Integrated Governance Report 2016/17 - Bromley CCG - Integrated Governance... · patients to zero by March 2019. The delivery of the plan is subject to investment which requires agreement

Integrated Governance Report 2018/19

Month 2 – May 2018

Thursday 6 September 2018

ENCLOSURE 7A

Contents

2

PERFORMANCE

Highlight Report for Month 2 Page 6

BCCG Performance Dashboard Page 8

LAS- Ambulance Response Programme Overview Page 9

London Ambulance Service Response Times Page 10

BCCG Performance Summary Page 11

BCCG Activity Dashboard Page 16

Pan London Performance Page 17

BCCG Quality Premium Changes Page 18

Acute Provider Performance Dashboard - Kings Page 21

Acute Provider Performance Dashboard – GSTT and L&G Page 22

Oxleas Performance Summary Page 23

Oxleas Performance Monitoring-KPI Page 24

CAMHS Performance Page 25

Primary Care Page 27

CCG Improvement & Assessment Framework (IAF) Page 31

BCCG Better Care Fund 2017 – 2019 Page 33

QUALITY

Quality Report Summary Page 35

Kings – Quality Dashboard Page 36

Kings Exception Report Page 37

Kings CQRG Page 38

Oxleas – Quality Dashboard Page 40

Oxleas Exception Report Page 41

Oxleas 3 Borough CQRG Page 42

BHC CQRG Page 44

BHC Safer Care Presentation Page 46


BCCG QAS Page 54

3

Contents

Cash Position Page 79

Better Payments Practice Code Page 80

Aged Debtors (Receivables) Page 81

Financial sanctions imposed by the CCG Page 82

Revenue Resource Limit Page 83

Recommendations Page 84

FINANCE

Financial Performance Duties Page 59

Summary of Position at M2 Page 60

CCG Programme Costs Summary Page 60

CCG Runnings Costs Summary Page 62

Acute Financial Position Page 63

Notes on Acute Budgets Page 64

Client Group Financial Position Page 65

Notes on Client Group Budgets Page 66

Community Services Position 2018/19 Page 67

Notes on Community Health Services Page 68

Primary Care & Prescribing Financial Position Page 69

Notes on Primary Care & Prescribing Budget Page 70

Primary Care Co-Commissioning Page 71

Notes on Primary Care Co-Commissioning Page 72

Earmarked Budgets and Reserves Page 73

Running Costs Page 74

Better Care Fund Page 75

Capital Page 76

QIPP Monitoring Page 77

Financial Risks & Mitigations Page 78

Introduction

This report provides an integrated view of the performance of Bromley Clinical Commissioning Group and its main service providers, to ensure focus on the key issues. The report has been structured to reflect the NHS Outcomes Framework, NHS Constitutional Standards and the statutory financial responsibilities of the organisation. The report seeks to give assurance to the Committee that the CCG is aware of any issues and that appropriate action is taken to understand the situation and improve performance wherever possible.

The report comprises:

Performance section – the first section of the report focuses on the performance of the CCG against the NHS Outcomes Framework and NHS Constitutional Standards. The performance of the CCG’s main acute providers, Oxleas NHS Foundation Trust (Mental Health) and Bromley Healthcare (Community), against national and local indicators is also included within section one.

Quality section – the content held in this section of the IGC report is intended to highlight key quality issues and areas of good practice identified for any of the CCG’s main providers by various sub-committees and quality groups.

Finance section – this section of the report reflects the reported financial position and any issues and mitigations.

Some data is only made available on a quarterly or annual basis. Where this is the case, the Performance Team seek alternative reporting mechanisms, if possible, to ensure the organisation has a current view on its performance against all monitored standards.

4

Performance Author: Ita Johnston, Acting Head of Planning & Performance

Highlight Report for Month 2 Page 6

BCCG Performance Dashboard Page 8

LAS- Ambulance Response Programme Overview Page 9

London Ambulance Service Response Times Page 10

BCCG Performance Summary Page 11

BCCG Activity Dashboard Page 16

Pan London Performance Page 17

BCCG Quality Premium Changes Page 18

Acute Provider Performance Dashboard - Kings Page 21

Acute Provider Performance Dashboard – GSTT and L&G Page 22

Oxleas Performance Summary Page 23

Oxleas Performance Monitoring-KPI Page 24

CAMHS Performance Page 25


CCG Improvement & Assessment Framework (IAF) Page 31

BCCG Better Care Fund 2017 – 2019 Page 33

5

Cancer – Bromley CCG missed three of the cancer wait targets in May. These include the 62 day wait from NHS screening service, 31 Day standard for Subsequent Cancer treatment, radiotherapy and 2 week wait for Breast Symptomatic standards. The 2 week Breast referral target and 31 day target has not been met for 3 months but there has been and improvement on Aprils performance from 88.9% to 92.2% in May.

RTT and 52 week waits –The number of patients waiting over 52 weeks in May were 34, a decline on April

performance of 32. The ICDT have now received detailed plans on how KCH plan to reduce the number of long waiting patients to zero by March 2019. The delivery of the plan is subject to investment which requires agreement by the trust Finance & Investment Committee. ICDT are overseeing the implementation of the action plan. NHS England require long waiters for March 2019 to be no more than 50% of the number waiting March 2018. However as a sector, we have committed to reducing this to zero.

Diagnostics – The 1% diagnostic target was not met in May, however there was an improvement in performance from 4.8 in April to 4.3 in May. The Kings Diagnostic Plan is in place and is being overseen by the ICDT. It is anticipated that the diagnostic target will not be met until March 2019.

A&E - Performance remains below the 95% national standard in May 91.5% at the PRU site & 79.8% trust wide . The

key drivers for performance in May 2018 included increased attendances at both sites, increased emergency admissions and continued challenges with reduced staff capacity. There were sixteen 12 hour trolley breaches 10 at Kings & 6 at the PRU) in May 2018 compared to 24 in April.. All breaches were reported as related to mental health patients.

