means of a
report to the Governing Body meeting after the Committee has met, and informally by other
means of communication.
The Committee shall review the establishment and maintenance of an effective system of
integrated governance, risk management and internal control, across the whole of the
organisation's activities (both clinical and non-clinical), that supports the achievement of the
organisation's objectives.
Progress last Month
The committee discussed :








Internal Audit Reports:
 Progress Report
 Outstanding Recommendations Report
 Financial Reporting
 Birmingham Better Care Fund
 Commissioning arrangements for children
 Personal Health budgets
 Updated Work plan 2016/17
 Key Developments Briefing
LSMS Work plan 2016/17
Counter Fraud
Managing conflicts of interest Statutory guidance
Draft Annual Accounts
Draft Annual Report
Annual report checklist
Draft Governance Statement
External Audit
Reports are quarterly
Internal Audit
Progress report highlighted the Head of Internal Audit Opinion as significant assurance.
Four audit reports were finalised as the following:
 Financial Reporting – significant
 Birmingham Better Care Fund - Moderate
 Commissioning arrangements for Children - Moderate
 Personal Health budgets –Significant
Updated work plan for 2016/17 was approved with the an additional heading for review of
conflicts of interest following the recent publication.
Local Security Management
The proposed 2016/17 plan was approved
Counter Fraud – Policies
The following policies were ratified by the committee:




Fraud and Corruption Policy
Communicating and embedding anti-fraud culture
Anti-Bribery Policy
Sanction Redress Policy
Managing Conflicts of Interest revised Statutory Guidance
The committee undertook an initial review of the new draft guidance and agreed the
following:



Further review to take place
Chair of Audit Committee to be the Conflict of Interest Guardian
Agreed to use the recommended forms with the guidance
Draft Annual Accounts
The committee were taken through the accounts and acknowledged the hard work
undertaken by the Finance Team.
Draft Annual Report
The committee reviewed and made amendments to the draft report. This will be further
reviewed by the committee in May.
Annual Governance Statement
The Annual Governance Statement was approved by the committee
Escalation to the Governing Body

To appoint the chair of the Audit and Governance Committee as the Conflict
of Interest Guardian

To highlight the Head of Internal Audit Opinion
Auditor Panel Meeting
Minutes of Meeting held on Thursday 17th March 2016
Board Room Kingston House
08.30 – 09.30 hrs
In Attendance:
Julie Jasper
JJ
Chair
Ranjit Sondhi
RS
Lay Member
James Green
JG
Chief Finance Officer
Janette Rawlinson
JR
Richard Nugent
RN
Michelle Carolan
MC Quality and Safeguarding Lead Nurse
Hazel Barnes
HB
Minutes – PA to the Chief Finance Officer, SWB CCG
Item
1.
Subject
Welcome and Introductions:
JJ declared the meeting open.
Apologies:
Apologies for absence were received from Vijay Bathla, Therese McMahon, Matthew West, Felix
Burden, Alison Hodgson
2.
Declarations of Interest:
To request members to disclose any interest they have, direct or indirect, in any items to
be considered during the course of the meeting and to note that those members declaring
an interest would not be allowed to take part in the consideration or discussion or vote on
any questions relating to that item.
JJ declared her role as a Board member of Dudley CCG Chair of Dudley CCG Auditor Panel.
VB declared his role as Chair of Finance and Performance Committee SWB CCG and all other
attendees declared their roles as members of Audit and Governance Committee for SWB CCG
3.
Minutes of meeting
The minutes of the last meeting held in January were accepted as a true record
Action Register:
Draft Terms of Reference were approved by Governing Body
Chair’s Report:
Julie Jasper had nothing to report.
Governance
Procurement Process Update
James Green advised that 7 CCG’s will be running a joint procurement of external auditors
process which will be run on the basis that each CCG will appoint their own preferred choice and
will be a cost sharing exercise. Auditor panel chairs and CCG CFO’s will take part in the
evaluation process. Which Framework to use and establishing which firms are on the
Framework have yet to be established before planning the process.
Ranjit Sondhi emphasised the need to be mindful that collaboration does not compromise
competition. Julie Jasper acknowledged the need to be clear that SWB CCG choose the firm
that is right for us.
James Green advised that the next step is to draw up a timeline of proposals in order for the
process to begin as External Auditors need to have been appointed by December 2016.
4.
5.
6.
6.1
Minutes of meeting held on Thursday 17th
November 2015
Page 1
Next Audit & Governance Meeting
Thursday 21st April 2016
Item
6.2
Subject
Draft Auditor Panel Terms of Reference
These were agreed by Governing Body. Julie Jasper was named as Chair and Felix Burden was
named as Vice Chair.
7.
Risk Register
Two risks were identified at the last meeting and remain with no additional risks identified today.
7.1
 Failure to appoint external auditors which was classified as low
 Risk of Procurement Challenge which was also classified as low
8.
Key Points
Governing Body Report
Julie Jasper will advise Governing Body of today’s meeting and outcomes.
9.
Any Other Business
No other business
Date and Time of Next Meeting: Thursday April 2015 1200 – 1300 Boardroom
November 2015
Page 2
GOVERNING BODY
Report Title: Organisational Development Report author and Title: Alice Copage,
Committee
Senior HR and OD Associate
Contact Details:
Agenda No: 7.8
the Governing Body)
Organisational Development Committee Minutes
The aim of the report is to provide the Governing Body of the issues discussed at the Organisational
Development Committee on 12th April 2016
Recommendations:
The Governing Body are asked to note the content of the report.
Action
Approve
Assurance
Decision
X
X
not decision
circumstances only)
Quality & Safety
Partnership
X
Implications:
Financial
Financial implication for OD budget for training
approved at OD Committee
Assurance Framework
Consultation: X
Patients
Staff
X
Committees
Public
Partners
Sponsored By: (Chief Officer or Committee Prof Nick Harding
Chair)
26th April 2016
Report
Staff Council Update
The Staff Council met on 22nd March 2016 and discussed a number of items. It was shared with the
committee that there is a plan for a 12 month development programme for staff council members.
The vice chair of the staff council has now been elected and this is Charlie Mason.
Workforce Dash Board
The committee received the CCG compliance figures for mandatory training and PDR compliance. It
was noted that PDR compliance and mandatory training published within the dashboard remained
low however a further document was produced to consider live data as at 12th April 2016 which has
showed a significant increase in compliance for mandatory training. Mandatory training compliance
is now reported at 86%. PDR compliance has also significantly improved to 87% and noted that of
those remaining 12 members of staff have their PDR scheduled therefore it is anticipated that the
April reported compliance will be 94% should all of these PDR’s take place.
Staff Contract Consultation
The OD Committee were informed that at the request of staff through staff council a consultation
will commence in the following months to transfer all staff to CCG Contracts and Terms and
Conditions. It was noted that there are approximately 70 staff on predecessor organisations terms
and conditions and therefore it was appropriate to now undertake a piece of work to align all terms
and conditions.
Recruitment Audit Outcomes
An audit has been undertaken of CCG recruitment processes. An action plan is presented to the
Audit and Governance Committee for assurance but due to the impact on staff the OD Committee
will continue to receive the action plan updates on a monthly basis to provide further assurance and
support. It was noted that there remained one area off original target that was discussed with Audit
and Governance and an extension of the completion of the personal files has been agreed.
CSU Mobilisation
It was noted in a previous OD Committee that the transfer between CSU providers had some risks
associated with it therefore the OD Committee agreed to be the sub-committee responsible for
managing this risk. The OD Committee reviewed a summary of all CSU services across the two CSU
providers and considered the KPI’s associated with the service lines. The OD Committee agreed to
continuously review this.
National Whistle Blowing Policy
In March 2016 a national whistle blowing policy was published by NHS England with the aim to
reduce the variation between NHS organisations in the way Whistle Blowing is managed. The
Committee noted that the CCG current policy was as good as the national policy however agreed to
adopt the best practice from the national policy alongside some local best practice identified at
Sandwell and West Birmingham Hospitals Trust. The updated policy will be ratified at the next OD
Committee and then published to all staff.
Policy Approvals
The OD Committee agreed the updated policies for Flexible Working and Annual Leave
Transformational Managers
The OD Committee considered an approach to supporting staff and clinical leaders in the
development of leadership skills and living the values. The OD Committee agreed to a layered
approach which would commence with the heads of service and senior managers attending a
leadership development programme in July. The OD Committee requested the programme to be
further adapted and explored for other managers in the CCG and Clinical Leaders.
Primary Care Leaders
The OD Committee received an update on the success of the regional Primary Care Leaders
Programme that had been led by Sandwell and West Birmingham CCG on behalf of 22 CCG’s in the
West Midlands. Following the success of the 12 month programme further funding has been
secured for a large scale event in July 2016 that is likely to see the delegates to expand to 400 clinical
leaders across the West Midlands
Risks
The committee also reviewed all associated risks and updated the register.
GOVERNING BODY
Report Title: LCG and Governing Body Report author and Title: Alice Copage,
Appointments
Senior HR and OD Associate
Contact Details:
Agenda No: 8.1
the Governing Body)
In April 2016 the terms of office for 3 LCG’s (Health Works, Black Country and ICOF) Chairs and Vice
Chairs were up for re-election. As a result of this the Chair of the CCG was also up for reappointment. The outcome of the appointments are:
Healthworks:
Chair – Prof Nick Harding
Vice Chair – Dr Ram Saugavanam
Black Country:
Chair – Dr Ian Sykes
Vice Chair – no appointment
ICOF:
Chair – Samar Mukherjee
Vice Chair – Inderjit Marok
Each of the 9 GP Directors were given an opportunity to apply for the Chairmanship of the CCG, the
outcome of which will be known after 4th May 2016 and therefore a verbal update will be provided
at the Governing Body
In addition to the LCG appointments an appointment to the Secondary Care Doctor has been made
with an expected start date in May 2016. Mr John Clothier will take over the role from Mr A. Felix
Burden
Recommendations:
The Governing Body are asked to note the appointments made.
Action
Approve
Assurance
Decision
X
X
not decision
circumstances only)
Quality & Safety
Partnership
Implications:
Financial
Assurance Framework
Consultation: X
Patients
Staff
Committees
Public
Partners
Chair)
Body/Committee
X
Andy Williams
26th April 2016
Report Title:
Alison Braham, Primary Care Quality Lead
GP CCG transfer requests - April 2016
Agenda No: 8.4
the Governing Body)
Chief Finance Officer: 
Supporting Documents/further Reading:
Please refer to Appendices 1 and 2.
Previous Decision
The Governing Body previously agreed in principle to the transfer of 7 member practices
from Sandwell & West Birmingham CCG to Birmingham South Central CCG, subject to final
approval by NHS England.
A copy of the previous report to Governing Body is attached for information (Appendix 1)
A further application has been received from City Health Centre outlining their intention to
transfer out of SWB CCG (Appendix 2). This is in addition to the 7 member practices who
previously applied to transfer to a neighbouring CCG.
The Governing body are required to confirm their agreement in principle to this.
Recommendations:
The Governing body are asked to agree in principle for a request to be made to NHS
England regarding:
-
The amendment of Sandwell & West Birmingham CCG’s Constitution to take account
of 8 member practices requesting to leave the CCG and 3 Practices requesting to
join the CCG (see also Appendix 1)
Action
Approve
Assurance
Decision
x
not decision
1
x
circumstances only)
Quality & Safety
X
Partnership
X
Implications:
Financial
Any financial allocation changes between the
involved CCGs would take effect from 1st April
2017. The approval of the identified changes would
generate a reduction of approximately 1,500
patients. Further details are outlined in the body of
the report.
Assurance Framework
All practices requesting to transfer out of the CCG
have been made aware that any funding received to
date from the Primary Care Commissioning
Framework (PCCF) will be reclaimed by SWB CCG.
Consultation: X
Patients
Staff
Committees
Public
Partners
Chair)
Body/Committee
2
GP Member practice CCG transfer requests
April 2016
Introduction
This paper outlines details of an application received from City Health Centre outlining their
intention to either transfer out of the CCG.
Previous applications received to date are included within Appendix 1.
Impact to resources
All practices requesting to transfer out of the CCG have been made aware that any funding
received to date from the Primary Care Commissioning Framework (PCCF) will be reclaimed
by SWB CCG. In addition, these practices will no longer be eligible to participate in the
2016/17 PCCF and 7 day access scheme if their request to transfer to another CCG is
granted.
Financial implications
Any financial allocation changes between the involved CCGs would take effect from 1st April
2017. The approval of the identified changes would generate a reduction of approximately
1,500 patients.
A reduction of 1,500 patients equates to approximately 0.25% of Primary Care and overall
CCG funding allocation.
The impact of a reduction in allocation of this size would be of minimal risk due to the
associated reduction in the organisations expenditure. However, a proportionate reduction
will also apply to the organisations running cost allocation and would need to be managed
accordingly.
The impact to Sandwell & West Birmingham CCGs financial allocation will need to be
evaluated in detail during the transition process in 2016/17.
CCG Governance
The Governing body are reminded that if a practice is successful in their application, the
CCGs involved are required to inform NHS England of their support for the transfer and seek
formal approval from NHS England to amend their individual constitutions accordingly. CCG
constitutions can only be changed once each year and must be submitted to NHS England
by the 1st June, to take effect on the 1st April the following year.
3
Transition period
During the transitional period, SWB CCG can support practices (both incoming and
outgoing) and will liaise with the appropriate CCGs to ensure a smooth transition prior to
leaving or joining the CCG.
Approval
Based on the recent application received from City Health Centre, the governing body are
asked to agree in principle for a further request to be made to NHS England regarding:
-
of 8 member practices requesting to leave the CCG. The governing body are
reminded that they previously agreed in principle to the transfer of 7 member
practices out of the CCG.
4
APPENDIX 1
FOR INFORMATION ONLY – THIS REPORT HAS PREVIOUSLY BEEN APPROVED BY
THE GOVERNING BODY
Report Title: GP CCG transfer requests Report author and Title:
February 2016
Agenda enclosure no:
the Governing Body)
Chief Finance Officer: Supporting Documents/further Reading:
Please refer to Appendices 1 and 2.
Previous Decision
N/A
This report outlines those GP practices who have submitted applications outlining their
intention to either transfer in or out of SWB CCG.
The Governing body are required to confirm their agreement in principle to these transfers.
Recommendations:
England regarding:
-
join the CCG.
Action
Approve
Assurance
Decision
x
not decision
1
x
circumstances only)
Quality & Safety
X
Partnership
X
Implications:
Financial
Any financial allocation changes between the
involved CCGs would take effect from 1st April 2017.
The approval of the identified changes would
generate a net reduction of approximately 8,200
patients (Approx. 24,400 transfers OUT and 15,200
transfers IN). Further details are outlined in the
body of the report.
Assurance Framework
All practices requesting to transfer out of the CCG
have been made aware that any funding received to
date from the Primary Care Commissioning
Framework (PCCF) will be reclaimed by SWB CCG.
Consultation: X
Patients
Staff
Committees
Public
Partners
Chair)
Date Report received
Body/Committee
for
Governing
2
APPENDIX 1
FOR INFORMATION ONLY – THIS REPORT HAS PREVIOUSLY BEEN APPROVED BY
THE GOVERNING BODY
GP Member practice CCG transfer requests
February 2016
Introduction
This paper provides details of GP practices who have submitted applications outlining their
intention to either transfer in or out of the CCG. Individual applications received to date are
included within Appendix 1 and 2.
Applications received
Currently there are 7 practices requesting to transfer out of the CCG and include:
•
•
•
•
•
•
•
Lozells Medical Practice (Dr Ahmed)
Cavendish Medical Practice (Drs Cheema)
Summerfield Primary Care Centre (Dr Cheema previously Dr Salim)
Summerfield Primary Care Centre (Dr Kulshrestha)
Burbury Medical (Dr Alam)
Queslett Medical Centre (Dr Alam)
Al Shafa Medical Practice (Dr Zafar Ali)
Aside from Dr Kulshrestha’s practice, these practices are all part of the Medica Group and all
wish to transfer into Birmingham South Central CCG (BSC CCG).
Applications requesting a transfer from one Clinical Commissioning Group (CCG) to another
must first be agreed with the CCGs concerned as the CCGs concerned need to assure
themselves that the transfer will not negatively impact upon the registered patients, the
business of the CCG, the services commissioned by the CCG or the wider CCG members.
The above Practices have entered into discussions with BSC CCG regarding their proposed
transfer and specific details of their individual applications (as initially shared with BSC CCG)
are outlined within Appendix 1. BSC CCG have confirmed their support to these
applications.
Transfers in
There are 3 Practices who wish to transfer into the CCG. Two are currently Birmingham
Cross City CCG member practices and one is a member practice of Birmingham South
Central CCG (Appendix 2).
•
•
•
Bellevue Medical
Hillcrest surgery
Kingstanding Road
3
APPENDIX 1
FOR INFORMATION ONLY – THIS REPORT HAS PREVIOUSLY BEEN
APPROVED BY THE GOVERNING BODY
Impact to resources
Further information regarding the GMS/PMS/APMS contracts will need to be sought from
BSC and BCS CCGs for those Practices requesting to transfer in.
All practices requesting to transfer out of the CCG have been made aware that any funding
received to date from the Primary Care Commissioning Framework (PCCF) will be reclaimed
by SWB CCG. In addition, these practices will no longer be eligible to participate in the
2016/17 PCCF and 7 day access scheme if their request to transfer to another CCG is
granted.
Financial implications
Any financial allocation changes between the involved CCGs would take effect from 1st April
2017. The approval of the identified changes would generate a net reduction of
approximately 8,200 patients (Approx. 24,400 transfers OUT and 15,200 transfers IN).
A reduction of 8,200 patients equates to approximately 1.5% of Primary Care and overall
CCG funding allocation. The impact of a reduction in allocation of this size would be of
minimal risk due to the associated reduction in the organisations expenditure. However, a
proportionate reduction will also apply to the organisations running cost allocation and would
need to be managed accordingly. The impact to Sandwell & West Birmingham CCGs
financial allocation will need to be evaluated in detail during the transition period in 2016/17.
CCG Governance
The Governing body are reminded that if a practice is successful in their application, the
CCGs involved are required to inform NHS England of their support for the transfer and seek
formal approval from NHS England to amend their individual constitutions accordingly. CCG
constitutions can only be changed once each year and must be submitted to NHS England
by the 1st June, to take effect on the 1st April the following year.
Transition period
During the transitional period, SWB CCG can support practices (both incoming and
outgoing) and will liaise with the appropriate CCGs to ensure a smooth transition prior to
leaving or joining the CCG.
Approval
England regarding:
-
join the CCG.
4
Report Title:
Proposed change to GP practices within
Healthworks and Pioneers for Health Local
Commissioning Groups
May 2016
Agenda No: 8.5
implications relating to Finance, Quality and Commissioning must be agreed and signed by the Chief
Officer. (see guidance note) Without this information the report will not be taken to the Governing
Body)
Supporting Documents/further Reading:
N/A
Previous Decision
N/A
This paper outlines details of a proposed internal GP practice transfer from within the Healthworks
Local Commissioning Group (LCG) into the Pioneers for Health LCG.
The Committee are asked to approve this proposal and make a recommendation to the CCG
Governing Body to that effect.
Recommendations:
The Governing Body are asked to recommend the internal transfer of City Road Medical Centre (Dr
Abrol, Practice Code: M85684) from Healthworks LCG into Pioneers for Health LCG.
Action
Approve
Assurance
Decision
x
not decision
circumstances only)
Quality & Safety
Partnership
x
Implications:
Financial
Assurance Framework
Consultation: X
Patients
Staff
Committees
Public
Partners
Chair)
Body/Committee
X
Proposed change to GP practices within Healthworks and
Pioneers for Health Local Commissioning Groups
1.
Background
1.1
The CCG has received a request from City Road Medical Centre (Dr Abrol, Practice Code:
M85684) to transfer from within their existing LCG (Healthworks) into Pioneers for Health LCG.
1.2
Dr Nick Harding (Chair of Healthworks LCG) and Dr Vijay Bathla (Chair of Pioneers for Health
LCG) are aware of this request and both are in agreement to the proposed transfer.
2.
Impact of proposed transfer
2.1
This proposal relates to the internal transfer of one member practice from within one LCG to
another, therefore any impact to the CCG and its resources are negligible.
3.
CCG governance and constitution
3.1
Subject to approval by the Governing Body, the CCG will inform NHS England of their support to
this transfer.
3.2
Formal approval may also need to be sought from NHS England to amend the CCG’s existing
constitution to reflect changes to member practices within each LCG.
4.
Recommendation
4.1
The CCG Governing Body are asked to recommend the following:

The internal transfer of City Road Medical Centre (Dr Abrol, Practice Code: M85684)
from Healthworks LCG into Pioneers for Health LCG.
Sandwell & West Birmingham CCG SANDWELL AND WEST BIRMINGHAM CLINICAL COMMISSIONING GROUP
Finance & Performance Committee Minutes of Meeting held on
Monday 21st March 2016 Kingston House, Boardroom, 13:00–15:00hrs
Members:
Dr Vijay Bathla
Julie Jasper
Ian Sykes
Janette Rawlinson
In attendance:
David Hughes
Martin Stevens
Laura Mainwaring
Hazel Barnes
Item
1.
2.
VB
JJ
IS
JR
Chair
Vice Chair
Finance Lead Black Country LCG, GP Representative
DH
MS
LM
HB
Deputy Chief Finance Officer
Head of Business and Contract Performance
Head of Financial Management
PA to Chief Finance Officer (Minutes)
Subject
Apologies for Absence
VB welcomed those present to the meeting. Apologies were received from James Green,
To request members disclose any interest they have, direct or indirect, in any items to be
considered during the course of the meeting and to note that those members declaring an
interest would not be allowed to take part in the consideration or discussion or vote on any
questions relating to that item.
JJ declared herself a member of Dudley CCG.
3.
4.
5.
6.
Minutes
JR asked for minutes from Governing Body to be included as minutes from 25th January as
there are no minutes available due to the theft of the recording. An amendment of the spelling
of Jon Dicken’s name was also requested. Item 7.1 should read “the national plan is due on
8th February 2016” not 2061
 Subject to these amendments the minutes were approved
Action Report
The action register was updated for circulation prior to the next meeting
Chairman’s Report
The chair had nothing to report
Performance Report
MS presented the report highlighting the salient points
Accident & Emergency (A&E)
Performance continued to fall below the 95% standard in January with only 90.91% achieved.
This may be due to higher demand throughout January as all other providers have also
struggled. Challenges have been around staffing.
An action plan received from SWBH Trust was presented for information and comment.
Cancer Waits
In January the CCG failed to meet the 31 day treatment targets for both surgery and
radiotherapy with 2 patients waiting over 31 days at UHB. One of which was an admin error
and the other due to capacity. 5 radiotherapy patients waiting were due to patient choice.
Sandwell
& West Birmingham CCG
Page 1
Finance & Performance Committee Meeting
Monday 21st March 2016
Sandwell & West Birmingham CCG However, UHB were within target for both target indicators
Ambulance Red 2 incidents
WMAS failed to meet the national target for the first time this year due to an increase in
demand
IAPT
National data has been published for November and the CCG achieved both entering
treatment and moving to recovery targets. Q2 data will be published on 20th April 2013.
RTT
Exception reports were attached for information.
The issue of admin errors is being
addressed through the re-education of staff with a complete learning programme in place
including an online training tool. Auditing will be done to monitor improvement although it is
anticipated that benefits are going take some time to be realised. SWBHT are still anticipating
2 x 52 day breaches a month.
Diagnostic waiting times
This continues to be good news with achievements within the 1% tolerance.
WMAS
DH referred to contractual negotiations for next year with WMAS unhappy with
commissioners’ liability to manage acute Trusts.
Other points noted:




Diagnosis rates for dementia have decreased. JR pointed out that incentive payments
for GP’s have now been stopped. An article in HSJ was also highlighted by JR stating
that “dementia diagnoses were given to gain payment”
There has been no update regarding emergency admissions and little improvement
made in relation to re-admissions within 30 days although year to date is a similar
position to last year.
There have been no new infections of MRSA for the CCG or SWBHT. There were 5
Cdiff infections.
There was no new data in relation to vaccinations. JR questioned why targets are
being missed and asked whether this was down to a lack of vaccines, lack of clinics or
people not taking up the vaccines offered. MS explained that it is difficult to establish
the reasons why.
Action: JJ will ask AH to provide an indication from Public Health regarding
vaccinations and MS will look at this area and attempt to narrow the figures down to GP
practice
A&E
Performance is still poor. IS pointed out that there is a national staffing problem in A&E’s
across the country with SWBH doing better than the average. MS advised that the CCG have
been retaining money from the Trust for several months and this was re-instated since
receiving the action plan. Monies were retained for the IG breach as they failed to provide this
report. MS asked the committee to consider releasing these monies.
SWBHT Action Plan Report and 2016/17 Planning
MS explained that trajectories for A&E are not currently agreed. A 2.6% improvement on the
Sandwell
Page 2
Sandwell & West Birmingham CCG monthly outcomes is currently required to close the gap of £4m.
IS said that there are currently 7 Consultant vacancies in A&E across City and Sandwell sites.
Of the current consultant staff, 6 are interim/temporary which is not a stable workforce. IS put
this down to a lack of private work being available for A&E consultants to attract them to post.
He suggested that a remuneration package was required and recommended that SWBHT be
asked what we can do to help attract staff and suggested that perhaps the Deanery could
offer incentives. DH questioned whether solving staffing issues would resolve the problems
as there are other wider issues.
DH recommended that the Action Plan go to Governing Body or Directors stating that the
report suggests failure which is a constitutional breach. JR agreed that the CCG cannot agree
to the plan as it does not meet the constitution.
The committee agreed to take the plan to Directors meeting on Wednesday 23rd March
to address the issues.

7.
Finance Report
DH presented the penultimate papers for 2015/16 with minimal updates scheduled for the next
meeting.
The CCG’s overall Revenue Resource Limit is £746m(an increase of £1m in relation to
Vanguard Modality) with a forecasted surplus of £12m for 2016/16 – an increase from the
originally planned £8.7m which was agreed with NHSE. QIPP target is on track and remains
at £8m. Overall rating is green against all finance and activity targets. In relation to
underlying recurrent surplus, DH explained that the figure will drop in future years if QIPP
targets are not achieved.
DH advised that the financial position has not moved significantly. Contract performance
shows a slight increase in performance from SWBHT with an over performance of £600,000 in
January. The bulk of this was in emergency care. DGOH’s rate of over performance is
slowing down. .ROH shows an over performance of £0.5m, mainly in relation to elective care.
SWBHT shows an underperformance of around £4.4 in maternity and ante natal. DH advised
that the over performance in A&E offsets this to some degree.
DGOH’s over performance showed a slowing down after a very difficult 12 – 18 months with
an over performance of £2.5 m.
DH reported little change in Prescribing Performance and only slight movement anticipated.
The CCG’s QIPP target planned and forecast for the year is £8.4m which DH advised has
been achieved by non-recurrent and fortuitous means. This will not be the case for future
years.
Little change was reported in Statement of Financial Position and the current CCG bank
balance was reported at £281 k at the end of February which is within the 1.25% ceiling set by
NHSE.

