- NHS West Kent CCG

Transcription

- NHS West Kent CCG

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

- NHS West Kent CCG

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