LAS - The CCG have met 3 out of the 4 categories target for Month 2. There was a slight underperformance on the

category 2 – 18 minute target. E- Referrals – Outpatient utilisation – Bromley have showed consistent improvement from September to November

2017. From November there has been a steady decline in performance resulting in a 9.5% drop in April. Despite a drop in April’s performance an improvement in performance has been seen in May .

6

Highlight for Month 2 Integrated Governance Report (1 of 2)

Mental Health - Overall Performance is improving. EIP continue to show a significant over performance in new cases in June. Memory Service is performing to plan with the exception of Assessment to Diagnostic Waiting times which require improvement. There has been a decline in in PCP waiting times from for June but this was due to one patient waiting 14 days. ASD contracted assessments per annum continue to fluctuate but are expected to achieve their target at end of year.

Dementia - The latest recorded dementia diagnosis data from NHS Digital for June 2018 showed that Bromley CCG has achieved a rate of 69.2% . Plans are in place to increase the target further to 70%.

IAPT Access – IAPT Access: Achieved 61% in June 2018. The service has seen a dip in the number of referrals being made and there has been a high level of staff sickness among locums, annual leave and vacancies in the Step 2 element of the service. Planned actions to remedy performance include da workshop held on 9th July to review the targets and to develop a detailed action plan. The CCG have already established a monthly performance review meetings between BHC and the CCG, weekly performance data provided to the CCG.

IAPT Recovery - 51.22% achievement in June 2018, (compared to 53.71% achievement in May 2018 and 41.07% in April 2018, with a target of 50%).

Planned actions to improve performance include the service running 6 IAPTus training workshops (aimed at improving data quality and focusing on recovery). These will be compulsory for all staff. Additionally, the step 3 CBT therapists are implementing recovery focused supervision. Improvement will also be supported with the newly created Senior Counselling post which has now been appointed to as well as the step 2 Clinical Lead returning from maternity leave .

IAPT waiting times- In June 2018, the CCG has achieved: 95.82% against a target of 75%, of the Patients Ended Treatment - First Appointment within 6 weeks of Referral 97.34% against a target of 95% of the Patients Ended Treatment - First Appointment within 18 weeks of Referral There is on-going monitoring of this target in the monthly performance review meetings. Quality Premiums -For 2018/19. The QP targets are performing reasonably well in some areas where data is available. It is expected that data will be

available for the missing 2 areas for month 3 reporting. The prescribing element of Blood Stream Infections (BSI) is performing well with the exception of E-coli which is performing above target.

Improvement & Assessment framework (IAF)- Q4 IAF has been published and Bromley have been rated as Good overall . Our assessment recognised the

strengths of the CCG leadership, our financial management and performance improvements. Of particular note are improvements in areas we particularly focused on after last year’s results, such as better quality hospital care, patient experience and the implementation of personal health budgets. Also noted was our improved performance in dementia diagnosis rates, 18 week referral for treatment standard and an outstanding rating for involving patients and the public in our work. Working with our partners, we have continued to perform in the top quartile of CCGs on a number of indicators including delayed transfers of care (how well we get patients who no longer need to be in hospital out into the community), appropriate prescribing and cancer survival rates.

Over the next few months, we will focus on improving areas that require further attention such as Progress against WRES, IAPT Access, Cancer patient

experience and Dementia post diagnostic support.

7

Highlights for Month 2 Integrated Governance Report (2 of 2)

BCCG Performance Dashboard

Indicator Description Month Target Current Month

Last month

Quarter 4 2017/2018

CONSTITUTION MEASURES

Referral to Treatment Pathways - Incomplete May 92% 84.4% 83.4% 82.5% Percentage of patients waiting 6 weeks or less for a diagnostic test May >99% 95.7% 95.2% 97.4% Percentage of patients who spent 4 hours or less in A&E – Kings May 95% 79.8% 78.8% N/A Cancer 2 Week Wait - All cancer Two week wait May 93% 96.1% 94.4% 96.3% Cancer 2 Week Wait - Two week wait for Breast Symptoms May 93% 92.2% 88.9% 97.9% Cancer 31 Wait - First definitive treatment within one month May 96% 96.7% 95.4% 94.7% Cancer 31 Wait - 31 day standard for subsequent cancer treatments, surgery May 94% 100.0% 100.0% 94.4% Cancer 31 Wait - 31 day standard for subsequent cancer treatments, drug May 98% 100.0% 100.0% 97.6% Cancer 31 Wait - 31 day standard for subsequent cancer treatments, radiotherapy May 94% 93.2% 100.0% 96.0% Cancer 62 Day Wait - Two month urgent (GP referral) May 85% 85.4% 81.5% 82.8% Cancer 62 Day Wait - 62 day wait following referral from NHS cancer screening service May 90% 87.5% 90.0% 82.4%

Cancer 62 Day Wait - 62 day wait following consultant decision to upgrade May N/A 78.3% 69.2% 80.0% Ambulance clinical quality – Category A (Red 1) 8 minute response time May 75% N/A N/A N/A

Ambulance clinical quality – Category A (Red 2) 8 minute response time May 75% N/A N/A N/A

Ambulance clinical quality - Category A 19 minute transportation time May 95% N/A N/A N/A

Mixed Sex Accommodation (MSA) breaches May 0 0 1 2 Cancelled Operations – 28 day rule (KCH Total Quarterly) May 0 42

Care Programme Approach (CPA) 7 day follow up (Quarterly) May 95% 100.0%

Number of RTT pathways waiting longer than 52 weeks May 0 34 32 67 A&E – 12 hour trolley waits (PRUH) May 0 6 18 20 Urgent Operations cancelled for a 2

nd time (PRUH) May 0 0 0 0

Ambulance Handover delays – 30 mins (King’s) May 0 204 199 N/A Ambulance Handover delays – 60 mins (King’s) May 0 18 45 N/A

IAPT - Measures the proportion of people that enter treatment against the level of need in the general population (the level of prevalence addressed or ‘captured’ by referral routes)

May 4.2 % Q 1.2% 1.1% 4.2%(Q4)

IAPT recovery rate May 50% 53.7% 41.1% 51.5%(Q4) IAPT waiting time – 6 weeks May 75% 96.7% 95.0% 95.5%(Q4) IAPT waiting time – 18 weeks May 95% 100.0% 100.0% 99.6%(Q4) Dementia Diagnosis Rate May 66.7% 68.5% 68.5% 67.9% (Q4) Healthcare acquired infection – MRSA – YTD May 0 0 0 0 Healthcare acquired infection – C-Difficile - YTD May 6(YtD) 3 6 12

8

Category Percentage of calls per Category

National Standard How long does the ambulance service have to

make a decision? What stops the clock?