8.
Resolution: The committee approved the contents of the report and
acknowledged associated risks.
The Committee approved the contents of the report. JR offered her
congratulations VJ expressed thanks on behalf of the committee
Finance and Performance Risks
The risk register was updated for circulation at next month’s meeting.
discussions surrounding SWBHT the risk was placed on the BAF register.
Sandwell
Page 3
In light of the
Sandwell & West Birmingham CCG 10.
AOB
IS advised the committee that DGOH have allegedly been coding all outpatients as new
patients for financial gain.
Action: MS to ask Business Intelligence to look into this.
JG presented an overview of The Right Care Programme based upon extracts taken from the
Commissioning for Value Packs provided by NHSE which all CCG’s are required to partake.
The thinking behind the programme is to identify opportunities to save resources and balance
the system overall by looking at areas with a view to improving outcomes and efficiency A
separate presentation document was provided.
JG explained that the analysis is based on a comparison with 10 other CCGs with a similar
demographic to SWBCCG. JG highlighted the headline opportunities based on outcomes and
expenditure within the SWBCCG footprint across a number of pathways.
JG outlined the next steps and suggested that although finance will need to be involved,
the work should probably be led through clinical areas and this has been shared amongst
most of the commissioning managers but has not yet been discussed with clinical leads.
JJ gave support to gaining external support to work on this and JR recognised the
importance of the piece of work 11.
Date and Time of Next Meeting:
Monday 25th April 2016 13:00-15:00.
Sandwell
Page 4
Enc SANDWELL AND WEST BIRMINGHAM CLINICAL COMMISSIONING GROUP QUALITY AND SAFETY MEETING Minutes of the meeting held on Monday 21st March 2016 Carters Green Business Centre, West Bromwich Present: Sam Mukherjee (SM) – ICOF Chair, Quality & Safety (Chair) Inderjit Marok (IM) – ICOF Vice Chair, Quality and Safety Claire Parker (CP) – Chief Officer for Quality Alison Hodgson (AH) – Deputy Chief Officer for Quality Tom Richards (TR) – Quality and Risk Lead John Clothier (JC) – Healthwatch representative Alison Braham (AB) – Primary Care Quality Lead Gene Kelly (GK) – Safeguarding Lead Michelle Carolan (MC) – Quality Lead for Care Homes Pam Kaur (PK) – Continuing Healthcare Department Manager Richard Nugent (RN) – Independent Committee Member Sumaira Tabassum (ST) – Medicines Optimisation Operational Lead Pharmacist Lesley Jones (LJ) – Customer Care Officer (minutes) In attendance: Michelle Wiles (MW) – Information Governance Apologies: Andrew Harkness (AHA) – Consultant in Public Health Martin Stevens (MS) – Head of Performance Liz Walker (LW) – Head of Medicines Management Therese McMahon – (TMM) ‐ Non Executive Board Nurse Item Subject Action 1. Apologies. Noted. 2. Declarations of Interest. None declared other than possible Medicines Management presentations. 3. Minutes of Last Meeting. Agreed as accurate. 4. 150615 – Exception Reports/Emerging Concerns. IAPT issues – report to the Committee from John Levy. John Levy to provide a one side briefing on data issues for update. Ongoing JL 210915 – BCPFT CQRM. Workforce data to Quality and Safety Committee members. Information to come back to the Committee once contract variation discussions completed. Current data does not give sufficient level of detail for assurance. Ongoing TR 161115 – Quality Report. SWBH – Perinatal target low. TR to investigate and report back to the Committee. 1 Enc Item Subject Information pending. April 16 161115 – SWBH – CQRM. Staff vacancy issues. CP/SM to pick up at next CQRM and report back. Information to be presented to the Governing Body in March 16. Presented to the Governing Body. Closed 211215 – Safeguarding Assurance around the compliance of record retention for children’s services and training. Goddard report to be forwarded to LCG Chairs and Vice Chairs for discussion at forthcoming LCG’s. Information to be circulated through Nick’s Newsletter. Action can then be closed. 180116 – SWBH – Cardiology. Transition of e‐referrals. It was suggested that a task and finish group be set up to manage transition to e‐referrals. CP to raise at CQRM. Ongoing issues with all electronic e‐referrals. CP to pick up directly with SWBH. Quarterly reports/updates to be on the Committee agenda. To be removed as action. 5. Quality Report – February 2016. Action TR GK TR summarised the main points of the report as follows: Serious Incidents/Never Events:  One new Never Event reported in February of wrong site surgery. The Committee discussed the actions taken following the incident. Learning points to be shared together with review of polices. A walk through review will also be performed.  Numbers of serious incidents reported as 15 for February and broke down as 8 SWBH, 1 BCPFT and 6 WMAS. TTR’s are taking place on the WMAS incidents. Visits:  Visit took place to Rowley Regis Hospital. Communication and record keeping issues identified. Issues with integration on the Ward due to two separate teams working on the Ward. No joint handovers or team meetings were taking place and separate note systems in place. An action plan has been put forward recommending improved joint working and senior carers to attend handovers. Sandwell and West Birmingham Hospitals  Incidents of pressure ulcers are decreasing.  Patient falls are levelling off at around 2 per month.  No new trends have been identified.  Complaints reported are to be picked up by the CCG Quality Team. These were highlighted to Healthwatch through CQC. CQRM information: 2 Enc Item Subject 
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3 c.diff incidents reported in December 94.5% harm free care C section rate of 23.1 Cancer care met referral to treatment targets. MSSA – none in December. Cancelled operations increased to 1% from 0.8% target. PDR compliance at 86.2% Sickness at 5.5% Vacancies 320 wte. Bank and agency usage still high. Expect reduction for the next report. CQUIN’s – all targets met apart from trajectory target on AKI. Meds falls CQUIN data will be backdated to Quarter 4. Black Country Partnerships Foundation Trust:‐ 
No new incidents of unexpected deaths. JC queried if incidents of Learning Disability deaths were being investigated as classified as community deaths. AH explained that assurances have been given that they are reported and the coroner also informed. An in depth report was presented to CQRM. 
Concerns are being reported by GP’s around communication with the Crisis Team. The Quality Team are investigating this trend further. CQRM information: 
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LD themes discussed at last meeting. Workforce has been highlighted as an issue as sickness levels are quite high. Exception reports have been presented in relation to the EIS indicators. This will be monitored. HCAI training indicator has not been met. Psychosis Medication reviews. Issues with collection of data will be reviewed and to be addressed. Demonstration of website for patients took place. This was well received. CQUIN’s for Quarter 3. Not all passed. Issues with no fully integrated clinical system and identifying patients. Mitigations currently in discussion with the CCG. Birmingham and Solihull Mental Health Trust: 
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3 All local LQR requirements met on the SPQR. Trend noted of values and behaviours in their complaints. Upward trend in incident reporting. 13 SUI’s reported. RCA’s for completion. Results at the next meeting. Sickness at 4.23%. Vacancy rates fell. Agency costs also fell. Mandatory training at 92.9% Risk assessment to be completed on RIDDOR reported incident. Request for data split to focus on West Birmingham patients being looked into. Action Enc Item Subject 
Dudley Group Foundation Trust  Quarter 4 report to be bought to the April meeting of this Committee. Birmingham Community Healthcare Trust.  High rates of DNA’s being reported. Reviews and mitigating actions being taken. More detail in the next report.  Paediatric Eye Clinic review showed high levels of professional standards.  7 SUI’s in last 6 months.  2 new complaints and concerns reported to Time2Talk over the 6 month period. SM asked if BCHT had any mitigating actions around reports of staff attitude/bedside manner. CP stated that these issues will be picked up with the Commissioners. CP explained that there were some concerns raised around the Health Harmonie services. These will be picked up in the monthly contract review meetings and a member of the Quality team will attend. The Committee also discussed issues with housebound patients and hoists on site for the home visits. Following meetings, feedback will be provided to the Governing Body through the exec summary. NHS 111/WMAS  TTR’s to take place on incidents as previously discussed.  Working towards skill mix on ambulances as they have identified some issues with skill levels.  Red 1 response time slightly off target due to Winter pressures.  See and treat rates are being investigated as part of report for CQUIN.  Calls failing target. Investigating whether NHS 111 calls are impacting on this indicator.  Handover – 15 minute target not being met. On the regional score. The Committee discussed some Hospital Trusts transferring through A and E and the delays caused for ambulances when this system is in place. AH explained that a collaborative meeting is taking place on Wednesday 23rd March. Feedback will be presented at the next meeting of this Committee. GP Incident reporting:  Highest levels of reporting incidents for February.  Highest number of separate GP’s reporting in February. All LCG’s reported within their relative sizes.  99% of incidents reported were of low level incidents.  Learning and reporting back processes are improving. The Committee acknowledged the improvement in GP reporting. SM suggested that the information be included in Nick’s Newsletter as positive feedback. 4 No new concerns or complaints picked up by the Time2Talk team. Action Enc Item Subject Complaints and Concerns: Action  The Time 2 Talk team have reported complaints, concerns, Query/Signpostings and compliment. No change in the trends. Medicines Management.  A 1% reduction in antibiotic prescribing has been reported following project by the Medicines Management Team. The Committee expressed their congratulations to the Team for the improvements made following their initiatives. ST was asked to feed this back to the Team. CP requested some changes be made to the Quality Report.  CQRM information to be current.  Colour coding (but not using RAG if they are all above target) on incident reports. A key to TR be provided.  Possible patient identification on detail of Never Events to be monitored closely. Appendix 1. Continuing Healthcare Report PK summarised the report for the members. Pending recommendations are being looked at and cases exceeding the 28 day targets. Report back to April meeting. The CHC Team are completing a value assessment. This will look at quality around complaints and what learning has been identified. In house training will be taking place. The team are also mapping complaints to the appeals received, and it has been recognised that the information given to families before assessments need to contain more clarity on the process. All retrospective cases have now been completed. There are 5 current high cost appeals cases ongoing which are being made a priority before the end of the financial year. The Committee congratulated the CHC team on its achievements in bringing appeals to resolution. Appendix 2. Safeguarding Report GK presented the Annual Assessment report from BSCB and Assurance Statement and summarised as follows:‐  The Sandwell Annual report will be completed for the CCG and bought to this Committee and Governing Body in the next few weeks.  CSE event was very successful in supporting GP’s. CP explained that the video shown would be presented at PLT event.  Further face to face safeguarding children training for GP’s (20 sessions) has been secured.  Adult safeguarding sessions have taken place and the feedback has been positive from attendees. More sessions will take place in the next financial year. 5 Enc Item Subject RN queried the engagement of agencies with Birmingham MASH. CP explained that the service is being reviewed. A review will also take place around staffing for the Sandwell MASH and the skill mix required. Action SM asked whether GP attendance to case reviews has improved. GK stated that there have been improvements and a report will be bought to the next meeting. It has been acknowledged that there are issues of timeliness of notification for GP’s in order for attendance to be improved. CP asked the Committee to consider funding for Safeguarding Boards. The Committee agreed plus 1.1% for inflation rises in contributions for the Sandwell Children’s Board. CP to take this recommendation to the Governing Body. The Committee agreed that a request of breakdowns of spending from the Adult Safeguarding Board be scrutinised before agreement on their increase request. Appendix 3. Infection Prevention Report. CP explained that a number of issues have arisen from the report including the contamination rates reported, and the outbreaks of Norovirus and e‐coli at SWBHT. A TTR is to take place on the neo natal ward and CP is awaiting the outcome. Visits to be arranged and David Jones to be included in any future visits to take place. CP explained that the rates will be challenged through the next CQRM. 6. Exception Reports/Emerging Concerns No exception reports presented at this meeting. 7. Medicines Management Waste Medication Flyer ST explained that the flyer had been produced for dissemination at Community Pharmacies and GP Surgeries. The Committee acknowledged the issues around over ordering and agreed the project. Rebate ‐ Edoxaban ST presented for approval by the Committee and explained that the scheme would not go forward as a script switch choice for GP’s. Rebate – Glucomen. ST presented to the Committee for approval. The Committee approved the schemes. Position Statement – Paracetamol and Ibuprofen ST presented the document for approval. The Committee has requested that the wording be changed to state that the information is advisory. The letters for Care Homes, Pharmacies and GP’s to be reviewed to reflect changes to the statement. The Committee requested that the 6 Enc Item Subject amended documents be presented to the April meeting of the Committee. 8. Policies and Procedures No policies were put forward at this meeting. 9. Information Governance Fair Processing Notice I G Handbook SOP for Subject Access Requests. MW presented the documents for ratification by the Committee. AH and CP explained that all documents have been scrutinised previously and agreed by the Committee in December 2015. The Committee agreed the above documents. The Fair Processing Notice for patients will be placed on the website. FPN Feedback Report. MW explained that the IG Tooklit will be evidenced by the end of March. MW expects that the IG compliance will be at 92% by 31.3.16. The Committee voiced concerns over data gaps and the clarity of information that is required by the Audit Committee. CP requested that MW forward what evidence is still required. MW agreed to forward a list of evidence required to CP by the end of the week. The Committee agreed the report be approved on the condition that the evidence supplied is submitted within the agreed timescale. It was agreed that this information be disseminated via email due to the time constraints. MW requested that this extract from the minutes be provided as evidence that documents have been approved by the Quality and Safety Committee. ADDITIONAL ITEMS: 10. Non Emergency Transport – Service Specifications . Schedule 6 – Contract Management. The documents were presented for approval by the Committee. JC explained that there were some issues with carers not being allowed to transit with patients. The safety aspects of this stipulation to be discussed at SCR. The Committee agreed that any additional comments should be given to LJ to pass onto the SCR Committee members. Action MW MW LJ LJ/ALL COPY MINUTES FOR INFORMATION: 11. CQRM –Sandwell and West Birmingham Hospitals Trust – No February meeting. 12. 7 CQRM – Dudley Group Foundation Trust – February Minutes Enc Item Subject The Committee accepted for information. Action 13. CQRM – West Midlands Ambulance Service – January Minutes The Committee accepted for information. 14. CQRM – Black Country Partnership Trust – None. 15. CQRM – Birmingham and Solihull Mental Health Trust – None 16. Health Forum – February Minutes. The Committee accepted for information. ANY OTHER BUSINESS 17. None discussed. FUTURE MEETINGS 18. 8 Date of the next meeting: Monday 18th April 2016 – 1.00pm – 3.00pm 2R Kingston House. Sandwell & West Birmingham CCG SANDWELL AND WEST BIRMINGHAM CLINICAL COMMISSIONING GROUP
Audit & Governance Committee
Minutes of Meeting held on Thursday 17th March 2016
Board Room Kingston House
09:00 – 12:00hrs
Members:
Julie Jasper
Janette Rawlinson
Richard Nugent
Ranjit Sondhi
In Attendance:
James Green
Simon Stanyer
Paul Capener
Tracey Barnard Ghaut
Matthew West
Michelle Carolan
*Amy Huckle
Carol Brown
Hazel Barnes
Item
1.
2.
3.
4.
5.
6.
6.1
JJ
JR
RN
RS
Chair
Lay Member
JG
SS
PC
TBG
MW
MS
AH
CB
HB
Chief Finance Office
Infrastructure, Government and Healthcare (IGH) UK Audit
Head of Internal Audit (CW Audit)
Assistant Director (Audit) CW Audit
Financial Controller
Quality and Safeguarding Lead Nurse
HR Business Partner *
Local Counter Fraud Specialist
Minutes – PA to the Chief Finance Officer, SWB CCG
Subject
Welcome and Introductions:
JJ declared the meeting open.
Apologies:
Apologies for absence were received from Vijay Bathla, Felix Burden and Alison Hodgson
To request members to disclose any interest they have, direct or indirect, in any items to be
considered during the course of the meeting and to note that those members declaring an
interest would not be allowed to take part in the consideration or discussion or vote on any
questions relating to that item.
JJ declared her role as a Board member of Dudley CCG. Members of the Auditor Panel shared
their declarations.
Minutes of meeting held Thursday 21st January 2016
JR requested an amendment to ToR under quoracy to read The quorum for meetings shall be 2
Lay Members one of which to be the Chair OR vice chair. A change or wording was also requested
under item 7.4 to ready recommendations to be allocated. The addition of Mark Rollason’s title
was requested under item 8.1 with a correction of a typo to read deliver.
 Subject to this amendment these minutes were approved
Action Register:
The action register was updated for circulation prior to the next meeting.
Chair’s Report:
Julie Jasper had nothing to report.
External Audit
Progress Report
SS summarised the work undertaken and informed the Committee that they are currently preparing
March 2016
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Sandwell & West Birmingham CCG Item
7.
7.1
7.2
7.3
7.4
7.5
7.6
Subject
for the final account visit. SS has met with David Hughes and Matthew West to resolve issues with
BCF and Primary Care Co-Commissioning and commended the work they have done. He has also
met with internal audit to ensure there is no duplication of work.
Work continues to collate evidence for VFM and to ensure a smooth final process. SS gave thanks
for the assistance provided by the Finance Team.
The timing and approach to the final accounts audit has been agreed which is scheduled to
commence on 25th April 2016.
JJ asked that the Committee noted the technical updates and thanked SS.
 The committee approved the Progress Report.
Internal Audit
Internal Audit Progress Report
TBG explained that there are now five finalised reports and one in draft stage in relation to
commissioning arrangements. There are currently four areas of work in progress.
The Cumulative opinion is currently sitting as significant with Primary Care Co-Commissioning and
Recruitment processes being mentioned as moderate. BCF and Partnership will be added to this.
PC gave assurance that it is very unlikely to change from significant in spite of service audit reports
awaited from SBS, Payroll and CSU but these are unlikely to have any effect. PC outlined the four
assurance levels and the committee agreed to strive for significant in all areas as there is no room
for complacency.
Key Performance Indicators
TBG highlighted just one KPI not meeting target which is Management Response time although this
is improved from this time last year at 73% (target 90%). This is an improving picture.
Implementation of Agreed Actions
TBG advised that there are currently 195 recommendations on the system of which 162 are closed
as implemented or no longer relevant. 32 are not completed of which 20 or not due and 12 are
overdue. These require updating and signing off. MW advised that he is in the process of chasing
these up for action and system update
Recommendation Tracker
JR advised that PCCC ToR have now been signed off by Governing Body but the deadline was
missed for this report. NHSE have also confirmed their agreement.
It was noted by the committee that it is SWBCCG’s responsibility to implement and update the
system. Non-compliance with this needs to be addressed internally.
Action: JG will address this and circulate the Recommendation Tracker requesting updates
Draft Internal Audit Plan for 2016/17 – for approval
TBG presented the draft Internal Audit plan for 2016/17 for consideration and approval. JG and JJ
both registered their approval. JJ questioned 15 days for HR and Recruitment and TBG advised
that this was based on this year’s work. JG acknowledged that this was the first limited assurance
the CCG has had and there is therefore work to be done to ensure there is an improved picture
next year.
 The Committee approved the indicative plan
Draft HOIA Opinion
Draft HOIA opinion was submitted in February and currently sits as significant. Moderate and
limited opinions will be listed in the statement. PC advised that there have been no areas of
deterioration and whilst there are more moderate and limited opinions listed these are all new
areas.
Board Assurance Framework Checklist
The Assessment of Assurance Framework 2016/2016 is a mandatory review and meets year end
requirements with Category A level of assurance.
Partnership Audit Report
This report was given by TBG for information and shows moderate assurance with 5
recommendations. PC explained that historically this committee has lacked clarity. He has now
observed one of their meetings and provided feedback with agreement to meet at a later date and
review this. He advised that their ToR is now much clearer. JR advised that constant re-visiting
March 2016
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7.7
7.8
7.9
8.
8.1
9.
9.1
9.2
9.3
Subject
their ToR is required in light of the new STP’s as there is still movement and development to be
done. Clinical leads are to be invited to the next Partnership meeting.
RS reported on the committee’s unsettled history and the past debate as to whether it should exist
at all. He advised that he still ponders the benefit of the Partnership Committee.
Financial Systems Audit Report
TBG advised that significant assurance has been given following internal auditor review of Financial
systems. 10 key control objectives were assessed, of which full level of assurance was given on 6
and significant assurance was given on 4 with recommendations around procedures, timeliness
and evidence.
JJ recognised this and congratulated SWB CCG.
Better Care Fund Audit Report
TBG explained that this was a new area of work and a level of moderate assurance has been given
with 10 recommendations. TBG acknowledged that governance arrangements continue to evolve
in this area.
JR acknowledged this as a fair assessment and recommended that this be a standard agenda item
to monitor this. JJ asked that JR ensures that this is on the Partnerships agenda
 Action: TBG to forward this audit report to Partnerships Committee via Sharon
Liggins
Information Governance Audit – Phase 2
TBG advised that at the time of completing the fieldwork on 24th February 2016. Only 81% (target
92%) has been achieved and recognised that there may have been some movement since then.
MC advised that assurance has been given by Alison Hodgson that evidence will be uploaded by
the end of the month deadline. It was recognised that we are currently in a better position than at
this time last year.
MC advised that some of the actions have been taken on by the Quality Team and others are with
CSU and require CCG monitoring to ensure completion.
 Action: JG will contact CSU and AH to discuss and report back to give further
assurance
MC gave assurance that there was confidence that the target will be met as a lot of work has been
done since the fieldwork was completed at the end of February 2016.
Counter Fraud Audit Plan 2016/17
CB presented the draft plan for approval. She advised that there will be link in Nick’s newsletter
this year to the Fraud which will be sent out by AH.
Action: CB to send a reminder to Sam Warnock
 The committee approved the Counter Fraud Audit Plan for 2016/17
PC advised that following publication of “Outcomes of the Review of NHS Protect” there would be
implications on CCG for resources for anti-fraud. However, he timescale for this is not yet known.
Governance
Primary Care Co-Commissioning Auditor Report Update
This item was deferred as apologies sent by Sharon Liggins
Standing financial Instructions and Scheme of Delegation
This was presented by MW and the committee were happy with the proposed changes which were
highlighted in yellow to SFI’s based on the updates. .
PC noted that on page 15 item 2.3.6 (Internal Audit Role) – this should now be Public Sector
Internal Audit rather than NHS. It was also recommended that 2.4.1 should read that Auditors
Panel to appoint Internal Auditors and not Audit and Governance Committee
 This Committee agreed subject to Governing Body delegation of authority
Draft Annual Accounts Timetable 2015/16
MW presented an update of the annual accounts timetable for assurance. Draft briefing papers will
be presented to April’s A&G meeting which will be a page turning exercise.
In response to RS querying how many GP practices there are, MW confirmed the number to be 101
RS asked that the annual report reflect our diversity and JJ asked that the full report be available at
March 2016
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9.4
9.5
10.
Subject
the AGM.
Action: Draft annual report to be circulated electronically for feedback
JG pointed out that the table of meeting attendances was not accurate and asked that this be
checked.
JR noted that Public Health should be sending a deputy to meetings if their representative is unable
to attend.
Action: MW to check attendance requirements (excluding deputies) in the constitution
JR recommended a visual to highlight public feeds into committees.
Action: MW will gain this information from Jayne Salter-Scott
JJ recognised the evaluation process of the annual report
Action: RS will put the draft annual report in front of PPAG for their response and comment
Draft Annual Governance Statement
This was presented by MW for comments. PC advised that a new section was needed entitled
“Feedback from delegation chairs regarding business use of resources and response to risk”. This
was noted by MW.
MW asked for comments and requests for additions to be sent electronically to him.
Recruitment Process Audit Update
Amy Huckle (AH) joined the meeting to update on HR issues and recruitment process audit.
AH advised that under the flexible working policy it was decided not to reinstate the 9 day fortnight.
JG pointed out that the CCG have never offered this so recommended that it not be mentioned. He
also stated that all flexible workings should be requested and approved on each individual request.
Action: All managers to be requested by Chief Officers to provide details of all staff who
have a flexible working pattern.
Mandatory Training - AH advised that as of Tuesday 15th March 2016 there was 86% compliance.
20 members of staff were non-compliant. 4 of which are currently out of business (ie on maternity
etc) and 16 are yet to complete training. AH advised that Alice Copage is currently in the process
of chasing individuals.
PDR- This currently stands at 87% compliant with 166 members of staff completing PDR’s. 22 are
yet to be completed and 12 are scheduled for March/April. AH advised that we are currently on
target for 94% at the end of April. OD and Q&S committees are monitoring this. JR pointed out
that these need to be completed by the end of the financial year to achieve target.
Personal File Audit – AH advised that a project group has been set up and there as of 14th March
2016 99 files were not complete. AH reported anxiety from staff and business supports conducting
the file audit. HB clarified that anxiety came from concerns about how and where personal and
confidential information has gone missing from files and that staff sought assurance around this.
AH advised that it is likely to be April before the target is met.
The committee agreed an extension to 30th April 2016
The following amendments were requested to the Detailed findings and action plan document
which was presented
Dates and months to be documented in the audit findings in relation to 2.2 – Establishments Control
Forms
Interview Assessment Process issues to be resolved with new recruitment team and item 5.2 and
5.3 should therefore read completed and ongoing
Item 6.1 and 6.2 should read completed and ongoing
Item 6.3 and 6.4 were given extensions to 30th April 2016
Action: AH to update and send an update for Governing Body meeting on 6th April 2016
Conflicts of Interest Register Analysis
MW presented this for information and comment.
March 2016
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Subject
JR pointed out discrepancies around Rem Com
Action: MW to gain an update from AH and amend
11.
Key Points
TBA Advised
Date and Time of Next Meeting:
Thursday 21st April 2016, Kingston House Boardroom
March 2016
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Sandwell & West Birmingham CCG SANDWELL AND WEST BIRMINGHAM CLINICAL COMMISSIONING GROUP
Organisational Development Committee
Wednesday 15th March 2016 2016, 10:00 – 12.00 hrs.
Meeting Room 2 4F, Kingston House
Members:
Dr Nick Harding
Alvina Nesbitt
Alison Hodgson
Sam Warnock
Alice Copage
NH
AN
AH
SW
AC
Chair
Staff Council Chair
Communications CSU
Senior HR & OD Associate (M&L CSU)
Item Subject
1.
Welcome and Apologies:
NH welcomed those present.
Apologies for absence were received from, Saba Rai, Therese McMahon, Jayne
Salter-Scott. Andy Williams, Claire Parker and Jon Dicken
2.
No declarations from attendees were disclosed at this point of the meeting.
3.
Minutes from the meeting held on Wednesday 23rd February 2016 :
The minutes of the meeting held on Wednesday 23rd February 2016 were accepted as
a true and accurate record.
4.
Matters Arising from the minutes:
Covered on the agenda
5.
Staff Council and Policy Development Update:
AN explained that there had been no meeting since the last OD Committee. At the
next meeting the council will discuss induction for new council members.
NH asked if the Staff Council was functioning well. AN responded that her view as
Staff Council Chair was that the staff council had become more embedded within the
organisation and the plan for next 12 months is to continue to embed the role
especially in relation to staff engagement. AN reported that the new members of the
staff council were excited and enthusiastic about the agenda for the next 12 months
and being able to represent colleagues.
6.
Workforce Dashboards:
AC presented the dashboard explaining the data is behind in reporting due to the cycle
of the workforce information being published. AC explained that she is currently having
Sandwell
Organisation Development Committee
Action notes of meeting held on
Tuesday15th March 2016
OD Committee Meeting
Page 1
Sandwell & West Birmingham CCG Item Subject
discussions with the new CSU provider to see if there is a possibility to publish live
data. AC explained that some of the figures within the dashboard were as accurate as
there are people on list who should not be such as clinical leads as they are not
employees. It was noted that the sickness figures have increased in January however
this is an expected trend and concern was not necessary at this stage unless a
continued high trend is identified. AC provided assurance that the sickness data is
checked monthly by the HR team and any triggers are highlighted with managers to
manage.
Mandatory Training and PDR Compliance
AC explained PDR and staff training figures are not up to date on the published
dashboard therefore an additional paper has been provided to more accurately report
the compliance figures.
Mandatory Training
AC explained that individuals who are not compliant with their mandatory training are
being highlighted to managers. The committee questioned people on the list who are
on long term leave. AC said that is why the target is set at 95% as it is recognised that
there are always some staff who are not in the business to undertake training for
example maternity leave or long-term sickness. Action from the previous meeting was
for HR to contact people directly which AC confirmed has happened. The Committee
noted that there continues to be improvement but compliance was not quite at the
required target yet.
Action: AC to chase all individuals to discuss non-compliance.
PDR
Data is not automatically updated on ESR as managers have to go onto the electronic
system and enter the data when PDRs are completed. Through interrogation of the
date it appears that managers are undertaking PDRs in two stages, the first being a
reflective meeting followed by a final PDR at which stage managers are recording the
PDR on ESR as complete. There are currently 49 staff on the non-compliant list
stating no PDR has been undertaken which makes the CCG 70% complaint. AC
explained she was not confident that this was an accurate reflection as following
approaching some members of staff on the non-compliant list it would appear that they
have had a PDR in recent weeks but that the information has not been recorded.
The OD Committee noted the upward trend of PDR compliance and the actions taken
to date to accurately report the compliance rate. The OD Committee agreed that AC
would speak to supervisors about the lack of compliance or reporting of completion.
It was noted that there appeared to be a small number of individual supervisors who
stand out within the figures and AC was tasked to explore this further. It was agreed
that PDRs need to be completed by the end of March and that a further message
should be been sent out by AW saying this is not optional.
AC discussed Annex W of Agenda for Change Terms and Conditions which if
implemented could result in staff not receiving an increment if they have not conducted
their PDR. This is a proposal AC is considering bring to a future meeting subject to the
national pay deal announcement which is due to be published this week. AC
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confirmed that it has already been confirmed that there will be a 1% cost of living
increase but it is yet to be announced if the increment freeze for band 8 and above will
be lifted.
Action: Annex W to be discussed at Staff Council if a proposal is put forward
7.
Staff Survey Outcomes:
AC reported that bullying and harassment results were worrying however, there have
been discussions staff council and officers meetings and all views have been
considered as part of action plan. It was noted that there is not a single solution. It was
discussed that AW shared the results with staff at PLT in February and that his
message hit the right tone.
AC explained she has a plan for May PLT which will challenge attitudes and values.
AC described the principles of ‘listening ears’. This is a 12 month programme of
development which will be presented at the next staff council and there will be training
for interested staff in coaching principles. Saba Rai had steered AC to two
organisations who could act as external ‘listening ears’ for the CCG.
NH questioned if the CCG has evidence that staff have been told of the processes to
follow if they feel they are being bullied or harassed. AC confirmed that not done
enough yet. AW has started communications and Staff Council have been involved.
The longer term plan will be ‘listening ears’ and policies and what it means in practice.
This will be further reinforced with individual team sessions.
NH discussed his perception that it is a low risk of happening but high risk of damage.
Action plan will go to staff council to check all is captured and will be kept on the
agenda of the O/D committee.
AN stated that staff are happy that the issue is being raised and is not part of the
culture of the organisation.
Action: To attach action plan to the O/D report to the GB
Recruitment Audit Outcomes:
AC explained that the biggest action from the audit action plan is the personal file
amnesty. AC explained that a project group was set up and have met regularly to
review progress however there are 99 staff files that remain incomplete. It is thought
that the CCG is missing 2 files which may be set up but cannot be located at this time.
This will be presented at the A&G committee this Thursday especially the issue of the
potential lost records. If they cannot be found there is a potential risk of fraud as
passport and NI number could be on the file.
NH asked if the individuals are aware. AC said yes, they are not happy but working
with the CCG to identify if the files can be found. If there is any potential costs to the
individuals the CCG will need to meet them.
AC said she was aware a colleague had archived over 50 files from the PCT to the
Department of Health and therefore AC had approached DH to see if they could locate
Sandwell
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the files before the CCG makes the decision to confirm that the files are lost.
There remains a mixture of documents missing from personal files and this could be
attributed to how this was handled different in each department.
The Initial target for completion was 31st March but it is clear this will not be met
following updates received yesterday.
There has been a barrier in some departments and AC has met with the teams to
alleviate concerns.
The OD Committee requested an update on the exceptions of the action plan at the
next meeting.
Action: Send a message out to staff about the importance of bringing their
documents in to complete the personal file amnesty including using the TV’s to
reinforce this message.
8.
Flexible working policy
AC explained that the policy presented to the OD committee is the current CCG policy
and was the first approved policy as a CCG in CCG. AC explained that a concern had
been raised by the A&G committee about requiring the policy to be reviewed. The OD
committee was informed that normally policies were developed by staff council and
then reported to OD committee for sign off however as this policy was contentious
when it was first developed it was appropriate to get an organisational steer on the
parameters of the policy before it is discussed at staff council. It was explained that the
current policy mentions the option of a 9 day fortnight within the opening statement but
that was an oversight as the organisational decision in 2013 was to remove this
option. A further updated required is potential to separate the terms of TOIL and
Flexible Working to provide clarity to staff.
AN said there is an appetite from staff for a 9 day fortnight but, Chief Officers are not
necessarily supportive especially in how it would be implemented across directorates
as previously it was not equally applied. Committee members did not feel it is not an
option that should be pursued.
As an organisation it was considered flexible working was available with lots of options
in how work and personal life can be managed. It was agreed that this message would
need to be delivered sensitively through the staff council.
AC stated if the staff council reject the organisational position then the discussion
would need to be presented to the Joint Negotiation Committee
Action: Policy to be discussed at staff council and back to OD committee in
April
9.
Risk Register:
The committee discussed and reviewed the register.
There remain 3 on log, 2 of which are a low but considered they should remain on the
register. Risk on Race equality schemes would be kept on the register until June when
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data will be published and the CCG can assure there selves that enough action in
2015/16 has been undertaken to meet the requirements. The 3rd risk is a moderate
risk relating to ICM/Lay member and Secondary care doctor appointments. ICM/lay
members have been re-appointed and secondary care doctor interviews are on 30th
March 2016 this will be updated in April 2016 depending on the outcomes of the
interviews.
NH suggested adding a risk personal file alignment needs to be added and a risk
around LCG appointments needs to be added until outcome of appointments are
known.
10.
AOB:
AC wished to formally note thanks to the CCG ‘dragons’ and the roles they played at
the last PLT event. AW had sent a message asking leads get in touch with their
‘dragons’ to move suggested plans forward, but nothing has happened to date.
SW suggested people may have thought it was a bit of fun and not taken it serious.
AC said we can take some of the ideas forward but need teams to come up with the
detail in readiness for April meeting.
The Treadmill is a success and will be going on the booking system.
A discussion was held about CSU mobilisation which will be on the OD committee
agenda in April
11.
Date and Time of Next Meetings:
Tuesday 12 April
Tuesday 17 May
Tuesday 12 June
Tuesday 19 July
Tuesday 09 August
Sandwell
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SWBCCG Partnerships and Collaboration Committee
Date: 26 January 2016
Time: 13:00 – 15:00
Venue: Kingston House, 438-450 High Street, West Bromwich,
B70 9LD
Room: 4R 1
Minutes
Attending:
Sharon Liggins (SL)
Basil Andreou (BA)
Paul Moseley (PM)
Janette Rawlinson (JR)
Paul Capener (PC)
Apologies:
Andy Williams (AW)
Andrew Harkness (AH)
Jayne Salter-Scott (JSS)
Item
1
2
3
Chief Officer for Partnerships
GP Chair
Commissioning Manager BCF Lead
Head of Internal Audit
Accountable Officer
Public Health Consultant
Senior Commissioning Manager – Engagement
Subject
Welcome & Apologies for Absence
Introductions were made and apologies from Andy Williams, Jayne Salter-Scott and Andrew
Harkness were noted.
There were no declarations made.
Previous Minutes/Action Plan
The Minutes from the meeting on 15 December 2015 were agreed. JR said that she had sent
apologies for her absence ahead of the last meeting and wanted this noted in the Minutes of that
meeting.
Paul Moseley confirmed that he is in contact with Asaf with regard to priority 1.
JR queried the phrase that Sandwell was intended to be a ‘dorminatory’ town as she could not find
the word in any dictionary. PM explained the intention was that SMBC had designated
development for the borough to be mainly housing, therefore it would be unable in the longer
term to raise sufficient funds via business rates to develop Public health funding as other areas
may when the ring fence on public health funding is withdrawn with it now being statutory duty of
local authorities rather than health bodies.
4
SL asked for an Action Log to be attached to future Minutes.
Sustainability Transformation Plans – update and discuss the potential implications
SL informed that the CCG’s current view for a Sustainable Transformation Plan as part of the
Operational Guidance is the RCRH footprint and the Plan will be submitted on that footprint.
However more recently there is correspondence circulating. Peter Hay, Lead for Birmingham
Council Services was invited to see Alison Tongue (Area Team) and he gave a Council perspective.
Later that week AW attended an AO meeting and the Area Team clearly indicated they saw two
footprints: Birmingham & Solihull STP footprint and Sandwell & Black Country STP footprint. We
are not able to change this.
It is agreed in principle that Sandwell and West Birmingham CCG for the West Birmingham will be
1
an associate commissioner to the Birmingham and Solihull STP and one of the key players in the
Black Country. There is a meeting in the Black Country this Friday to discuss leadership for
coordinating the STP footprint. It has been announced that Walsall’s performance is inadequate;
the Wolverhampton component of our patch is leaning towards Stafford so the dynamics of the
footprint will be interesting.
The CCG is still working on a RCRH Plan but the RCRH footprint may extend to Black Country; or
there may be a Plan with defined geographies as components of a larger Plan.
This Committee needs to think about engagement and membership as this evolves. If SWBCCG is
an associate commissioner in Birmingham this may be challenging.
There is a cohort of members wanting to move to a Birmingham CCG (30,000 patients/ about 7th of
the CCG management cost). There is also a cohort wanting to join the SWBCCG but no official
application has been received as yet.
JR asked where these risks sit – finance and performance or governing body? SL informed that we
cannot give notice on the constitution until June 2016 and if the CCG considers it will destabilise
our organisation the CCG can legitimately insist on the transfer taking place April 2017. She also
suggested this is to be expected with member organisations but wondered whether we had any
strategy to attract and recruit new members to replace any lost.
There are implications of the new GP contracts. SL raised a particular risk around primary care as
in the STP Plan for Birmingham they state they consider primary care as part of their Plan – we
need to be mindful about the implications.
The Committee agreed to a regular update on this.
5
BCF guidance:
Sandwell
PM tabled a document headed “Sandwell Better Care Fund, Sandwell Health & Wellbeing Board 28
January 2016” (copy attached). BA informed that Richard has sent out a new agenda for the HWBB
meeting taking place on 28 January 2016.
PM gave an update. Key progress in 2015/2016 includes: increased support from the voluntary
sector; Community Offer is going from strength to strength; 7 day services now offered through
the Independent Living Centre; reconfigured social work team (MDTs) aligned to primary care are
now set up across the patch; Home Bed Instead pilot has now been evaluated (by Birmingham
University) – findings will be shared within the Intermediate Care Steering Group and SCR; the
Community Offer is currently under review and this will be available from the end of March – this
will help reshape the Community Offer. Adapt Pathway is really successful; DTOC is zero.
There was a discussion about DTOC. SL said it would be useful to have a breakdown of DTOC for
Sandwell residents as the current figures do not show impact. JR suggested checks on hospital
DTOC data would be useful.
SL said a lot of work is being done to improve DTOC however when reviewing BCF budgets it
became clear that there is a greater emphasis on step down and not step up – very light on
preventative.
PM informed that BCF has been extended to 2019/2020 and funding has increased by £1.5b
2
expected from 2017/2018. It is unclear what financial impact this will mean for Sandwell. There
was a discussion about business rates and PM informed the formula is likely to be changed. PM
informed there has also been a move to increase the council tax pre-set to 2% and ring fence this
for adult social care (@£1.7m for Sandwell).
NHS Planning Guidance has been received; plans will now be regional. PM gave an overview of
this. There was a discussion about the local plan for data sharing. PM informed that the stumbling
block for Your Care Connected is consent in each case is needed for information shared with social
care. JR queried the governance in respect of data sharing. SL informed this is a national issue
which the new models of care may solve.
PM informed that neither the technical guidance nor the reporting template have been received.
These are expected by the end of January and it is anticipated that the submission deadline for the
first draft may slip.
Birmingham Care Integration Board
Birmingham is proposing to have a holding position, the plan would go forward, carry over the size
of the pool but possibly add in the mental health and DTOC from the Systems Resilience Group.
They are suggesting keeping all the targets the same and not changing the narrative; we need to
contemplate what associate membership will mean. There is a Central Programme Team in
Birmingham. There are challenges as to how this will work. SL informed that Andy Williams will be
attending the Executives Board meeting next week and this will feed back to this group. Angela
Poulton has a workstream under RCRH (to be defined) called Better Care led by Tracey Taylor of
Birmingham Community Trust and Alan Lotinga from Birmingham City Council; Sandwell Council
hasn’t stepped forward to lead. The meeting will be held shortly. It has been suggested that
common themes from both BCF plans will be put into RCRH. It is concerning that Birmingham has
suspended the Programme Board for MTDs, schemes are still in development stage and no targets
were achieved this year in either Sandwell or Birmingham.
SL informed that the BCF Plan is a 1 year plan; the guidance says that the BCF will continue until
such time as health economies go outside of its remit and expands.
The Plans have to be in by 8 February, the challenge in both Plans is they have to mirror the
Operational Plan. Plans have to be signed off by the HWBB so will not come back to this group
before submission. This process comes under Council governance and will be covered under H&W
Chair’s actions.
PM said he is refreshing and updating the current 2 year plan; he proposes to carry over the
schemes with a different focus and evaluating the schemes from year 1. An outline plan for DTOC
is mandatory and PM has spoken to Jon Dicken who suggests we outline what is currently being
done and how this can be improved. PM informed that dementia needs to be considered – the
local metric for 2016/2017 is measurement of prevalence; there was a discussion about dementia.
There is no defined budget in BCF for dementia.
6
West Midlands Combined Authority – Letter from Sandwell MBC
 There was a discussion about the response to the Sandwell MBC’s letter. It was suggested that
additional information be input relating to training and investment made in skills, Health
Futures Training Centre and that SWBCCG won CCG of the Year twice.
7
Partnership Committee Framework
 SL referred to the Partnership Committee Framework Report produced by Jayne Salter-Scott.
The framework was designed to articulate what we were hoping to achieve through
3
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8
partnership work, it lists all our partners. It was acknowledged that some outcomes listed
were hard to measure and attribute to partnership working. It was also acknowledged that the
partnerships are enacted through forums external to the committee, i.e.
There was a discussion about member engagement. BA stated that engagement is very
negative for a number of reasons.
JR commented that this mapping of the various partners is a useful piece of work to lay
foundations for the future. She was unsure who the audience of this report was as it appeared
to be a mix of operational and corporate. She said it would be helpful to know the role of the
partnership’s committee in relation to these strands and would like to see more about the
potential of the VC sector. She asked if it is meant to be strategic or organisational work in
progress? She offered support for this and asked where the partnerships committee fitted and
what it could be usefully doing with these new arrangements. Neither the listening exercise
nor today’s agenda seemed to cover what is needed in future – more reflecting what has
happened in the past.
SL acknowledged that there was membership disengagement prior to April 2015 when a
listening exercise highlighted that change was needed. Since taking on primary care cocommissioning the dynamics have changed; federations are also shifting the dynamics. Some
messages may be getting lost in translation. There is a clinical lead session on 27 January to
discuss some of these issues; perceived unachievable targets and money in the PCCF are real
issues.
BA said that some messages to member practices are not well managed. There was a
discussion about GP expectations and the role of the partnership committee. There are
different communication styles, BA said since changes to clinical lead roles have taken place
some leads feel they have been neglected/not kept up to date by lead roles. In addition
practices don’t get a direct response to entries they have put on Datix.
It was agreed this topic will be a single agenda item for the next meeting – to look at the
opportunities and barriers and agree how some of the relationships can be strengthened.
SL informed that the next staff PLT will focus on what it is like to work in this organisation.
The Partnership Committee Framework Report will be adjusted and a column inserted to show
the role of the partnership committee in respect of the relevant partners. The committee
should concentrate on those areas that it can influence/steer. Practical solutions are needed.
JR suggested that all members should be given details of the different leads in the different
organisations and themes.
Sandwell Health and Wellbeing board Agenda
 There was a discussion about the forthcoming HWBB. PM will be updating the Board;
integration and planning guide/ STP footprint will also be on the agenda. There was a
discussion about potential STP footprints.
ANY OTHER BUSINESS
 Paul Capener suggested that the Partnership Committee Framework Report can be used to
form the focus of what this Committee should/should not be doing. It can be used to reflect
on the remit/role of the Committee. It was agreed there will be a Partnership Committee
Development Session on 3 March 2016 dedicated to TOR and Engagement Framework. Paul
Capener will attend.
 WMCA Consultation was completed online.
Recommended Forward Planner: March - TOR and Engagement Framework
MEETING WAS BROUGHT TO A CLOSE
4
DATE AND TIME OF NEXT MEETING
Thursday 3 March 2016 - interim Partnership & Collaboration Development Session
Tuesday 15 March 2016 – Partnership & Collaboration Committee Meeting
Actions/Decisions
Action/
Decision
Comments
By Whom
5
Completed
ENCLOSURE 1
Sandwell & West Birmingham CCG Primary Care Co‐Commissioning Committee Date: 3rd March 2016 Time: 10.00 – 13.00 Venue: Kingston House Room: 2F Boardroom Minutes Attending: (RS) Ranjit Sondhi Chair (SL) Sharon Liggins Chief Officer – Partnerships (AW) Andy Williams Accountable Officer (JJ) Julie Jasper Lay Member (RN) Richard Nugent Independent Committee Member (AC) Andy Cave Head of Operations and Public Involvement, Healthwatch Birmingham (DH)David Hughes Deputy Chief Finance Officer (JR) Janette Rawlinson Vice Chair (AH) Andrew Harkness Consultant in Public Health (BM) Dr Robert Morley Executive Secretary, Birmingham Local Medical Committee (MP) Mike Perks Primary Care Finance Lead (MW) Matt West Financial Controller (RSu) Dr Ray Sullivan Chair, Sandwell Local Medical Committee (TM) Therese McMahon Board Nurse (MG) Mark Guest Chief Executive Officer, Healthwatch Sandwell (AB) Alison Braham Primary Care Quality Lead (ME) Martina Ellery Deputy Head of Primary Care, NHS England (JMc) Jane McGrandles Head of Primary Care Contracts (RL) Rachel Loveless Primary Care Development Manager, SWB CCG (RSa) Dr Raminder Sawhney Primary Care Development Lead (OA) Olivia Amartey Deputy Chief Officer, Operations (BA) Dr Basil Andreou GP and Partnerships Lead (CM) Charlie Mason Corporate PA – Partnerships (CP) Claire Parker Chief Officer – Quality (SM) Dr Sam Mukherjee GP and Quality Lead Apologies (AL) Andrew Lawley Head of Premises and Capital Development (CG) Chris Guest Divisional Manager – Direct Services, SMBC Item Subject 1. Welcome & Apologies RS welcomed everyone to the meeting and thanked members for attending. Apologies noted as above. 2. Declarations of Interest JJ stated that she is a lay member of Dudley CCG. TM declared her interest for the financial plans in relation to the workforce element as she is contracted to the CCG for this area of work. RSa,BA,RS,SM declared their interest in the Primary Care Commissioning Framework. 1 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
ENCLOSURE 1
3. 5. 6. Minutes of the Previous Meeting The Committee agreed the minutes as an accurate record of the meeting with the following amendment: ‐ ‘BM stated that they do not have to complete the E‐Declaration’. BM clarified that practices are contractually obliged to provide the information to the CCG, there is no contractual obligation to use the E‐Declaration. If there are genuine reasons why a practice cannot use the E‐Declaration, the CCG should be able accept the information in other forms than just the E‐Declaration. Action log All actions are complete. Contracting Update RS declared an interest – Dr Bhalla is a relative. The Committee were asked to note the contents of the report for information. Contract Variations JMc summarised the contract variations that have been processed during January including the removal of Dr R Ahmed, the addition of 2 non‐clinical partners and the removal of Dr Salim from the contract. GP Choice Out of Area Registrations The responsibility of securing local services for patients who are resident within the local geographical area but registered as an out of area patient was handed to the CCG through delegated authority. The service is currently being provided across the West Midlands under an agreement between NHS England and Primecare which ends on 31st March 2016. The activity for the service is very small, from July‐November 2016 there has been a total of 18 telephone consultations and 1 home visit across the whole of the West Midlands. The current arrangement is not a cost effective model and NHS England has recommended that alternative arrangements should be made for 2016/17. The current cost of the service is £165,253 (upfront cost), £30 per telephone consultation and £80 per home visit. The Primary Care Contracts Team has sought the views of the LCG Chairs/Vice Chairs on the potential of seeking sign‐up from one practice for each LCG. At the time of the report, no feedback had been received. The Committee expressed concerns over the amount of money that the service has cost for the minimal activity it has produced. ME explained that all CCGs were sighted on the contract costs and all were in agreement before signing. SM and BA stated that they were not sighted on the figures and were not aware of the upfront cost. ME stated that originally this service was put out as an Enhanced Service but NHS England could not get cover for all the CCGs based on sign up to the service, the risk of gaps in service was too high and so the service was contracted as a retainer for a GP to be on call across the 14 CCGs. BM stated that the CCG needs to quantify what the need is by finding out how many patients are under the registered under out of area practices. ME explained that this information is not available. AW suggested that an alternative arrangement could be for the patient who is not registered to ring the CCG through Time2Talk and the CCG will sort exceptionally as the activity is very low. JMC will look into alternative arrangements to the current service. BM stated that the information and costings of this service are in the public domain and made the 2 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
ENCLOSURE 1
7. Committee aware that if the BMA asked BM of any issues he would find it difficult to not highlight this to the BMA. Action: JMc to investigate alternative arrangements for the out of area registration service. Finance Finance Month 10 Update The Committee were asked to discuss and approve the contents of the report and note the associated risks. The financial position remains on target to deliver a breakeven outturn, including the committed expenditure within the reserve plan. DH stated that a number of risks have reduced throughout the financial year. From April 2016, cash payments shall be processed by the CCG enabling greater control over payments being made. The year to date position reflects an under spend of £71k at month 10, compared to a £305k under spend at month 9. To date £1,096k of the total £2,048k reserve funding has been spent. In addition to the delegated resource allocated by NHS England, the CCG has invested £2.2m in this financial year, with a full investment value of £7.6m for 2016/17. This investment is for the Primary Care Commissioning Framework and 7 Day Patient Access which commenced during 2015/16. The key risks are: ‐ Not fully utilising the reserve funding in year. This risk has reduced in month due to the expected increase in reserve expenditure monitored by the Primary Care Operations Group. ‐ The majority of the financial processes, such as Exeter payments and premises reimbursements will be taken on by the CCG from April 2016. Some transactional processes such as locum or rate reimbursements are to be provided within the Primary Care HUB agreement with the NHS England Regional Office. The Committee approved the contents of the report and noted the associated risks. Finance Reserves Monitoring Report The Committee were asked to note the contents of the report and approve the newly identified schemes. £2,047k has been identified as committed expenditure and expenditure to date is £1,096k. plans exceed the available resource by £393k in order to manage slippage and non‐delivery of any committed schemes within the financial year. The Committee were recommended to approve the Malnutrition Community Project 2016‐17 scheme. In total the proposal is for £8280.40. The scheme is in its 3rd year of work and the project will be undertaking a community multi‐
disciplinary training workshop to reduce pressures on General Practices for the management of malnourished patients. The event will cost £3,980.40. The anticipated costs for CCG wide marketing material and campaign resources are expected to be approximately £4,300. The Primary Care Operations Group have scored the scheme against the approval criteria, the overall score was 14. 3 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
ENCLOSURE 1
8. JJ commended the Primary Care Operations Group for managing the financial position so well. The Committee noted the contents of the report and approved the newly identified scheme. Primary Care Financial Plan 2016/17 The Committee were asked to discuss and approve the contents of the report and note the associated risks. Further updates will be provided to the Committee in April 2016. DH discussed the financial plan with the Committee. The key business rules for 2016/17 have remained similar to the previous year. The rules are: ‐ Minimum 0.5% contingency ‐ 1% non‐recurrent spend (this must not be committed at the start of the financial year) ‐ Meet a breakeven position for delegated primary care co‐commissioning resource DH explained that although the 1% must not be committed at the start of the financial year, the team do have plans as a standby for this resource. In 2016/17 the CCG will receive an allocation of £77.2m. This is 4.1% growth increase when compared to 2015/16. There is no requirement to plan for a surplus in 2016/17 for the delegated co‐commissioning resource. In 2017/18 – 2020/21, the CCG will likely see its income increase at rates between 2% and 5%. This will increase the CCG’s delegated primary care income in 2020/21 to £87.4m. DH explained that the national rate of growth is 6.9% which will increase resource to £5 per patient investment. In conclusion, there is an increased level of investment in primary care in 2016/17 as a result of the increased delegated allocation and the CCG funding to support the Primary Care Commissioning Framework and 7 Day Patient Access scheme combined. Despite the additional funding allocated for 2016/17, the CCG faces some challenges to meet the increased expenditure for contract uplifts and there are some significant risks that need to be managed diligently in order that the statutory break even duty can be achieved. The Committee noted the contents of the report and noted the associated risks. A further update will be brought in April to the Committee. Risk and Issue Register Report LM presented the risk and issue register for the Committee to note. No risks are recommended for closure at this Committee. There are 13 risks on the register, 6 amber, 6 low and 1 very low. There are currently no red risks on the register. Risk 228 – CCG awaiting transfer of the electronic records of GP contracts. LM stated that this risk has reduced from moderate (6) to low (4) as the CCG now has access to Sharepoint and within 4 weeks the team will have full access to electronic records. Risk 249 – Discontinuing the Nursing Home LIS may have an impact on the service delivery for patients. LM stated that this risk has increased from a moderate (10) to moderate (12) as the original mitigation was to include this in the Primary Care Commissioning Framework, this is not expected at 4 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
ENCLOSURE 1
this time and as a result the risk has increased. The Committee agreed following JJ suggestion, to include a reputational risk on the register in relation to the out of area registrations. Action: LM to include a reputational risk in relation to the out of area registrations. 9. Internal Audit Report Update LM updated on the recommendations set out in the Internal Audit Report which was presented to the Committee at the January 2016 meeting. The report contained 11 recommendations, currently 8 of these are completed and 3 are on‐going. LM stated that all the recommendations are on track to be completed shortly and an update on the 3 on‐going areas will be presented at the Committee next month. JJ felt assured that the team is on top of the recommendations and an update will be presented at Audit and Governance Committee next month. 10. Primary Care Commissioning Framework (PCCF) AHa presented the updated version of the PCCF following feedback from Clinical Leads and Directors. The Committee were asked to note the contents of the report and approve the proposed changes to the PCCF. The proposed changes are as follows: ‐ Number of standards reduced to 10 ‐ Funding increased to £12.50 ‐ Removal of KPIs relating to NEL activity ‐ KPIs to be changed to realistic outputs/outcomes ‐ Funding structure remains the same for the next 2 years (70/30 Delivery/output split) ‐ List size only to be revised at the end of the year unless list size grows by 5% or more in year. BM stated that the commitment to this scheme is praiseworthy but has concerns with the burden this will have on general practice with the work that is involved. This may have a detrimental effect on other services. AW stated that he and RSu met to discuss the resource issues. The CCG wish to increase investment in primary care to improve services and they discussed the structural shortfall. There may be things that the CCG can do but this would be a parallel piece of work to the PCCF. BA stated that as Clinical Lead visiting practices he has seen a positive reaction to the PCCF. SL commended the work gone into the document and thanked Directors and LCG Chairs and Vice Chairs for their input. The Committee approved the proposed changes to the Primary Care Commissioning Framework. 15. ANY OTHER BUSINESS Practice Transfers AB provided an update for information to the Committee on a practice transfer report that was approved by the Governing Body yesterday. 7 practices wish to transfer out of Sandwell & West Birmingham CCG: ‐ Lozells – Dr Ahmed ‐ Cavendish Medical Centre ‐ Summerfield – Dr Cheema ‐ Summerfield – Dr Kulshrestha 5 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
ENCLOSURE 1
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Burbury Medical Centre Queslett Road Al‐Shafa Medical Centre 3 practices wish to transfer in: ‐ Bellevue Medical Practice ‐ Hillcrest ‐ Kingstanding Road AB stated that the Governing Body approved 4 principles that the CCG will adopt for practice transfer requests. These are: ‐ CCG boundary and geographical footprint ‐ Take into account relationships with providers ‐ Respect the right to express an interest ‐ Not knowingly transfer/accept practices where there are serious issues The Governing Body approved the transfer requests to be submitted to NHS England to amend the constitution. AW explained that the constitutional change has to be approved by NHS England and they also have the right to assign practices to CCGs. 16. DATE AND TIME OF NEXT MEETING 7th April 2016 10.00‐1.00pm Guidance on Declarations of Interest Definition of Interests A Governing Body/Committee member has a personal interest if the issue being discussed at a meeting affects the well being or finances of the member, the member’s family or a close associate more than most other people who live in the area affected by the issue. Personal interest are also things related to an interest the member must register such as outside bodies to which the member has been appointed by the CCG or membership of certain public bodies. A personal interest is also a prejudicial interest if it affects the finances of the member, the member’s family or a close associate and which a reasonable member of the public with knowledge of the facts would believe it likely to harm or impair the member’s ability to judge the public interest. Declaring interest If a member has an interest, they must normally declare it at the start of the meeting or as soon as they realise they have the interest. If a member has a personal and a prejudicial interest, they must not debate or vote on the matter and must leave the room. 6 | SWBCCG Primary Care Co-Commissioning Committee PUBLIC
Patient and Partnership Advisory Group Meeting
9th March 2016
2.00pm - 4.00pm
Meeting Room 1
Handsworth Community Fire Station
Present:
Ranjit Sondhi (Chair) Vice-Chair of SWBCCG
Richard Nugent
Independent Chair
John Clothier
Healthwatch, Representative – Sandwell
Graham Price
Patient Representative - Sandwell Health Alliance
Chris Vaughan
Patient Representative - ICOF LCG and Chair of
Summerfield and Winson Green Patient Network
Alison Hortin
Patient Representative - HealthWorks
Awtar Ghataora
Patient Representative - Pioneers for Health
Inderjeet Kaur Phull Patient Representative - Pioneers for Health
Pam Jones
Patient Representative - Black Country
Jayne Salter-Scott
Engagement Lead SWBCCG
In attendance:
Jason Meredith Better Care
Sham Mali
Rachel Loveless Primary Care Development Manager
Linda Martin
Businss Support Officer
Apologies: Leona Bird
Trevor Fossey
Deska Howe
Geoff Foster
Partnership Representative – SCVO
Patient Representative - Black Country
Patient Representative - Sandwell Health Alliance
Partnership Representative – Strategic Commissioning
and Redesign Committee
1. Welcome and introductions:RS welcomed everyone to the meeting and asked the members to introduce themselves.
2. Apologies for Absence:As above
3. Declaration of Interest:None
4. Review of minutes and actions from previous meeting:The minutes from the meeting held on the 10th February 2016, were discussed for
accuracy. AH stated the clarification meeting with ZK, JSS and SM should read as an
induction meeting.
1 Matters arising and Action Log Sheet:Completion and prompt return of meeting logs:
On-going - Agenda item 5.
Health Service Journal (HSJ):- In hand
The CCG does not have a corporate subscription. S Liggins will take the discussion to
the Chief Officers. JSS will follow this up with SL.
BVCSC replacement for Jason Meredith:
At present BVSC do not have the capacity to send a representative.
CV will also highlight this issue the West Birmingham Healthwatch Meeting.
Representatives from the LCG attend the PPAG meetings but there are no
representatives from the Voluntary Sector. Tracey O’Brian (BVSC) is aware of the issue
following a conversation with JSS.
CV attends the Birmingham Healthwatch Meeting – CV unfortunately did not recognise
anyone at the last meeting. CV suggested making a formal approach to the Interim Chief
Executive.
ACTIONS:
 JSS to compile a letter on behalf of RS re: representative for PPAG.
 Minutes emailed to Tracey O’Brien, for information.
B Aucott to be invited to attend PPAG meeting:
CV has spoken the BA, the patient’s council is still in abeyance.
Feedback/Update of Consultant Advice and Triage Service (CATS) to be an agenda
item at a future meeting:
Forward Plan
Dr Sawhney (Clinical lead) for Primary Care to be invited to a future PPAG meeting:
Forward Plan
Your Care Connected:
Forward Plan
S Mir to arrange an induction meeting with AH and ZK, to which JSS will attend:
Meeting arranged for the 14th March 2016
PPAG Development Plan: Feedback and comments
Alice Copage to give an update at the next PPAG meeting.
ACTION:
 PPAG Development Plan - Agenda item at the next PPAG meeting (13th April)
Tour of the Nishkam Centre:
ACTION
2 
LM to canvass for dates for a future tour of the Nishkam centre
JSS to liaison with K Judge re: feedback from the PPG Toolkit planning meeting.
GP - Still waiting for feedback from the PPG Toolkit meeting held in December - JSS
stated that a lot of work has been done on the toolkit to ensure it is fit for purpose.
JSS updated the PPAG members of the transition period from the CSU, who recently lost
the tender for the CCG’s communication and engagement support. Arden and Gem CSU
will be taking over the support from the 1st April 2016. RS asked for the PPAG members
to be kept up to date with Toolkit.
ACTION:
 PPG Toolkit update to be an agenda item at the next PPAG meeting in April.
CV to feedback from the ICOF Board meeting
ACTION:
 CV to feedback from the ICOF Board meeting.
TF asked the CCG to look at the issue of patients having access to their records,
JSS to look into this.
5. Update from PPAG Members – Feedback logs
RS – Referred to the minutes from the Primary Care Co-Commissioning Committee
meeting (7th January 2016 and 4th February 2016).
RN - Clarified the agenda and minutes from the Governing Body Meeting
(2nd March 2016).
JC - Quality and Safety Meeting (15th February 2016) - See feedback form.
CV - Healthy Villages Inaugural Meeting (26th February 2016) - See feedback form.
DH/GP - See feedback form: Equality Awards Event 2016, a successful evening –
4 issues highlighted:




Inappropriate use of the phrase ‘Hard to reach’
PPAG and CCG presenters to meet their finalists ahead of the presentation.
Presenter to describe the sliders used.
Representatives to be able to talk about their work
RS asked if the GP’s could participate more.
Practice Managers Meeting: the managers discussed the difficulty of involving patients
in the Patient Participation Groups (PPG’s).
IKP - Pioneers for Health Board Meeting - discussed GP’s referring patients to
hospitals, where the services are not available. AH - GP’s should have an IT
information database to show where the services are available - JSS will look into this
issue.
AG – GP’s discussion - some GP’s are reluctant to sign up to 7 day working. JSS
stated the GP’s are still looking into the process of 7 day working and referred to the
Primary Care Framework. Patient Network meetings: need to ensure Practice
Managers and PPG members attend these meetings. - Email invites are regularly sent
3 to the Practice Managers, also asked to pass the invite to the PPG members. This
issue will be discussed at the next Engagement Team Meeting.
PJ - Black Country Patient Summit (2nd March), good turn-out despite the weather.
Agenda items: Primary Care and End of life care. Patients do not understand the
changes in progress. GP was concerned at the lack of Practice Manager’s attendance at
the patient summits; some Practice Managers feel they may face underlining issues from
the patients.
6.
ACTION:
 JSS to look into the issue of GP’s referring patients to hospitals where the
services are not available.
Route2Wellbeing - Presentation
Jason Meredith took members through the presentation he had prepared.
The NHS and social care services in Birmingham are now caring for people with
increasingly complex conditions and multiple conditions. Birmingham Better Care (BBC)
is ensuring changes happen, through integration and schemes. JM also informed the
PPAG of the online directory service. JSS highlighted the similarity of the BBC to the
Sandwell community offer and suggested inviting JM to give an update at a future PPAG
meeting.
Comments:
 RN asked to what extent is the public sector involved in the design of the directory?
Through regular conversations/meetings. Members from 95 organisations have
attended meetings. Route2wellbeing has been set up to include data from different
areas. This is an opportunity for organisations to come together to put forward
tenders etc.
 AH – would be good for the PPAG to focus on the directory of service. The PPAG
members asked for the directory to be discussed at a future meeting.
 GP asked about the Health and Social Care - 7 day working for social workers –
Adult social workers are facing huge cuts. – Birmingham City Council will
significantly increase their contribution to the funding.
ACTIONS:
 Route2Wellbeing Directory service to be an agenda item for a future meeting –
Forward plan.
 Presentation to be emailed to the PPAG members.
7. Review projects and evaluations for the Healthy Communities/Push Sites
SM clarified the background of the schemes: strengthen lead commissioning, to build and
test a local population based commissioning approach. Improve care co-ordination,
putting people in the centre. The evaluations will start in April 2016.
SM clarified the 10 Healthy Communities/Push sites:
 Dr Hallan - Case Management Service
 Dr Hallan - Weekend Clinic
 Dr Arun/Dr Saini - Care Coordinator for vulnerable patients
 Dr Solomon - Case Management Service
4 