Category 1 8%

• 7 minutes mean response time

• 15 minutes 90th centile response time

The earliest of: • The problem being identified • An ambulance response being dispatched • 30 seconds from the call being connected

The first emergency vehicle that arrives on scene stops the clock.(There is an additional Category 1 transport standard to ensure that these patients also receive early ambulance transportation)

Category 2 48%

• 18 minutes mean response time

• 40 minutes 90th centile response time

The earliest of: • The problem being identified • An ambulance response being • dispatched • 240 seconds from the call being connected

If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock. If the patient does not need transport, the first emergency vehicle arriving at the scene of the incident stops the clock.

Category 3 34% • 120 minutes 90th

centile response time


If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock. If the patient does not need transport, the first emergency vehicle arriving at the scene of the incident stops the clock.

Category 4 10% • 180 minutes 90th

centile response time


Category 4T: If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock.

Since February 2015, three other ambulance services - South West, Yorkshire and West Midlands - have been involved in trials led by NHS England of the new standards. They focused on four main areas: Identifying the most seriously ill patients as early as possible through processes known as Pre-Triage Sieve and Nature of Call. Giving control room staff more time (up to 240 seconds) to assess incidents through a process known as Dispatch on Disposition. Developing new clinical code sets and response categories using the best available clinical evidence. Developing new targets, indicators and measures. The trials have also been independently reviewed by the University of Sheffield.

The new standards are intended to: Prioritise the sickest patients quickly to ensure they receive the fastest response Ensure national response targets to apply to every patient for the first time – so ending

‘hidden waits’ for patients in lower categories Ensure more equitable response for patients across the call categories Improve care for stroke and heart attack patients through sending the right resource first

time.

Due to the nature and impact of these changes, the previous performance measures are not comparable. However, NHS England have published National Standard for a number of the key measures which are included here.

LAS – Ambulance Response Programme Overview

9

10

London Ambulance Service Response Times

Category National Standard May 2018 South East London April 2018 Bromley CCG May 2018 Bromley CCG

7 minutes (mean) 00:06:47 00:06:58 00:06:52

15 minutes (90% Centile) 00:11:12 00:12:05 00:11:28

18 minutes (mean) 00:17:33 00:15:39 00:18:13

40 minutes (90% Centile) 00:35:48 00:31:01 00:37:26

Category 3 120 minutes 01:56:54 01:26:40 01:44:14

Category 4 180 minutes 02:22:56 01:40:51 01:38:50

Category 1

Category 2

The table below shows London Ambulance Response times for Bromley CCG and SE London.

Data is taken from the LAS Monthly Performance Reports

BCCG Performance Summary (1 of 5) CCG Performance Dashboard – RTT

Overall RTT performance for Bromley CCG met the trajectory of 84.0% for May 2018, reaching 84.4%. This was an improvement on 83.4 % in April 2018.

The chart below shows Bromley CCG’s RTT performance against the agreed improvement trajectory, the chart also includes 2017/18 performance and the national standard

RTT performance for Bromley CCG at KCH in May 2018 was 81.4%, where all specialties were non-compliant with the exception of Geriatric

Medicine. The Trust continues to insource through a contract with 18 Week Support to provide additional capacity and reduce backlog It is expected this this

will continue into Q1 (2018/19) Additional support has been provided by 18 Week Support, whereby a team of 8 validators via Source Group (independent provider of support for

waiting list management) to focus on a review of the Ophthalmology and Dermatology waiting lists for a period of 2-3 weeks in Q1 (2018/19). RTT performance for Bromley CCG at GSTT in May 2018 was 89.3%. Specialties that were compliant were; Cardiology, ENT, General Surgery,

Gynaecology, Plastic Surgery, Thoracic Medicine and Other

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50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

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

2018/19 Performance National Standard 2018/19 Trajectory 2017/18 Performance

BCCG Performance Summary (2 of 5) CCG Performance Dashboard – RTT

The table below shows RTT performance by specialty for Bromley patients The table also details the number of Bromley patients waiting longer than 52 weeks by specialty Specialties with the longest waits were Trauma & Orthopaedics (19), General Surgery (7).

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Up to 18 weeks Greater than 18 weeks Activity Change

% Change Greater than 52 weeks

Treatment Function April May April May April May General Surgery 1,992 1,961 823 832 9 1.1% 5 7

Urology 1,410 1,425 329 321 -8 -2.4% 0 1

Trauma & Orthopaedics 2,756 2,971 963 862 -101 -10.5% 17 19

Ear, Nose & Throat (ENT) 2,102 1,993 453 472 19 4.2% 0 1

Ophthalmology 2,188 2,221 369 333 -36 -9.8% 5 2

Neurosurgery 129 133 27 34 7 25.9% 0 0

Plastic Surgery 124 119 58 46 -12 -20.7% 0 0

Cardiothoracic Surgery 33 33 9 11 2 22.2% 0 0

General Medicine 654 632 96 74 -22 -22.9% 0 0

Gastroenterology 869 892 101 95 -6 -5.9% 0 0

Cardiology 1,102 1,072 105 104 -1 -1.0% 0 0

Dermatology 1,443 1,532 296 244 -52 -17.6% 0 0

Thoracic Medicine 559 573 61 73 12 19.7% 0 0

Neurology 702 684 94 107 13 13.8% 0 0

Rheumatology 453 484 71 62 -9 -12.7% 0 0

Geriatric Medicine 123 119 9 8 -1 -11.1% 0 0

Gynaecology 1,882 1,863 378 363 -15 -4.0% 1 0

Other 6,133 6,423 669 607 -62 -9.3% 4 4

Total 24,654 25,130 4,911 4,648 -263 -5.4% 32 34

BCCG Performance Summary (3 of 5)

CCG Performance Dashboard – Diagnostics Bromley CCG did not meet the 1% diagnostic waits standard in May 2018, reaching 4.3%, this was an improvement from 4.8% in April

2018. Non-compliant modalities were MRI, Audiology Assessments, Sleep Studies, Urodynamics and Endoscopies Performance for Bromley CCG at KCH in May 2018 was not achieved, with performance of 4.7%. Key drivers for performance at Kings

included downtime of ageing equipment adding pressure to the system, inadequate capacity to meet demand and delayed purchase of new cystoscopy equipment.

Performance for Bromley CCG at GSTT in May 2018 was not achieved, reaching 2.0%. Key drivers for this performance included increase in MRI referrals and insufficient capacity to meet growing demand in Sleep Studies.

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Total tests / procedures Total Waiting List Total Waiting 6+ weeks Total Waiting 6+ weeks

Test / Procedure April May April May April May April May

Imaging

Magnetic Resonance Imaging 2,129 2,267 472 422 13 4 2.8% 0.9%

Computed Tomography 2,335 2,418 602 571 6 1 1.0% 0.2%

Non-obstetric ultrasound 3,952 3,972 3,084 2,957 4 5 0.1% 0.2%

Barium Enema 38 33 2 2 0 0 0.0% 0.0%

DEXA Scan 496 437 503 456 0 0 0.0% 0.0%

Physiological Measurement

Audiology - Audiology Assessments 243 270 184 160 3 3 1.6% 1.9%

Cardiology - echocardiography 1,209 1,307 658 719 4 0 0.6% 0.0%

Cardiology - electrophysiology 2 1 0 0 0 0 0.0% 0.0%

Neurophysiology - peripheral neurophysiology 34 193 110 124 0 0 0.0% 0.0%

Respiratory physiology - sleep studies 48 86 45 42 1 2 2.2% 4.8%

Urodynamics - pressures & flows 76 126 27 23 6 5 22.2% 21.7%

Endoscopy

Colonoscopy 322 394 385 356 123 87 31.9% 24.4%

Flexi sigmoidoscopy 99 109 97 104 30 28 30.9% 26.9%

Cystoscopy 237 214 43 42 6 6 14.0% 14.3%

Gastroscopy 372 341 344 342 120 128 34.9% 37.4%

11,592 12,168 6,556 6,320 316 269 4.8% 4.3%

BCCG Performance Summary (4 of 5) CCG Performance Dashboard – A&E

A&E performance remains below the 95% national standard in May at 91.5% at the PRUH site and 79.8% trust wide.

There were sixteen 12 hour trolley breaches at KCH in May 2018 compared to twenty four in April. The key drivers for performance included - increased All Types attendances at DH compared with May 2017; increased emergency

admissions at DH compared with May 2017; continued challenges with reduced staff capacity. The table shows performance at Kings Trust and PRUH site. The trajectory is for Kings Trust.

There were six 12 hour trolley breaches in May at the PRUH There were no reported breaches against the zero tolerance mixed sex accommodation target in May

14

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 Performance - Kings 2018/19 Performance - PRUH National Standard

BCCG Performance Summary (5 of 5) CCG Performance Dashboard – Cancer & Other Standards

Performance against the cancer wait standards is reported in May with three targets being missed for Bromley patients, the same as April. The table below details the breaches against each standard

Bromley CCG met the trajectory of 80.3% for Cancer 62 Day performance in May 2018, achieving 85.4%. This was a improvement in performance from 81.5% in April 2018. From 1st April 2018 the Transforming Cancer Services Team (TCST) - London is no longer able to access the free text patient level breach reasons, which the analysis of breaches has been based on. TCST expect to be able to access coded breach information in the new cancer waits system but this isn’t expected to be until July 2018 activity. TCST will report on this as soon as it is available.

IAPT (2017/18) – Final data has now been submitted for IAPT services. We have achieved 4.2% for IAPT access against the rolling quarter target of 4.2%. Below

is a breakdown of the whole year performance:

For May 2018 the monthly target for IAPT access is 1.25%, the CCG has not met that target with performance of 1.2% (based on local data). Performance against the recovery rate standard improved in May with performance at 53.7% (50% standard).

Dementia - The recorded dementia diagnosis data from NHS Digital for May showed that Bromley CCG had achieved a rate of 68.5%, the same as April. No MRSA cases were assigned to Bromley CCG in May.

The CCG has met the monthly target for C.Diff in May with 3 cases reported against a monthly target of 6.

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Standard Target M2 Performance Breaches Trust

2 Week - Breast Symptomatic 93.0% 92.2% 5 TBC

31 Day Subsequent Radiotherapy 94.0% 93.2% 3 TBC

62 Day Screening Service 90.0% 87.5% 2 TBC

IAPT Measures Threshold Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Access Rate

1.25% (up to end 2016_17)

1.4% (2017_18 onwards)

1.40% 0.69% 0.98% 1.17% 1.53% 1.46% 1.33% 1.12% 1.02% 0.70% 1.24% 1.53% 1.43%

Rolling Quarter Access Rate - - 2.83% 3.68% 4.16% 4.32% 3.91% 3.47% 2.84% 2.96% 3.47% 4.20%

Quarter Actual Access Rate 4.20% - - 2.84% - - 4.32% - - 4.32% - - 4.20%

Plan Access Rate - - - 3.75% - - 3.75% - - 4.00% - - 4.20%

Standard (Quarterly) 4.20% - - 4.20% - - 4.20% - - 4.20% - - 4.20%

BCCG Activity Dashboard

RAG Rating – As per NHSE reporting requirements

Variance +/- 0 – 2% Variance +/-2-5% Variance +/- 5%

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Four of the six activity categories are showing red rated variances at month 2; Referrals; follow up outpatient attendances, non elective admissions and A&E attendances.