Dr Solomon - Paediatric.
Dr Solomon - Point of Care, diagnostic testing
Dr Soyannwo - Tower Hill Healthy Community
Dr Sibal - Team around the patient
Dr Chandra - Advanced care Planning for A&E attendees
Dr Gupta - Improving and strengthening community resilience
Comments:
 GP - How does this differ from the Smethwick Medical Centre, Nurses allocated
to certain patients? (Dr Arun/Dr Saini’s project)
 RS expressed concerns, as he had not heard anything about the push sites - there
seems to be a mixture of success for these projects. SM - Each project is a
fantastic piece of work; these will help to develop business cases.
 SM apologised to the PPAG members as a number of members were involved in
the process of selecting these projects. If the cases go forward, the PPAG
members will be asked be involved in the rectification process.
 RN - Case Managers – similar project needs quality rather than looking at the
costs. SM - It’s not about cost reductions but support to the patient and the family.
 AH - Need recommendations from patient’s experiences – feedback
 AH - Need to ensure financial assessments are based on a robust finding from the
patient’s opinions. This is a new area of research, patient feedback is required.
 PJ – Challenge for a better equality of service
 CV - Is there intelligence in place, if a patient has other issues, are other agencies
alerted, - all issue are noted.
ACTION:
 Healthy Communities/Push Sites evaluation update to be an agenda item at a
future PPAG Meeting.
8. Primary Care Update – Presentation
Rachel Loveless updated the PPAG members on the:
 Primary Care Co-Commissioning, the vision and the local challenges.
 The introduction of the Primary Care Commissioning Framework (PCCF) to the GP
Practices. A team of Clinical Leads will support practices to implement the
framework. Five Primary Care Development Managers will help to deliver.
 Improvements already in practices, introducing new services; extended opening
hours and a text messaging service.
 98 practices within the CCG have signed up to this in November 2015.
65 practices are ready to start on the 1st April 2016, 17 practices have a few
issues.
 Standards have been reduced from 15 to 9.
Comments:
 RN - What happens to practices, who do not sign up? The practices do not receive
the money.
 JC - What can be done for local patients, so they feel they are getting the support
they need and help from the services to deliver care?
 PJ - Patients need to know what’s happening – need to inform patients.
5 
AG - The standards have been reduced from 15 to 9, which standards are no
longer used? Some standards have been amalgamated.
The PPAG members discussed having Primary Care as a standard agenda item
9. Any other Business