The high level activity plan values have been extracted from the CCG’s operating plan submission reflecting activity across all providers – reported variances will not necessarily correlate with contractual performance at individual providers

The majority of the year-to-date actual figures have been extracted from SUS, using the prescribed methodology published in the 2018/19 planning guidance

The referral actuals have been taken from MAR data as they are not recorded on SUS

Activity Line Month Annual

Plan YTD Plan

YTD Actual

Variance

Total Referrals (General & Acute) May 142,789 23,798 25,934 -2,136

Consultant Led First Outpatient Attendances

May 109,891 18,315 18,993 -678

Consultant Led Follow Up Outpatient Attendances

May 268,648 44,775 50,574 -5,799

Total Elective Admissions May 50,632 8,439 8,752 -313

Total Non Elective Admissions May 27,832 4,639 5,233 -594

Total A&E Attendances May 80,429 13,405 11,706 1,699

Pan London CCG Performance

The IGC has requested data relating to performance for non Bromley CCGs

The table below sets out performance against key standard for south London CCGs (data for A&E and IAPT Recovery are currently N/)

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CCG Name A&E

(Mar-18) RTT

(Apr-18)

Diagnostic Waits

(Apr-18)

Cancer 62 Day

(Apr-18)

IAPT - Recovery Rate YTD (Feb-18)

Dementia Diagnosis

Rate (Apr-18)

STANDARD 95.0% 92.0% 99.0% 85.0% 50.0% 66.7%

Bexley 85.8% 97.8% 80.9% 63.4%

Bromley 84.4% 95.7% 85.3% 68.5%

Croydon 92.9% 98.9% 94.1% 67.2%

Greenwich 88.1% 98.9% 85.1% 65.3%

Kingston 93.5% 99.7% 97.5% 61.6%

Lambeth 86.2% 99.1% 69.2% 75.4%

Lewisham 85.4% 99.4% 78.5% 72.7%

Merton 90.7% 99.3% 96.7% 71.0%

Richmond 92.8% 98.8% 92.7% 67.8%

Southwark 86.0% 98.7% 77.6% 75.1%

Sutton 90.1% 98.5% 92.0% 75.1%

Wandsworth 91.1% 99.3% 93.2% 74.9%

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Quality Premium Changes - 2018/19 (1 of 3)

The Quality Premium (QP) scheme is about rewarding Clinical Commissioning Groups (CCGs) for improvements in the quality of the services they commission. The scheme also incentivises CCGs to improve patient health outcomes and reduce inequalities in health outcomes and improve access to services. As in previous years, it is important that we retain a focus on the fundamentals of everyday commissioning. The QP scheme has been updated to align with the requirements in the 18/19 Planning Guidance on the moderation of emergency care demand. The QP scheme will continue to improve progress on key quality priorities such as cancer, mental health, RightCare and bloodstream infections.

# Indicator Name Weighting

A1 Type 1 A&E attendances 50%

A2 Non elective admissions with zero length of stay

B Non elective admissions with length of stay of 1 day or more 50%

# Indicator Name Weighting

1 Early Cancer Diagnosis 17%

2 GP Access & Experience 17%

3 Continuing Healthcare 17%

4 Mental health 17%

5 Blood Stream Infections 17%

6 RightCare 15%

Emergency Demand Management Indicators (NEW)

Quality Indicators (No Change) New indicator set for 2018/19

Constitution Gateway not applicable

Requirement Reduction to Quality Premium

The number of patients on an incomplete pathway not to be higher in March 2019 than in March 2018 -50%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer -50%

Constitution Gateway (Amended) Gateway reductions apply to Quality

indicators only

QP Construct Summary New indicator set of Emergency Demand Management (EDM) Constitution gateway reductions do not apply to EDM set No change to Quality Indicator set Constitution gateway reductions apply to Quality indicators only

Quality & Financial Gateways remain and apply to both sets Potential QP payment is £5 per head of CCG population The pot is split 75.5% EDM & 24.5% Quality In theory if both constitution gateways are failed, this year it is still

possible to achieve a significant proportion of the payment

Quality Premium 2018/19 (2 of 3)

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Quality Premium target Definition April 2019

Target Baseline

Proportion

of QP

Sub-

division of

QP

Q1, 2018/19 Q2, 2018/19 Q3,

2018/19

Q4,

2018/19

Emergency Demand Management Indicators

New for 2018/19

A1) Type 1 A&E

attendances

Total number of type 1 A&E

attendances for 2018/19 is no greater

than their total planned number of type

1 A&E attendances in 2018/19.

72,635 72,635

50.00%

25.00% TBC

A2) Non elective

admissions with zero

length of stay

Total number of actual non-elective

admissions with LOS =0 days in

2018/19 is no greater than their total

planned number of non-elective

admissions with LOS = 0 days in

2018/19.

TBC TBC 25.00%

May 2018: 7.8%

Zero LoS for PRUH

ED Admissions

B) Non elective

admissions with length of

stay of 1 day or more

Total number of actual non-elective

admissions with LOS >=1 days in

2018/19 is no greater than their total

planned number of non-elective

admissions with LOS >=1 days in

2018/19.

TBC TBC 50.00% N/A

Quality Premium 2018/19 (3 of 3)

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Quality Premium target Definition April 2019 Target Baseline Proportion of

QP Sub-division of QP

Q1, 2018/19

(or up to shown month where full

Q not yet available)

Notes

Quality Indicators

NHS Constitution Requirement

NHS Constitution Gateway Requirement The number of patients on an incomplete pathway not to

be higher in March 2019 than in March 2018 >92.0% N/A -50% N/A

May 2018: 84.39%

Trajectory: 84.0%

NHS Constitution Gateway Requirement Maximum two month (62-day) wait from urgent GP

referral to first definitive treatment for cancer >85.0% N/A -50% N/A

May 2018: 85.37%

Trajectory: 80.3%

N.B. The elements relating to Red 1 Ambulance response times and the maximum 4 hour A&E wait targets have been suspended for 2018/19

National Requirements

Early Cancer Diagnosis

Demonstrate a 4 percentage point improvement in the

proportion of cancers (specific cancer sites,

morphologies and behaviour*) that are diagnosed at

stages 1 and 2 in the 2018 calendar year compared to

the 2017 calendar year.

TBC 62%

17.00%

N/A Not currently available

Achieve greater than 60% of all cancers (specific cancer

sites, morphologies and behaviour*) that are diagnosed

at stages 1 and 2 in the 2018 calendar year.

TBC TBC N/A Not currently available

GP Access & Experience

(Published August 2018)

Achieve a level of 85% of respondents who said they had

a good experience of making an appointment, 85%

72%

achievement

in July 2017 17.00%

N/A 70%: Bromley CCG rating

69%: National Rating

Achieve a 3 percentage point increase from July 2018

publication on the percentage of respondents who said

they had a good experience of making an appointment.

75%

72%

achievement

in July 2017

N/A 2% reduction in score from July 2017 score

Continuing Healthcare

To achieve the Quality Premium for this part, CCGs must

ensure that in more than 80% of cases with a positive

NHS CHC Checklist, the NHS CHC eligibility decision is

made by the CCG within 28 days from receipt of the

Checklist (or other notification of potential eligibility).

80% N/A

17.00%

8.75% 49%

To achieve the Quality Premium for this part, CCGs must

ensure that less than 15% of all full NHS CHC

assessments take place in an acute hospital setting.

<15% N/A 8.75% 26%

Mental health Part c) Improved Access to Children & Young People’s

Mental Health Services 32% N/A 17.00% Not currently available

Blood Stream Infections

Part A) reduction in the number of gram negative blood

stream infections across the whole health economy.

10%

162 cases

Baseline vs.

2016-level

17.00%

7.65%

56 cases (target of 40.5 per Q)

April 2018: 21

May 2018: 19

June 2018: 16

Part B) reduction of inappropriate antibiotic prescribing

for UTI in primary care.

Target Value 30%

reduction or greater

(5363 prescriptions)

Baseline vs.

2016-level 3.40% 12 months to May 2018: 3520

Part C) sustained reduction of inappropriate prescribing

in primary care.

<0.965 items per STAR-

PU in 2018/19

<1.161 items per STAR-

PU in 2017/18

Baseline vs.

2016-level 5.95% 12 months to May 2018: 0.851

Local Requirement

RightCare - IAPT IAPT reliable recovery: % of people who have completed

IAPT treatment who achieved "reliable improvement" 55.0% N/A 15.00% 48.78%

Acute Provider Performance Dashboard – King’s

Kings - Denmark Hill Kings - PRUH

KCH (whole Trust)

Indicator Title Month Target

Current Month

Last month

Current Month

Last Month Month 2

CONSTITUTION MEASURES Referral to Treatment Pathways – Incomplete – SITE SPLIT NOT AVAILABLE May 92% 81.2% 80.6% Not Available Not Available 81.2% Percentage of patients waiting 6 weeks or more for a diagnostic test May 99% 99.0% 98.9% 93.9% 93.6% 96.6% Percentage of patients who spent 4 hours or less in A&E May 95% 79.7% 79.2% 91.5% 89.5% 79.8% Cancer 2 Week Wait - All cancer Two week wait May 93% 94.5% 91.6% 95.9% 93.7% 95.3% Cancer 2 Week Wait - Two week wait for Breast Symptoms May 93% 100.0% 100.0% 91.7% 84.6% 92.4% Cancer 31 Wait - First definitive treatment within one month May 96% 99.2% 93.1% 100.0% 94.3% 98.9% Cancer 31 Wait - 31 day standard for subsequent cancer treatments, surgery

May 94% 93.1% 80.0% 100.0% 87.5% 93.6%

Cancer 31 Wait - 31 day standard for subsequent cancer treatments, drug May 98% 100.0% 96.0% TBC TBC 100.0%

Cancer 31 Wait - 31 day standard for subsequent cancer treatments, radiotherapy

May 94% 100.0% 92.3% 100.0% TBC TBC

Cancer 62 Day Wait – 62 wait – GP Referrals May 85% 77.5% 82.3% 85.1% 86.9% 83.7%

Cancer 62 Day Wait – 62 wait – Screening May 90% TBC TBC TBC TBC 92.7%

Cancer 62 Day Wait - 62 day wait following consultant decision to upgrade

May No current operational

standard 100.0% 100.0% 100.0% 100.0% 80.3%

Mixed Sex Accommodation (MSA) breaches May 0 0 0 0 0 0 Number of RTT pathways waiting longer than 52 weeks – SITE SPLIT NOT AVAILABLE

May 0 331 305 Not Available Not Available 331

A&E – 12 hour trolley waits May 0 10 6 6 18 16 Urgent Operations cancelled for a 2

nd time May 0 0 0 0 0 0

Ambulance Handover delays – 30 minutes YTD May 0 292 141 111 58 403 Ambulance Handover delays – 60 minutes YTD May 0 5 2 58 43 63