2 – 3 items for discussion at the Governing Body Meeting
10. Items attached for information:
None
11.
Future agenda items: Forward Plan
 Health and Social Care integration from a CCG perspective - Review
 GP’s to have PPG’s as compulsory from 1st April – How will the CCG
support this?
 Capital Review Group - Estate Strategy
 Primary Care Investment fund amp, when completed
 Forward Thinking Birmingham
 Feedback update of CATS
 Changing roles of patient representatives within the federations.
 Your Care Connected
 NEPT Timetable
 Dr Sawhney (Clinical Lead for Primary Care)
 Alan Kenny Update of the Midland Met Hospital - July/August and October
 Route2Wellbeing Directory Service – May
 Primary Care - Standard agenda item
12. Date and time of future meeting:
13th April 2016, 2.00pm – 4.00pm
Venue to be Kingston House
6 ICO
OF Board
d Meeting Minu
utes
Miinutes of the Meetting held on Tuesd
day 15.3..16
,
Presen
nt:
Dr S. M
Mukherjee (S
SM) (Chair)
Dr I. Ma
arok (IM) (V
Vice Chair)
Dr R. M
Muralidhar (R
RM)
Chris V
Vaughan (CV
V)
Saj Sarrwar (SS)
Dr I Zam
man (IZ)
Mary M
Mungovan (M
MM)
Dr M Siinha (MS)
Org
ganisation//Practice
New
wtown Health Centre
Rottton Park Medical Centtre
New
wtown Health Centre
Pat ient Repres
sentative
Chu
urch Road Surgery
S
Broa
adway Hea
alth Centre
Pra
actice Nurse
e, Newtown Health Cenntre
Chu
urch Road Surgery
S
In Atten
ndance:
Jas Dossanjh (JD)
Lindseyy Smith (LS)
Michelle
e Williams (MW)
(
Kally Ju
udge (KJ)
port Officer, SWB CCG
G
Bussiness Supp
Prim
mary Care Developme
D
nt Managerr, SWB CCG
G
Prim
mary Care Developme
D
nt Managerr, SWB CCG
G
Com
mmissioning
g Engagement Manageer, SWB CC
CG
Apolog
gies:
Details
Item
1.
INTRODU
UCTIONS
1 and
2
Welcome
e, Introductions and A
Apologies
Action
SM welco
omed memb
bers to the m
meeting.
3.
Declaratiions of Inte
erest
Declaratio
ons of interrest were d
declared from all GP’s in relation to items 6,,
PCCF and 7, GPP.com.
4.
Minutes of the Prev
vious Meet ing and Ac
ction Regis
ster
The minu
utes of the meeting h eld on 16thh February were acceppted as an
n
accurate record.
ee update on actions
s on last pa
age.
Please se
ons on item 2 of action register.
Discussio
LS stated
d that she will
w do an ovverview update at Steerring Group Meeting.
She share
ed with the board the ffollowing:
 Sttandard 1. 3 practices require help
p on openin
ng hours an d looking
to
o collaborate
e.
 Sttandard 2. There
T
is a m
mix respons
se but mainlly most cann do these
in house. IM was of a vie
ew that from
m a quality point
p
of view
w we
1

should look at DMARDs collaboratively. With regards to the ECGs,
further information and work is required before set up and delivery.
There were suggestions made and this was discussed in detail.
IZ suggested outsourcing the insulin start to the community diabetes
team. SM stated that we should hold fire and look at this with
further with the Vanguard set up.
Action: SM to pick up at next All Members Steering Group.
5.
CCG/ LCG Chairman’s Report
The CCG Chairman’s report had been circulated to members prior to the
meeting and the Chair gave an overview of the highlights within.





Investment in Primary Care
Revisions in the PCCF
Standards reduced from 16 to 9
Refocus of the key performance indicators within the PCCF
This will be filtered down to the LCG members forum
The Equality awards took place last month, this was successful
6.
ITEMS FOR DISCUSSION
6.1
Primary Care Commissioning Framework
SM explained that the changes have been incorporated into the PCCF and
has been sent out to practices with a return date of signing by 31.3.16.
IZ was concerned that if this is being delivered from the 1st of April, where
do you stand if nothing has been set up? MW stated as long as you are
engaging and show you are in the process of setting up and being ready to
deliver then this is satisfactory. The PCDMs will also be doing assurance
visits to support and prepare practices accordingly. MS spoke of issues
with finance information that is required. SM stated that there is a sheet that
you can populate and forward to the CCG and everything is justified to
them. SM suggested bringing in a member of the finance team to the
Steering group to meet the members and answer any questions if this is
required.
7.
FEDERATION UPDATES
7.1
GPP.com
SM informed the group that himself and Dr Marok, on behalf of GPP.com
have had conversations and were invited to join the modality vanguard. He
felt it would be necessary to achieve future goals/plans to move towards a
MCP model.
They mett with the CEO of Moda
ality and ha
ave agreed to work withh them. Alll
board me
embers hav
ve viewed th
he MOU an
nd have agrreed to signn. They willl
be partne
ers of the Modality
M
Va
anguard. Th
he timeline is to go livve from the
e
second quarter. Fro
om Septemb
ber we will have a national budgeet and Aprill
2017 goe
es live. By delaying to
o second quarter
q
they
y will be assking us to
o
operate as
a a shado
ow, the worrk has to start
s
now. SM is havving regularr
meetings to get this agreementt set up. All members will
w be inforrmed of this
s
in the nexxt meeting. SM confirm
med that ICO
OF and Mod
dality Vanguuard will be
e
running separately
s
and
a does n
not mean th
hat ICOF ha
as been repplaced. SM
M
will be having further talks wiith Sharon Liggins in Directors meeting to
o
further exxplore how this will wo rk with wha
at we do as a Locality or what we
e
do as th
he Vangua
ard. Furth
her discuss
sions took place in relation to
o
functionin
ng of ICOF and
a the Mo
odality Vang
guard.
S to comp
pile a slide
e to inform the group of the Van guard.
Action: SM
Action: SM
S to circu
ulate the MO
OU to the wider
w
group.
Action: Invite a member of Mo
odality Van
nguard to come
c
in to keep us
updated on progres
ss.
Elections
s: Chair an
nd Vice Ch
hair.
d that an ele
ection has b
been called
d for Chair and
a Vice Chhair. The
SM stated
process iss to be com
mpleted by m
mid-April. Both SM and
d IM are sta nding
again. Me
edica will no
ot be able to
o vote in the
e elections.
s to carry out
o the elecction.
Action: KJ to obtain a link fo r members
7.2
Medica
ZA was not
n present at
a the meetting and the
ere was no update
u
receeived.
8
UPDATES FROM COMMITTEE
ES
8.1
R
ive Feedbacck
Patient Representati
CV reporrted the Pattient Summ
mit has been
n agreed fo
or the 12th A
April at 12-3pm, at the Drum in
n Newtown. The agen
nda has bee
en set. KJ stated thatt
there are
e 2 patient summits a year and
d would be
e beneficiall for board
d
memberss to attend. There will also be the
e model of the new h ospital and
d
someone
e is to hand to take anyy questions.
SM said it would be useful to ob
btain good examples
e
of complex isssues that
arise as case
c
studies
s. There we
ere some discussions around
a
how
w we could
engage members
m
of the public tto attend he
ealth screen
nings in the interactive
part of the
e agenda.
k into draftiing a table and will ciirculate to tthe board
Action: KJ to look
for confirmation.
They are advertising
g for a secon
nd patient rep
r for this Board.
B
3
9.
ANY OTHER BUSINESS
Nurses Forum
MM stated there are no local group for nurses. We have had a nurses’
forum recently and have the next one is in May. The uptake was low. It
was suggested to keep communication flowing through Nick’s News and
ensure these get filtered through to the nurses.
SMS Messaging
LS informed all that the ‘IPlato’ SMS Services has been passed. The roll
out will be at the beginning of May. There will be overview at April all
members. All practices will be sent out an agreement to sign up to.
Training with 1:1s for the practices with seminar forum available. There is
also an app available called My GP, there are also health updates. We can
also send out health campaign messages.
New practices joining ICOF
SM stated that we need to put the message out to other practices to join
ICOF. To join it is £1 and is agreed with the solicitor. If any practice does
that they would be part of the Vanguard.
PDS Update
SM stated that the report shows that we are doing well.
10.
DATE AND TIME OF NEXT MEETING
21st April at 12.00noon, Lozells Methodist Centre. This is before the
Steering Group meeting at 1pm.
Action Summary
Date
Description of Action
By Whom
Date Due
Completed
LS
18/2/16
LS
18/2/16
17/3/16
Yes
AH
18/2/16
Yes
21.1.16 LS to obtain ECG figures per practice if
possible
15.3.16 This is not possible. Close action
LS to carry out a gap analysis to see what
21.1.16 each practice can deliver
18.2.16
AH invited appropriate wording with
regard to ECGs
18.2.16
6 SM aske
ed IM to ex
xplain the ffacility to
record hospital
h
pre
escription tto all
memberrs at the steering gro up on 19
Februaryy
18.2.16
6 Dr Riaz Ahmed sa
adly passed
d away. SM
has aske
ed Dr Ali to
o prepare a
an
announccement tha
at can be p
placed in
Nick’s News.
N
This
s should be
e conveyed
d at
the steering group on 18 Feb
bruary 2016.
IM
18/2/16
Yes
SM
M/Dr Ali
18/2/16
Yes
18.2.16
6 CCG contact numb
bers to be added to the
t
slides
AH
18.2.16
6 Wording
g under “Ke
ey changess” point 7 to
t
be re-wo
orded.
AH
18.2.16
6 AH info
ormed tha
at provisio
onal data re:
consulta
ations has
s been obtained but
some of this data
a needs tto be veriified
before a final decis
sion can be
e made.
118/2/16
Yes
118/2/16
Yes
AH
18/2/16
18.2.16
6 AH agre
eed to obttain updatted data from
f
public he
ealth re: prrevalence.
AH
21/4/16
18.2.16
6 AH agre
eed to amend the w
wording re: list
size cha
anges on the slide tto explain the
changess and give examples
AH
18/2/16
18.2.16
6 SM/IM to
t feedbac
ck to the mental he
ealth
leads th
hat the ex
xamination s for hearing
and sigh
ht should be
b reviewed
d.
SM/IM
15/3/16
LS
18/2/16
21/4/16
18.2.16
6
15.3.16
6
ol to be sen
nt to
Checklisst for infecttion contro
MM and IM.
Yes
Yes
Yes
LS to co
ontact David Jones
15.3.16
6 Elections for Chairr and Vice Chair
KJ to ob
btain a link
k for memb
bers to carrry
out the election.
e
15.3.16
6 SM to co
ompile a sllide to info rm the gro
oup
of the Va
anguard.
KJ
SM
5
15.3.16 Action: SM to circulate the MOU to the
wider group.
SM
15.3.16 SM Invite a member of Modality Vanguard
to come in to give a progress update
SM
15.3.16 Patient Summit Agenda
KJ to look into drafting a table with
possible examples and will circulate to the
board for confirmation.
KJ
Minutes of the Black Country LCG Board
Thursday 17 March 2016 1.00 – 3.00pm
Portway Lifestyle Centre, Newbury Lane, Oldbury B69 1HE
Present:
George Solomon (GS)
Dr I Sykes (IS)
Dr A Saini (AS)
Dr P Desai (PD)
Rachel Loveless (RL)
Andrew Harkness (AH)
Sandeep Pahal (SP)
Lesley Ralph
Trevor Fossey (TF)
Pam Jones (PJ)
Black Country Family Practice, Chair
Oakham Surgery, Vice Chair
Portway Family Practice, SCR Lead
Whiteheath Medical Centre, Clinical Lead
SWBCCG Primary Care Development Manager
Public Health Consultant
SWBCCG Medicines Quality Pharmacist
SWBCCG Business Support
Patient Representative
Apologies:
Sam Muthuveloe (SM)
Kat Meredith (KM)
Orville Williams (OW)
Gita Lad
Tom Richards
1
Haden Vale Surgery, Clinical Lead
SWBCCG Commissioning Engagement Manager
SWBCCG Finance Officer
SWBCCG Medicines Quality Technician
SWBCCG Quality Lead
Welcome and Apologies
IS welcomed everyone to the meeting as GS was delayed.
Apologies were noted.
7
It was agreed that Medicines Management would be first on the agenda as SP had
to leave early.
Medicines Management
SP informed that Optimum RX is being piloted in Warley. Last year’s PDS is being
reviewed to ensure all practices met their deadlines. A draft PDS for this year is
being finalised. IS requested this is an agenda item at the next meeting.
SP informed that once the PDS is approved by Q&S it will be presented at the All
Members meeting (hopefully on 21 April) and then she will organise individual
meetings with practices.
The target for antibiotic prescribing was met by most practices in the LCG and the
CCG is looking to meet the NHSE Quality Premium. A CRP machine is being piloted
at Malling walk-in – this is a tool to identify if a patient has an infection.
There was a discussion about antibiotic prescribing by walk-in centres. The
threshold for walk-in centres to prescribe antibiotics is low. A lot of effort is being
1
done at GP level. Efforts need to be coordinated with the walk-in centres. SP said
the walk-in centre will always be an outlier. SP said an audit can be run as part of
the pilot to try and identify separate data. A concern was raised that this is
creating a culture where parents are taking their children to the walk-in centre for
antibiotics and then taking them to see the GP afterwards. SP asked for examples;
there may need to be a discussion with Malling HQ. IS said these examples need
to be input on Datix to show the trends. There was a discussion about sharing
information in and out on SystmOne as when patients access the walk in centre
their record is not always available to the GP. AH suggested that access to patient
records and communication should be two-way; System 1 provides for this. The
default position for consent on SystmOne seems to be “do not give consent”. SP
said data sharing across providers in SystmOne is a national issue.
RL informed that a number of complaints are made to Time2Talk about the walkin centres but as patients are not giving consent then nothing official can be done.
IS suggests this shows a problem. RL agreed to organise a meeting with Malling
once to discuss the issues. PJ said that Malling GP patients are being sent to the
walk-in centre.
SP said with regard to PCCF: peer to peer review session is required for prescribers
and she suggested this be at the All Members meetings. A GP from each practice
should attend. This will be done in order to meet the KPI and it must be made
clear that if a GP cannot attend they will need to make their own arrangements to
meet this KPI. Topics suggested are overspend/underspend. This was agreed.
This would also be a platform for practices to share best practice.
SP informed that the overspend this year was £700,000, this is below last year and
similar to SHA LCG. A New EPAC data needs to be run however due to some
anomalies. Practices will need to demonstrate that they are working towards
achieving the target.
PJ said that at a recent network meeting she learned that a form for patients
prescribed with morphine is being introduced. SP wasn’t aware of this but next
year’s PDS will focus on pain relief. She suggested this form may be for newly
prescribed patients and not patients on repeat morphine prescriptions. PJ asked if
she could feed into this and RL agreed to arrange this.
SP then left the meeting.
2
PCCF
All GPs declared their interest in PCCF.
AH presented an update on PCCF. There are a number of topics that may be
included in PCCF Additions; electronic referral and recruitment of apprentices are
being considered.
There was a discussion about the cap on weekend working relating to the 7 day
2
access scheme. The 3 hour cap on GP time means that smaller practices cannot
afford to have a nurse offering appointments also. AH informed that David
Hughes is looking into this. As it is pilot phase Dr Saini should feed his concerns
to David Hughes.
A discussion took place about online access and that NHSE expect that 10% of
appointments will be made online and GPs will be expected to facilitate this. TF
highlighted self-care is not being promoted/isn’t in PCCF; a lot of patients look
after other patients. AH said that self-care may be included going forward. TF
raised that Route2Wellbeing needs to be improved; it is important to get the
process right and ensure that providers have sufficient capacity.
Dr Saini asked about home visits, where practices are collaborating to cover access
can Primecare visit care homes if necessary. IS stated that the PCCF does not allow
the use of OOH providers to perform visits during normal working hours; AH stated this
does not follow the intentions of PCCF.
PJ raised the issue of inconsistency as not all practices are offering the same. AH
informed that the PCCF cannot be mandatory but it is a step towards getting a
balance and engaging with practices to drive a reduction in variation. Substantial
monies are being invested to help achieve this.
There will be PMS monies released next year and this will be invested in primary
care; the CCG finance team will decide how this will be utilised.
The Minutes of the last Board meeting on 4 February were reviewed and agreed.
3
Finance and Performance
RL presented OW’s proposal. All present were happy with the proposal. It was
agreed that data expressed as per 1,000 allows for ease of comparison between
different sized practices.
There was a discussion about prescribing overspends; the quality of prescribing
being measured by outcomes; underspending practices doing justice to patients;
concern where practices are not engaging to improve overspend/underspend.
The Board will raise concerns with quality team if necessary.
GS left the meeting and said he would email Board members about the election
timetable.
4
5
SCR Report
AS will circulate an update to everyone.
Patient Engagement
IS has emailed KM about the Patient Summit. It was fed back to IS that the EOL
presentation was too complex. IS asked for a copy of the presentation which RL
3
will provide and would present this at his PPG. PJ said she would include this in
the next network meeting also.
IS reiterated that it is important that the right message is being delivered and it
appeared there was a lot of misunderstanding and confusion at the Patient
Summit.
RL offered support from herself or the engagement team.
PJ said she had attended the Patient Summit and there were too many items on
the agenda. She said it is important that it is aimed at the right level and
suggested that half the meeting should be available for questions and/or
comments. IS suggested it is worth thinking now about the next Patient Summit.
“A day in the life of a GP” was a popular idea. A good number of GPs need to be
present to answer questions and perhaps attendees can send questions in
beforehand or can fill out a card upon entry (to ensure the questions are relevant
for this forum). There was a discussion about the next Patient Summit.
TF said he had feedback from patients there is a great deal of variation between
PPGs. Some had no GPs in attendance, some were very dictatorial. There was a
discussion about managing activists; getting balanced discussions and getting
younger patients involved. Engagement team can assist with these events.
PJ informed that she has now joined the Intermediate Care Strategy Group.
6
Primary Care Quality
PD presented the Quality Report. He referred to:
1. Incident reporting on Datix
The LCG has improved incident reporting and is now amongst the better
ones in the CCGs at 23%. He has recently had Datix 2 training in his
practice. The Board reviewed the report. The report is obscured as a
result of Malling not reporting on Datix. RL said that Malling have a new
PM and RL has been to see her, they have their own internal reporting
system and she wasn’t aware of Datix. RL will ask Tom Richards to see
her. It was noted that single-handed GP practices have very few incidents
reported. It was agreed that report per 1,000 would allow for better
comparisons between different sized practices. AH suggested it would be
better to have relative and physical numbers. There was a discussion as to
whether this is a clinical or clerical task – IS confirmed that all staff should
be able to report all incidents (RL said this should include issues with MDT
meetings, providers etc. also).
2. Complaints and concerns
The Board discussed the results. There were 31 complaints/concerns and
1 compliment. It was a concern that 7 of the complaints/concerns were
about GP conduct (disclosure of data). It was agreed it would be useful to
analyse the type and nature of complaints/concerns.
4
8
PD informed that the next Q&S Committee will be dedicated to medicines
management. There will be a focus on reducing waste.
PCCF – practice visits
RL informed that all practices have now been visited. 1 or 2 practices have been
rated ‘amber’ due to some issues they are struggling with/working through with
regards to standards 1 or 2; others are rated green. The Primary Care CoCommissioning Committee has asked PCDM to provide focused support for those
rated amber or red. Practices now have to return their reassurance document
with sign-up forms for 1 April. RL has had a good response to the reduced PCCF.
1 practice is rated red for standard 1 and 2. They are not in a positon to open
their half day and do not want to collaborate. They have issues with standard 2
also. Co-Commissioning Committee is reviewing. RL will support practices with
PCCF but will not be dealing with contractual issues.
There is a practice in another LCG that hasn’t been successful in signing up this
year was due to access. She has the option to sign-up in September.
IS reiterated that collaboration is key for small practices.
RL will bring the assurance template to the next Board meeting for review.
Any Other Business
Elections
The timetable for the LCG Chair and Vice Chair elections was circulated. Quality
team and Jayne Salter-Scott will be leading the election process. Chair and Vice
Chair sit on governing body.
RL will check the position with regard to other elected posts. RL was asked to
check if these could be put out to all LCG members for transparency. If
appropriate this can be an agenda item at the next All Members.
These posts would be for a 3 year tenure.
National GP Patient Survey
The results have now been published and are publicly available. RL asked if this
would be useful to use at the next Board meeting to decide if some results can be
raised at the All Members. RL agreed to ask Alison Braham what data is used by
CQC.
AH explained the Quality Premium. One of the core criteria is improvement in GP
patient satisfaction. There are 2 measures: overall achievement of 85% across the
CCG or a percentage increase from the previous year. This works out to the
equivalent of £1 per patient to the CCG (@£0.5million).
There was a discussion about patient feedback/survey results being personal
perception, focused on access and quality. PD asked if the surveys linked to
5
prescribing data; IS said in the Royal College of GPs magazine it stated that the
lowest prescribers of antibiotics were least popular. The survey doesn’t represent
whether the patient got “what they wanted” or “what they needed”. AH said
Friends and Family is a snapshot only; feedback is retrospective and from recall of
memory, the number of responses per practices is disproportionate. It was
agreed that a better system is needed. AH favours a quick response at that point
in time using a touch screen.
Date of Next Meeting
Date: 21 April 2016
Time: 3.00pm – 4.000pm
Venue: Portway Lifestyle Centre, Newbury Lane, Oldbury B69 1HE
6
SANDWELL HEALTH ALLIANCE L.C.G. PROGRAMME BOARD MEETING
Minutes of the Meeting held on 29 March 2016
1:30-3.30pm at Izons Road Surgery, West Bromwich B70 8PG
Present:
Dr B A Andreou (BA)
Dr Pri Hallan (PH)
Claire Blackburn (CB)
Mike Perks (MP)
Jodi Woodhouse (JW)
Sumaira Tabassum
Loraine Deeming
Graham Price (GP)
Chair
Clinical lead
Primary Care Development Manager, SWB CCG
Primary Care Finance Lead, SWB CCG
Primary Care Quality Lead, SWB CCG
Medicines Management, SWB CCG
Medicines Management, SWB CCG
Apologies:
Dr A Ahmed (AA)
Dr D Manivasagam (DM)
Yvette Townsend (YT)
1.0
1.1
1.2
Vice Chair
Partnerships Lead
Clinical Lead
INTRODUCTION
Welcome and Introductions
BA welcomed everyone to the Board Meeting.
Apologies for Absence
As noted above. The meeting proceeded on the basis that Dr Ahmed had confirmed his
attendance (his apologies were given after the meeting had begun).
Sumaira Tabassum and Loraine Deeming were attending in place of Shabana Ali.
BA announced the sudden death of Sandwell MBC Darren Cooper and expressed
condolences on behalf of Sandwell Health Alliance LCG.
1.3
Declarations of interest
There were declarations of interest in respect of PCCF and the Prescribing Development
Scheme.
1.4
Minutes from Previous Meeting/Actions
Minutes were agreed as an accurate record of the meeting.
The actions from the previous Minutes were reviewed and the following points made:
1