21

Acute Provider Performance Dashboard – GSTT & L&G

Guy’s & St Thomas’ Lewisham & Greenwich

Indicator Title Target

Month

Current Month

Last Month

Q4 Current Month

Last Month

Q4

CONSTITUTION MEASURES Referral to Treatment Pathways – Incomplete 92% May 89.8% 89.1% TBC May 87.0% 88.2% TBC Percentage of patients waiting 6 weeks or more for a diagnostic test 99% May 98.2% 97.9% TBC May 99.6% 99.4% TBC Percentage of patients who spent 4 hours or less in A&E 95% May 86.0% 86.5% 88.2% May 90.1% 87.6% 84.1% Cancer 2 Week Wait - All cancer Two week wait 93% May 96.6% 97.0% 98.6% May 96.5% 94.7% 96.3% Cancer 2 Week Wait - Two week wait for Breast Symptoms 93% May 90.0% 76.0% 93.4% May 96.5% 91.2% 91.6% Cancer 31 Wait - First definitive treatment within one month 96% May 94.2% 95.7% 92.9% May 97.9% 99.1% 98.4% Cancer 31 Wait - 31 day standard for subsequent cancer treatments, surgery

94% May 80.0% 91.7% 91.4% May 100.0% 100.0% 97.1%

Cancer 31 Wait - 31 day standard for subsequent cancer treatments, drug 98% May 98.1% 98.5% 98.8% May 100.0% 100.0% 100.0%

Cancer 31 Wait - 31 day standard for subsequent cancer treatments, radiotherapy

94% May 95.3% 94.2% 94.2% May TBC TBC TBC

Cancer 62 Day Wait - Two month urgent (GP referral) 85% May 74.1% 72.7% 72.1% May 82.4% 85.4% 80.7%

Cancer 62 Day Wait - 62 day wait (Screening service) 90% May 100.0% 100.0% 57.9% May 100.0% 88.9% 90.5%

Cancer 62 Day Wait - 62 day wait following consultant decision to upgrade No current operational

standard May 54.4% 61.7% TBC May 77.8% 55.6% TBC

CONSTITUTION SUPPORTING MEASURES Mixed Sex Accommodation (MSA) breaches 0 May 11 0 0 May 0 0 8

Cancelled Operations – 28 day rule 0 May 42 May 0

Number of RTT pathways waiting longer than 52 weeks 0 May 16 8 27 May 0 0 0

A&E – 12 hour trolley waits 0 May 0 0 0 May 0 0 40

Urgent Operations cancelled for a 2nd

time 0 May 0 0 0 May 0 0 0

Ambulance Handover delays – 30 minutes 0 May N/A 121 N/A May N/A 49 N/A

Ambulance Handover delays – 60 minutes 0 May N/A 0 N/A May N/A 28 N/A

22

Mental Health - LB Bromley commissioners have been attending monthly CMB and the aim to make these performance meetings more integrated. An Interim Board (LBB) has been set up to review the LBB elements of the Oxleas Contract as there is currently no clear reporting on KPIs in place and look at shadow performance indicators for this year. As it stands the data currently provided from a commissioning perspective does not include narrative or highlight any gaps in provision or unmet need – this will need to be explored with Oxleas which we hope will be presented at future CMB Meetings.

DToC - There were no DToC at the end of June. Through early identification of a ‘Possible Delayed Discharge’ the Weekly Mental Health DToC meetings facilitate the pathway between social care, housing and residential services and have had a positive impact in reducing numbers.

EIP – whilst the number of new cases and caseload decreased in June the overall YTD/rolling performance for new cases is on target. Bromley EIP service has been sighted as one of the best in London and NHSI will be visiting imminently for shared learning/good practice.

Memory Service - referral to assessment consistently achieving target for the last 6 months. Assessment to diagnosis is proving more of a challenge with waits exceeding 6 weeks and requires further capacity and demand work to be undertaken. Caseloads are stable over the year with some fluctuations at present and are higher than planned.

The Dementia Diagnosis Rate currently sits at 69.2% in June 2018 and continues to exceed the 18/19 national local target – Bromley are on target to reach the local target of 70%. Once the local target achieved will be looking to implement this as the target going forward.

Primary Care Plus (PCP) – In May there had been a significant improvement in performance for the service where the wait time decreased to 16, however in June this has increased to 25 days due to one patient who waited more than 14 days – on average the wait time is still above target at 23.5 days. Oxleas reported Capacity issues due to staff on sick leave and unable to recruit to these posts – Oxleas will be required to provide a Recovery Plan.

ADHD and ASD - performance has tended to fluctuate but it is anticipated that targets will be met by the end of the financial year. Wait Times are not currently captured on the dashboard and this has been requested as well as the Waiting List numbers for future commissioning packs.

23

Oxleas Performance Summary

Oxleas Contract Monitoring – KPI

24

Bromley 2018/2019 Contract: Bromley Commissioner Pack Highlights ACUTE INPATIENTS Target June 2018 Performance May 2018 Performance April 2018 Performance CBD OBD % CBD OBD % CBD OBD % AMH Bed Days (52 beds) - 1560 1388 89% 1612 1,397 87% 1560 1295 83%

OPMH Acute Inpatient Bed Days (25.26 beds) - 758 482 64% 783 591 75% 758 723 95%

REHAB. INPATIENTS - Barefoot Lodge Target CBD OBD

In-month Performance

CBD OBD In-month

Performance CBD OBD


Bromley Bed Occupancy (5 beds) - 150 129 86% 150 139 93% 150 90 60%

Delayed Discharges of Care (Target: <7.5%) Target

Total Delay Days

Total OBD's In-month

Performance Total Delay

Days Total OBD's


Total Delay Days

Total OBD's In-month

Performance

AMH <7.5%; <3.5% from Sept-2017

11 1388 0.80% 6 1397 0.40% 94 1295 7.30%

OPMH <7.5%; <3.5% from Sept-2018

0 482 0.00% 7 591 1.20% 28 723 3.90%

MH Liaison Team Target In-month Performance In-month Performance In-month Performance