BA said there remains some dissatisfaction about the PDS scheme, objections were
mainly around the tone of the document. BA suggested that these type of
schemes could be discussed with LCG boards at an early stage and documents can
be adapted for clinically led where appropriate. CB said that the issues raised
following the tone of presentations given at the PLT had been addressed across all
departments and it was agreed that further discussions should take place when
Shabana Ali was present.
GP said where presentations or tables/graphs are circulated he would appreciate a
summary of key points in advance of the meeting so that he can participate in
discussions with prior knowledge of the content.
2.0 PCCF
2.1
CCG Governing Body Minutes/Chairs Report
BA suggested that a Chair’s Report be resurrected to keep Board members up to date. BA
and CB will draw up a schedule of what is to be included in this report. GP asked for this
report could also be circulated to patient reps.
BA reminded everyone that the Governing Body Minutes are available on the CCG website.
2.2
Commissioning and Redesign Committee
AA was absent from the meeting so no update was available.
PH informed the Board of the following:
Lymphoedema
Lymphoedema procurement has commenced and PH is the clinical lead. This is at
notification stage currently; tenders will be sent 1 June (after which date this cannot be
discussed at Board level). Tenders have to be returned by 12 July with a completion date
of 9 September. A marketing event will take place on 6 April 2016. Lymphoedema is
currently provided by Lymphcare in Sandwell and BCHC in Birmingham. The contract value
is £319,000. Mohammed Khalil is leading from the CCG.
Community Nursing
There is a single point of access in Birmingham and the same maybe developed now for
Sandwell. Initial meetings have taken place.
BA met with the new Director for Community Nurses (Sarah Shingler) last week at his
practice and is awaiting feedback. Sarah is looking at redesign – workload sharing,
separating urgent and routine.
Community Contracts
PH is still working with Paul Russell (SWB CCG) to evaluate community contracts.
BA explained there had been a discussion about the STPs at the last Directors meeting. The
aim is to better integrate health and social care. There are 44 STP areas covering the
country, each serving around 1.3m people and typically comprising several CCGs, NHS
providers and local authority areas. We have been asked to be a part of an STP with the
CCGs in Dudley, Walsall and Wolverhampton, along with the NHS providers and local
authorities in the area. Another STP has been formed around Birmingham Cross City,
2
Birmingham South Central and Solihull CCGs and includes their local NHS providers and
Local Authorities. Recognising the natural flow of patients, Birmingham City Council and
Birmingham Community Health Care FT have membership in both STPs as does Sandwell
and West Birmingham Hospitals Trust and ourselves as SWBCCG.
PH asked how patients will be affected and said that the LCG should promote what is best
for patients and practices in this area and ensure they are not negatively impacted. The
LCG should meet together as a small group to discuss what is best for them and patients
and then give an opinion/point of view. BA said the issues with boundaries are with social
care and not health.
Approximately 30,000 patients of Medica are due to transfer to South Central CCG, mainly
due to the flow of their patients to the Birmingham side.
BA referred to a NHS England publication which contained a map of Sandwell, West
Birmingham and Black Country, listed as having a population of 1 million. Some STPs are
not yet defined but there is a deadline and the publication says services should not be
planned around constitutions but around larger patient groups
CB referred to Andy Williams’/Nick’s News for an explanation of the STP and reasons for
the agreed boundaries.
PH referred to the last clinical lead meeting where Nick presented lots of choices. CB will
check if the decision has already been made.
Mike Perks, Loraine Deeming and Sumaira Tabassum joined the meeting.
2.3
GP gave an update on the PPAG meeting on 9 March. The topics were:



PCCF update;
Route2Wellbeing with Jason Meredith giving a presentation; he is returning again
in June to give a further presentation;
Healthy community push sites. GP said it was felt by the presenter that there
hadn’t been quite 12 months but there was an update with positive results and
possible reduced A&E attendances.
At the last network meeting there were 2 presentations:
i.
ii.
Your Care Connected – Stephen O’Hanlon. One Practice Manager asked what
would happen if a patient attends hospital but then does not take the advice given
and there was no clear answer; and
EOL – new service from mid-April. There had been a lot of discussion about the
difficulty in finding good care homes and the costs of good care homes. PH said
the CQC rating report is useful for comparing care homes.
BA informed that he gets email updates from Your Care Connected; they had attended an
All Members and a LMC meeting, BA has been invited to their Board meeting but was
unable to attend. There are some IT issues to resolve.
3
3.0 PRIMARY CARE DEVELOPMENT/COMMISSIONING FRAMEWORK UPDATE
3.1
PCCF update
CB has invited representatives from finance, quality and medicines management
(engagement was unavailable due to annual leave) and encouraged the Board to come up
with a plan for future meetings and what information these representatives can produce
that will assist in development the PCCF.
PH said he would like information on the strategic direction.
PH also asked for information on the push site work. He has data about savings on A&E
and emergency admissions but has no other information.
PH enquired as to what other clinical leads are doing and BA said they were only doing as
directed by the CCG; there has been loss of focus since the CCG restructure.
AA to provide the Board with an update on the mental health hub at the next meeting.
CB agreed to discuss with what reports can be provided as a commissioning update.
BA highlighted PH’s concerns about not having an input into commissioning. BA said the
mechanism for input is not working effectively; decisions are presented afterwards; not
allowing for contributions to be made. PH said this also refers to strategic decisions – a lot
of information going through Directors meetings are not filtered down, GPs are not able to
have an input before some of the bigger decisions are made; there is a disconnect between
GPs and the CCG. CB said this is meant to come through LCG representatives and asked
for PH’s suggestions. PH said the disconnect needs to be fixed.
There was a discussion about the PCCF - clinical lead sessions had been held, there was a
lot of consultation and the PCCF was changed as a result of comments and feedback.
PH had spoken to MP about the finances. PH stated some changes were made to the
baselines for practices but elements that were not changed were not fed back, no
reasons/explanations were given.
3.2
Quality
BA gave examples of difficulties with Sandwell NHS Trust. There was a discussion about
SWB NHS Trust asking the GP to chase up test results.
JW impressed the need for issues to be reported on Datix so that the Quality Team can
address the issues, monitor trends and issues can then be raised at the CQRM meetings.
There are also issues with Health Harmonie. Dr Andreou will forward to JW a letter sent
to out by a Dr Ryan to a patient (criticising Health Harmonie). JW informed that Health
Harmonie’s contract review meeting has been brought forward as a result of Datix reports.
CB will check with Liz Green (Commissioning Manager) what progress has been made
with regard to Health Harmonie scans being sent directly to patient records as PH said
this had been very useful in comparing against previous scans.
There was a review of the Quality Report that had been circulated. BA will have a look at
4
the report in detail and will decide how frequently he would like these reports and will
then inform CB and JW. JW said the learning and experience group and new comms team
at the CCG will be working to identify incident trends, these will then be grouped and there
will be a page on the CCG website with guidelines on how to handle common issues.
IT issues can also be reported on Datix.
3.3
Medicines Management
Sumaira referred to the report that had been circulated by Shabana Ali. There was a
general discussion and review of the report. PH said he was happy with the report and
suggested that the 5 frequent outliers could be identified and offered targeted support.
It was agreed that medicines management need to start engaging with practice staff, using
a question and answer format, asking the practice staff what support they want, offering
face-to-face or email support, on a weekly basis.
DM is the medicines management lead and it was agreed that SA and DM will work
together, copying in BA.
It was suggested that good results should be recognised; perhaps an awards event.
3.4
Finance
MP said he had come with a blank page for the Board to tell him what information they
want him to provide. MP has access to secondary care data which can help to identify
practices that need the most support.
It was agreed that MP would produce a full report for the next Board meeting for
members to then decide what future finance information they would like to have.
The SHA LCG matrix team can coordinate and produce one set of data to present to
practices. This can be agreed at Board level and then a suitable report can be introduced
at All Members. A starting point would be 2015/16 with data that was previously included
in the finance report.
4.0 ANY OTHER BUSINESS
BA is not available for the date of the next meeting scheduled for 26 April. It was agreed
that LR will canvass Board members for an alternative date.
5.0 DATE AND TIME OF NEXT MEETING
Monday 25 April 2016, 1:30pm – 3:30pm @ Oakwood Surgery
5
Glossary of Common
Terms & Abbreviations
Edition 5 (April 2016)
1
Second Floor, Kingston House, 438-450 High Street,
West Bromwich B70 9LD
Chair: Dr Nick Harding
18 Weeks
Patients have the right to have access to services within a maximum waiting
time of 18 weeks. This time frame starts with the day the service provider
receives a referral letter or the day a first appointment is booked by the patient
using Choose and Book; through to the first day of treatment.
Acute
Acute as a term in medicine often refers to symptoms or illness that has a
sudden onset, quickly progresses and which often becomes very severe in
nature.
Advocate
An advocate is an individual who acts upon the behalf of another and provides
support to them. Self-advocacy is encouraging people to speak up for
themselves and to represent their own interests.
Aftercare
Treatment or care provided after the acute phase of an illness or following
hospitalisation.
Alzheimer's Disease
An illness in which the main symptom is a progressive loss of memory and
higher mental functions. Accounts for about 60% of cases of dementia.
Assessment
A detailed evaluation, usually performed by a doctor, nurse, occupational
therapist or social worker, of an individual’s mental, emotional, and social
capabilities.
Baseline
In medicine a baseline refers to an initial measurement of a person's mental
or physical health status at the commencement of treatment.
Benchmark
In healthcare settings the term benchmark usually refers to an agreed
standard of care or treatment against which others may be measured or
judged.
Bluefish
Bluefish is a data warehouse that holds data from I-Patient Manager (IPM)
and allows generation of reports.
British National Formulary (BNF)
The British National Formulary is a very commonly use Doctors' handbook of
medications, which explains their side-effects, indications for use and
recommended doses.
2
Capacity
This term means that a service user has the ability to understand and retain
information about their medical and/or psychiatric condition and their need for
treatment.
Care Quality Commission
The Care Quality Commission is the independent regulator of health and
social care in England. Their aim is to make sure better care is provided for
everyone, whether that’s in hospital, in care homes, in people’s own homes,
or elsewhere.
They regulate health and adult social care services, whether provided by the
NHS, local authorities, private companies or voluntary organisations. They
also protect the rights of people detained under the Mental Health Act
Carer
This term is given to a relative or friend who helps to support the service user.
They may provide personal and/or emotional care, help with medication,
finances and other daily activities. They may provide this for a few hours a
week or on a 24/7 basis. The term 'carer' in this context does not include any
paid staff or volunteers providing support on behalf of a group or organisation.
Carers have legal rights to assessment and a right to certain information
about the person they support
Child and Adolescent Mental Health Services (CAMHS)
CAMHS is a term used to refer to mental health services for children and
adolescents. CAMHS are usually multidisciplinary teams including
psychiatrists, psychologists, nurses, social workers and others.
Chronic
A condition that develops slowly and/or lasts a long time.
Clinical Audit
Clinical audit is a quality improvement process that seeks to improve clinical
care, treatment and outcomes through undertaking a systematic review of
care against explicit criteria; identify areas for change if required; and then
implementation of positive change to improve standards.
Clinical Governance
A framework that ensures that NHS organizations monitor and improve the
quality of services provided and that they are accountable for the care they
provide. Clinical Governance is about ensuring that the right person receives
the right treatment, at the right time, by the right individual, so as to receive
the best possible quality of care.
3
Clinician
A person who provides direct patient care such as a doctor, nurse,
occupational therapist, pharmacist, psychologist, etc.
Commission for Social Care Inspection
An independent service set up by the Government to inspect and report on
care services and councils.
Datix
Datix is the leading supplier of patient safety software for healthcare risk
management, incident reporting software and adverse event reporting. It is
used to improve patient safety, healthcare and service user safety. The
software is widely used within both public and private healthcare
organisations.
Dementia
The term dementia describes a set of symptoms that include loss of memory,
mood changes, and problems with communication and reasoning. There are
many types of dementia. The most common are Alzheimer’s disease and
vascular dementia. Dementia is progressive, which means the symptoms will
gradually get worse.
Diagnosis
A clinical judgment or decision about what a particular illness or problem is. It
is made following an examination or assessment of symptoms.
Duty of Care
This relates to reasonably ensuring that individuals are kept safe from harm.
Emergency Planning
Emergency planning refers to service providers having plans and processes
in place for a wide range of incidents/emergencies that may affect patient
health/care.
Equality relates to creating a fairer society to allow all individuals to have the
opportunity to fulfill their potential. Diversity recognizes the positivity of
individual and group differences.
Essence of Care
A comprehensive series of professional benchmarks for care and treatment
development by the Department of Health, which covers a range of issues
including: continence, bladder and bowel care; personal and oral hygiene;
food and nutrition; pressure ulcer prevention and care; privacy and dignity;
record keeping; safety of clients with mental health needs within acute mental
health and general hospital settings; self care and communication.
4
Executive Summary
An Executive Summary is a short document/section which summarizes the
key points of a longer document.
Healthcare Commission
The Healthcare Commission is an independent body, established by the
Department of Health, which has been set up to promote improvement in the
quality of public health and healthcare across England and Wales.
Hypertension
High / elevated blood pressure. Blood pressure ranges fluctuate depending
upon physical and emotional state, family history and age.
Infection Control and Prevention
Infection Control and Prevention relates to activities undertaken to protect
individuals from acquiring infections and to reduce the transmission of
infections associated with health care.
Information Governance
Information Governance is the way by which the NHS handles all
organisational information - in particular the personal and sensitive
information of patients and employees. It allows organisations and individuals
to ensure that personal information is dealt with legally, securely, efficiently
and effectively, in order to deliver the best possible care.
Integrated Governance
Integrated Governance is defined as systems, processes and behaviours, by
which trusts lead, direct and control their functions in order to achieve
organisational objectives, safety and quality of service and in which they
relate to patients and carers, the wider community and partner organizations.
Joint Strategic Needs Assessment
This is a process which identifies the current and future health and well-being
needs of a local population, informing the priorities and targets set by local
area agreements and leading to agreed commissioning priorities that will
improve outcomes and reduce health inequalities.
Local Area Agreements
Local area agreements are made between central and local government in a
local area. Their aim is to achieve local solutions that meet local needs, while
also contributing to national priorities and the achievement of standards set by
central government.
Locum
A temporary health or social care professional. This person does not have a
permanent contract with the Trust.
5
Morbidity
Morbidity is an incidence of ill health. It is measured in various ways, often by
the probability that a randomly selected individual in a population at some
date and location would become seriously ill in some period of time.
Mortality
Mortality relates to fatal outcomes; death.
Multidisciplinary Team
A group of professionals who work together to help plan and carry out
treatment for service users. This group can be made up of a range of
professions including health and social care staff.
Multiple Care Providers
Under this new care model outlined in the NHS five year forward view, GP
group practices would expand, bringing in nurses and community health
services, hospital specialists and others to provide integrated out-of-hospital
care. These practices would shift the majority of outpatient consultations and
ambulatory care to out-of-hospital settings.
NHS England
NHS England is an operationally independent body, who is accountable to the
Government. Their aim is to secure the best possible health outcomes for
patients in England. They were formally established as the National
Commissioning Board.
NHS Litigation Authority
Provides indemnity cover for legal claims against the NHS, assist the NHS
with risk management, share lessons from claims and provide other legal and
professional services for our members.
National Institute for Health and Clinical Excellence (NICE)
The National Institute for Health and Clinical Excellence, commonly referred
to as NICE is the independent organisation responsible for providing national
guidance on the promotion of good health and the prevention and treatment of
ill health.
Never Event
Never Events are serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been
implemented.
Ofsted
Ofsted is the Office for Standards in Education, Children’s Services and Skills.
They report directly to Parliament and are independent and impartial. They
6
inspect and regulate services which care for children and young people, and
those providing education and skills for learners of all ages.
Outbreaks
An outbreak is the occurrence of cases of a particular disease, which exceeds
what would normally be expected for that group.
Outcome
An outcome can be defined as an intended result, effect, or consequence that
will occur from carrying out a program, activity or treatment.
Palliative Care
Palliative care is the active holistic care of patients with advanced progressive
illness. Management of pain and other symptoms and provision of
psychological, social and spiritual support is paramount. The goal of palliative
care is achievement of the best quality of life for patients and their families.
Many aspects of palliative care are also applicable earlier in the course of the
illness in conjunction with other treatments
Primary Care
This is a term that is used to describe the care and help that is given as a first
port of call to people in their own communities, for example, by their GPs or
health visitors in the health service; by social workers in social service
departments and by teachers and youth workers in the education service.
Prognosis
An estimate of the outcome of a disease; a prediction.
Quorum
The minimal number of officers and members of a committee and/or
organisation. Usually a majority, who must be present for a valid transaction
of business.
Referral to Treatment
See “Stop the Clock”.
Respite Care
Occasional, but usually a planned, short period of residential care intended to
provide a short break for carers.
Right Care, Right Here (formerly Towards 2010 Programme)
This is a programme which plans to invest up to £700 million in health and
social care services; and facilities, in Sandwell and West Birmingham.
Risk Register
7
Determines the likelihood of any adverse situation occurring and the
consequence/impact for an organisation if it did occur. Risks can then be
ranked in order of priority for an organisation.
Royal College of Nursing
A nationally recognised professional body that represents the interests of
nurses and provides support in professional matters.
Safeguarding
Safeguarding means protecting people’s health, wellbeing and human rights;
and enabling them to live free from harm, abuse and neglect. It is
fundamental to creating high-quality health and social care
Serious Untoward Incident
This is a term used to describe a serious incident or event which led or may
have led, to the harm of patients or staff.
Service User
A person receiving the services of a health authority or voluntary or
independent organisation is called a service user.
Single Assessment Process (SAP)
The Single Assessment Process aims to make sure the care needs of older
people are assessed thoroughly and accurately, but without procedures being
needlessly duplicated by different agencies. SAP is intended to promote
effective communications and ensure that older people receive effective and
efficient care.
Stop the Clock
The Referral to Treatment status code will allow a “clock stop” to be monitored
for each individual patient journey. This is a crucial process in achieving the
18 weeks waiting time standard.
Substance Misuse
Substance Misuse is a term commonly used to describe the harmful use of
any substance, such as alcohol, street drugs and/or prescribed, or over-thecounter medications.
SystmOne
SystmOne is a centralised clinical system that provides healthcare
professionals with a complete management system including electronic
patient records.
8
Vanguards
In January 2015, the NHS invited individual organisations and partnerships to
apply to become ‘vanguards’ for the new care models programme, one of the
first steps towards delivering the NHS Five Year Forward View and supporting
improvement and integration of services. There were three vanguard types –
integrated primary and acute care systems; enhanced health in care homes;
and, multispecialty community providers.
9
Glossary of Terms and Abbreviations
Abbreviation
A&E
AAACM
AC
ACAP
ACM
ACT
ADASS
ADHD
ADQ
AETB
AF
AGM
AGS
AIDS
AMD
AMD
AMU
AO
AOR
AQP
APA
ASB
ASCOF
AT
BADGER
BAF
BBCS
BCM
BCMHP
BCPFT
BMC
BME
BMT
BNF
BPCC
BSAB
BSBC
BSE
BTC
CA
CAMHS
Meaning
Accident and Emergency
All Age All Cause Mortality
Audit Committee
Adults & Communities Access Point
Assessment & Care Management
Acute Trust Contracts
Association of Directors of Adult Social Services
Attention Deficit Hyperactivity Disorder
Average Daily Quantity
Assistive & Equipment Telehealth Board
Atrial Fibrillation
Annual General Meeting
Annual Governance Statement
Acquired Immune Deficiency Syndrome
Acceleration Monitoring Device
Age Related Macular Degeneration
Acute Medical Unit
Accountable Officer
Accountable Officers Report
Any Qualified Provider
Annual Performance Assessment
Anti Social Behaviour
Adult Social Care Outcomes Framework
Area Team
Birmingham & District General Practitioner
Emergency Rooms
Board Assurance Framework
Birmingham, Black Country & Solihull
Business Continuity Management
Black Country Mental Health Partnership
Black Country Partnership Foundation Trust
Birmingham Metropolitan College
Black & Ethnic Minority
Borough Management Team
British National Formulary
Better Payment Practice Code
Birmingham Safeguarding Adults Board
Birmingham, Solihull and Black Country Cluster
Bovine Spongiform Encephalopathy
Birmingham Treatment Centre
Clinical Audit
Child and Adolescent Mental Health
10
CBSA
CBPG
C&P
CCG
CCGS
CDiff
CDR Intel
CDRP
CE
CEO
CFO
CG
CHC
CHD
CIP
CLQBASP
COB
COF
COP
COPD
CPP
CQC
CQN
CQR
CQRM
CQUIN
CRB
CRG
CRHT
CRL
CRM
CRS
CSCI
CSG
CSS
CSU
CTScan
CTS
CVD
CYP
CYPP
DAG
DAS
DCSF
Commissioning Business Support Agency
Commissioning Business Planning Group
Contracting & Procurement
Clinical Commissioning Group
Clinical Commissioning Groups
Clostridium Difficile
Clinical Information System
Crime Disorder Reduction Programme
Chief Executive
Chief Executive Officer
Clinical Governance
Continuing Health Care
Coronary Heart Disease
Cost Improvement Programme
Citizen-led Quality Board for Assessment &
Support Planning
Childhood Obesity Prevention
Commissioning Outcomes Framework
Contract Over Performance
Chronic Obstructive Pulmonary Disease
Child Protection Plan
Care Quality Commission
Contract Query Notice
Clinical Quality Review Meeting
Commissioning for Quality and Innovation
Criminal Records Bureau
Clinical Reference Group
Crisis Resolution Home Treatment
Capital Resource Unit
Contract Review Meeting
Cancer Reform Strategy
Commission for Social Care Inspection
Contract Steering Group
Commissioning Support Service
Commissioning Support Unit
Computer Topography Scan
Carpul Tunnel Syndrome
Cardio Vascular Disease
Children and Young People
Childen & Young Peoples’ Plan
Disability Action Group
Direct Access Services
Department for Children Schools and Families
11
DECCA
DEFRA
DES
DH
DNA
DOLs
DOS
DPA
DTA
DTOC
DV
DVT
DWMHPT
DWMHT
E&D
EAPC
EAS
EAU
ECHR
E Coli
ED
EDS
EIA
EMSS
EoC
EOE
EPP
EPPCIC
EPRR
ES
ESR
ESS
EUCC
EUC/OOH
EWTD
F & PC
FACS
FCQ
FCR
FFCE
FIMS
FNC
FOI
FOIA
Drug Education counselling & Confidential Advice
Department for Environment, Food & Rural Affairs
Direct Enhanced Services
Department of Health
Deoxyribonucleic acid
Depravation of Liberties
Directory Of Service
Data Protection Act
Decision to Admit
Delayed Transfer of Care
District Valuer
Deep Vein Thrombosis
Dudley & Walsall Mental Health Partnership Trust
Dudley & Walsall Mental Health Trust
Equality & Diversity
Equitable Access in Primary Care
Early Assessment/Access Service
Emergency Assessment Unit
European Convention on Human Rights
Escherichia Coli
Emergency Department
Equality Delivery System
Equality Impact Assessment
Elected Minor Surgery Service
Essence of Care
East of England
Expert Patients Programme
Expert Patients’ Programme Community Interest
Company
Emergency Planning Resilience & Response
Enhanced Services
Electronic Staff Record
Emergency Services Scheme
Emergency Urgent Care Centre
Emergency Urgent Care/Out of Hours
European Working Time Directive
Finance and Performance Committee
Fair Access to Care Services
Finance, Contracting & QUIPP
Full Cost Recovery
Finished First Consultant Episode
Financial Information Management System
Free Nursing Care
Freedom Of Information
Freedom of Information Act
12
FOT
FT
GDP
GMC
GMS
GOWM
GP
GPAQ
GUM
GVA
H & WB Board
HC
HCA
HCAI
HCPS
HED
HEE
UHB
HCC
HIV
HoIA
HPV
HR
HSE
HSMC
HSMR
HTT
HWBB
HWW
IAPT
ICM
ICOF
ICT
IFR
IG SoC
IGT
IOB
ILC
IM&T
InfG
IntG
IPM
ISP
ITF
Forecast Out Turn
Foundation Trust
General Dental Practitioner
General Medical Council
General Medical Services
Government Office West Midlands
General Practitioner
General Practice Assessment Questionnaire
Genito-Urinary Medicine
Gross Added Value
Health & Well Being Board
Health Centre
Health Care Assistant
Healthcare Acquired Infection
Health Care Professionals
Health Evaluation Data Team
Health Education England
University Hospitals Birmingham
Healthcare Commission
Human Immunodeficiency Virus
Head of Internal Audit
Human Papilloma Virus
Human Resources
Health and Safety Executive
Health Services Management
Hospital Standardised Mortality Ratio
Home Treatment Team
Health and Well Being Board
Healthwatch Walsall
Improving Access to Psychological Therapies
Intelligent Commissioning Federation
Information Communication Technology
Individual Funding Requests
Information Governance Statement of
Compliance
Information Governance Toolkit
Improving Outcomes Board
Independent Living Centre
Information Management & Technology
Information Governance
Integrated Governance
I-Patient Manager
Information Sharing Protocol
Integrated Transformation Fund
13
ITT
JCU
JHWS
JNCC
JSNA
JSU
KPI
KSF
LA
LAA
LAC
LAT
LCFS
LCG
LD
LDC
LDP
LEA
LES
LGA
LGBT
LGUSS
LINKs
LM
LMC
LOC
LPSA
LSAB
LSC
LSCA
LSMS
LSP
LTC
MASH
MB Chb
MC
MCA
MD
MDT
MECC
MEXT
MFF
MHA
MH
MHRA
Invitation To Tender
Joint Commissioning Unit
Joint Health and Well Being Strategy
Joint Negotiating Consultative Committee
Joint Strategic Needs Assessment
Joint Strategic Unit
Key Performance Indicator
Key Skills Framework
Local Authority
Local Area Agreement
Looked After Children
Local Area Team
Local Counter Fraud Specialist
Local Commissioning Group
Learning Disabilities
Local Dental Committee
Local Delivery Plan
Local Economic Assessment
Local Enhanced Service
Local Government Association
Lesbian, Gay, Bi-Sexual and Transgender
Local Government User Satisfaction Survey
Local Involvement Networks
Lay Member
Local Medical Committee
Local Optometry Committee
Local Public Service Agreement
Local Safeguarding Adults Board
Learning and Skills Council
Local Safeguarding Children’s Board
Local Security Management Specialist
Local Strategic Partnership
Long Term Condition
Multi Agency Safeguarding Hub
Bachelor of Medicine & Bachelor of Surgery
Medical Centre
Mental Capacity Act
Doctor of Medicine
Multidisciplinary Team
Making Every Contact Count
Management Executive Team
Market Force Factor
Mental Health Act
Mental Health
Medicines and Health Regulatory Agency
14
MMC
MMH
MMR
MoU
MRCGP
MRI
MRSA
MSA
MSSA
MUR
NA
NAPP
NEPT
NCB-AT
NCHOD
NCMP
NEET
NHS
NHSBT
NHSCB
NHSCMCSU
NHSD
NHS FT
NHSLA
NHST
NHSTDA
NIC
NICE
NLC
NQR
NRLS
NMC
NPfIT
NRF
NRLS
NSLA
NTDA
NVQ
NWPHO
OATS
OCD
OD
Medicines Management Committee
Midland Metropolitan Hospital
Measles, Mumps and Rubella
Memorandum of Understanding
Member, Royal College of General Practitioners
Magnetic Resonance Imaging
Methicillin-Resistant Staphylococcus
Mixed Sex Accommodation
Methicillin-sensitive Staphylococcus Aureus
Medicine Use Review
National Audit
National Association of Patient Participation
Non-Emergency Patient Transport
National Commissioning Board-Area Team
National Centre for Health Outcomes &
Development
National Child Measurement Programme
Not in Education, Employment or Training
National Health Service
National Blood and Transfusion Service
NHS Commissioning Board
National Health Service Central Midlands
Commissioning Support Unit
NHS Direct
National Health Service Foundation Trust
National Health Service Litigation Service
NHS Trust
NHS Trust Development Authority
Net Ingredient Cost
National Institute for Health & Clinical Excellence
National Leadership Council
National Quality Requirement
National Reporting & Learning System
Nursing and Midwifery Council
National Programme for Information Technology
Neighbourhood Renewal Fund
National Reporting & Learning System
National Level Service Agreement
National Health Service Trust Development
Authority
National Vocational Qualification
North West Public Health Observatory
Out of Area Treatments
Obsessive Compulsive Disorder
15
ODC
ODC
OOH
ORMIS
ORTHO
OSC
OT
PAF
PALS
PAU
PB
PbR
PC
PCAT
PCC
PCP
PCR
PCT
PDR
PEG
PH
PHE
PHP
PGD
PHAST
PICU
PIDS
PLT
PM
PM
PMO
POCA
Pol.CV
POVA
PPA
PPE
PPG
PPI
PRG
PROMs
PSA
PU
PYLL
Q2
Operational Development Committee
Out of Hours
Operating Room Management Information
System
Orthopaedic
Overview and Scrutiny Committee
Occupational Therapy
Programme Assurance Framework
Patient Advisory & Liaison Service
Paediatric Assessment Unit
Pooled Budget
Payment by Results
Partnerships Committee
Primary Care Assessment & Treatment
Palliative Care Centre
Personal Care Plan
Personal Care Record
Primary Care Trust
Personal Development Record
Provider Escalation Meeting
Public Health
Public Health England
Personal Health Plan
Patient Group Directions
Public Health Action Support Team
Psychiatric Intensive Care Unit
Project Initiation Documents
Protected Learning Time
Programme Management
Practice Manager
Project Management Office
Protection of Children Act
Policies of limited Clinical Value
Protection of Vulnerable Adults
Prescription Pricing Authority
Patient & Public Engagement
Patient Participation Group
Patient & Public Involvement
Patient Representative Group
Patient Reported Outcome Measures
Public Service Agreement
Pressure Ulcers
Potential Years of Life Lost
Quarter 2
16
Q&P
Q&S
Q & SC
QIPP
QoF
QUIPP
QRA
QSGs
RAG
RAP
RCA
RCN
RCRH
RES
REM
ROH
RRH
RRL
RSS
RTA
RTT
RWHT
SAB
SAP
SAU
SC & I
SCR
SDA
SDIP
SDS
SEA
SED
SERP
SES
SFI
SGH
SHA
SHMI
SHO
SHOES
SIC
SIs
Sit Rep
SLA
Quality & Productivity
Quality & Safety
Quality and Safety Committee
Quality, Innovation, Productivity and Prevention
Quality Outcome Framework
Quality, Innovation, Prevention, Productivity
Quality Review Audit
Quality Surveillance Groups
Red, Amber, Green
Remedial Action Plan
Root Cause Analysis
Royal College of Nursing
Right Care Right Here
Regional Economic Strategy
Rapid Eye Movement
Royal Orthopaedic Hospital
Rowley Regis Hospital
Revenue Resource Limit
Regional Spatial Strategy
Road Traffic Accident
Referral to Treatment
Royal Wolverhampton Hospitals NHS Trust
Safeguarding Adults Board
Single Assessment Process
Single Assessment Unit
Social Care & Inclusion
Serious Case Review
Severe Disability Allowance
Services Development Improvement Plan
Spine Directory Service
Significant Event Audit
Service Experience Desk
Skills & Economic Regeneration
Single Equality Scheme
Standing Financial Instructions
St. Giles Hospice
Strategic Health Authority
Standardised Hospital Mortality Index
Senior House Officer
Sandwell Healths Other Economic Summits
Statement of Internal Control
Serious Incidents
Situation Reports – organisational statistical
returns
Service level Agreement
17
SMBC
SMT
SoRD
SQP
SSCA
SSCB
SSDP
STaR
STEIS
STAR-PU
STP
SUI
SWBCCG
SWBH
SWBHT
SWBT
T&O
TFA
TIA
TOP
TOR
TTR
TTT
TUPE
UCP
UECIP
UECN
UHB
UNIFY/STEIS
UTO
VAEB
VCS
VFM
VTE
WGA
WHG
WHNT
WHT
WMAS
YTD
Sandwell Metropolitan Borough Council
Senior Management Team
Scheme of Reservation and Delegation Review
Safety Quality and Performance
Sandwell Safeguarding Adults Board
Sandwell Safeguarding Children Board
Strategic Services Development Plan
Service Transformation and Redesign
Strategic Executive Incident System
Specific Therapeutic group Age-sex Related
Prescribing Units
Sustainability & Transformational Plan
Serious Untoward Incident
Sandwell & West Birmingham Clinical
Commissioning Group
Sandwell & West Birmingham Hospital
Sandwell & West Birmingham Hospitals Trust
Sandwell and West Birmingham Trust
Trauma & Orthopaedics
Tripartite Formal Agreement
Transient Ishaemic Attack
Termination Of Pregnancy Service
Terms of Reference
Table Top Review
Transformation Transition Team
Transfer of Undertakings
Unscheduled Care Programme
Urgent & Emergency Care Improvement
Programme
Urgent and Emergency Care Network
University Hospital Birmingham
Strategic Executive Information System
Untoward Occurrence
Vulnerable Adults Executive Board
Voluntary and Community Sector
Value For Money
Venous Thrombo Embolism
World of Government Accounts
Walsall Housing Group
Walsall Healthcare NHS Trust
Walsall Healthcare Trust
Year to Date
18

SWBCCG Board Meeting - Sandwell and West Birmingham CCG

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