80% seen within 2 Hrs 80% of referrals reviewed within 2 hours

77% 84% 79%

Readmissions within 28 Days Target In-month Performance In-month Performance In-month Performance % Readmissions - 7.60% 3.70% 8.90%

AMH Acute Admission Gatekeeping Target

Total Qualifying

Admissions

Total Gatekept


Total Qualifying

Admissions

Total Gatekept


Total Qualifying

Admissions

Total Gatekept


Bromley Wards (>95%) >95% of eligible admissions

57 56 98% 45 45 100% 41 39 95%

EIP TEAM Target

In Month Activity

Average Expected


In Month Activity

Average Expected


In Month Activity

Average Expected


EIP Caseload - 93 76 122% 107 76 141% 91 76 120% EIP New Cases - 4 3 133% 8 3 267% 3 3 100%

Waiting Times: 50% seen within 2 weeks of referral - 4 6 67% 3 4 75% 3 5 60%

Memory Service Waiting Times Target Average Wait (weeks)


Average Wait (weeks) In-month

Performance Average Wait (weeks)


Referral to Assessment Waiting (<6 weeks) < 6 weeks from receipt of referral

5 120% 6 100%

6 100%

Assessment to Diagnosis Waiting Times - 10 60% 12 50% 12 50%

Bromley CCG Dementia Diagnosis (DD) % Target

Total Prevalence

66.7% Target

Month Actual Total

Prevalence 66.7% Target

Month Actual

Total Prevalence

66.7% Target

Month Actual

Year End target to achieve >66.7% DD Rate

National: >66.7% 4109 2741 2843 4103 2737 2811 4096 2732 2805

SEL: >70.0%

PCP Assessment Waiting Times Target Month: Average Wait

(Days) In-month

Performance Month: Average Wait

(Days) In-month

Performance Month: Average Wait

(Days) In-month

Performance

AMH: Average Waiting Time for OFFERED Assessment (Target = 14 days):

Average WT within 14 days

In Development

AMH: Average ACTUAL Wait Actual Average WT 25 56% 16 88% 24 58%

ASD & ADHD Assessment Data Target Target Actual


Target Actual In-month

Performance Target Actual


ADHD (60 Contracted Assessments per annum) 5 Assessments PCM (60/12 months)

5 5 100% 5 5 100% 5 3 60%

ASD (52 Contracted Assessments per annum) 4.3 Assessments PCM (52/12 months)

4.3 3 69.20% 4.3 2 46.20% 4.3 3 69.20%

Oxleas - CAMHS Performance (1 of 2)

CAMHS Referrals Wait (weeks) from Referral to First Assessment

CAMHS Caseload Attended Contacts

25

0

20

40

60

80

100

120


2016/17

2017/18

2018/19

0

2

4

6

8

10

12

14

750

800

850

900

950

1000


2016/17

2017/18

2018/19

0

200

400

600

800

1000


2016/17 2017/18 2018/19

Oxleas - CAMHS Performance (2 of 2) Tier 4 Admissions

The CAMHS data has been refreshed to April 2018 It is noted, however, that CAMHs case loads have

increased over the corresponding time frame. This may be a result of an increase in severity of presenting need and/ risk or the current pathway. In June there has been a steady reduction in case loads due to close partnership working between Tier 2 provider and Oxleas. The provider has invested additional resources for initial assessment to CAMHs service. This initiative will support the reduction waiting times. Furthermore referrals into specialist CAMHs service has reduced in comparison to previous year averaging 45 referrals accepted. Discussion in regards to high caseload are in progress.

It has been observed crisis presentation at A/E for self harm and OD has decreased .

Activity from 1st December 2017 , now only reflects CCG activity (Tier 3), hence the reduction in reported referrals from that date. Both providers are required to submit minimum data sets. CCG are in the process of analysing both minimum data sets and tracking individuals outcomes through the referral journey. This piece of work is ongoing. Dialogue is due to convene to enhance dataset to include vulnerable groups.

Tier 4: Tier 4 (inpatient) CAMHS services are not provided by Oxleas, and are commissioned by NHS England at a National level to South London and Maudsley trust. The data shown in this report is for information only.

26

0

1

2

3

4

5

6


2016/17 2017/18 2018/19

Primary Care Overview

PMS Premium Services. Practice Development Plans for both wave 1 and 2 practices are being reviewed by the PDP Panel each month, which includes CCG and LMC representation. To date, 43 practices have submitted plans; noting that two practices have opted out of providing the PMS Premium. The deadline for all revised plans and clarifications (where plans were not fully approved at first submission) was 30th June 2018 but a further ‘mop up’ exercise to get all plans fully approved will conclude in mid August. A reflection piece on this element of Bromley CCG’s PMS commissioning activity together with analysis of themes across the plans

commenced in June and learnings will be shared with the PCSG/PCCC, SEL colleagues, LMC and feed into the PCNA from September 2018

Primary Care Needs Assessment and Strategy. Dr Agnes Marossy is continuing her work on the Bromley Primary Care Needs Assessment. The Clinical Reference Group met on 27th Feb and 26th June with GP practice staff and CCG colleagues to discuss the workforce issues facing general practice and how best to address them, and how workload impacts profoundly on resilience. Data gathering for the second annual workforce survey is now complete from 100% of practices and findings have been presented to the PCSG. This has shown that the numbers of GPs have decreased since last year; and a quarter of salaried GP posts are vacant. Other deep dive work is ongoing around DNA rates. The PCNA is now moving towards an implementation stage, working with two collaborations of practices (Penge and Crays) and working

across Bromley on new role skill mix and workload filtering. A Primary Care Strategy is being developed that will set out how we use the PCNA to guide the CCG work programme, GPFV spending and decision-making in coming years.

Practice engagement. The Primary Care team has a named team member for each practice as the first point of contact for that practice and

to undertake quarterly practice visits. Progress with practice visits over the past year has been: 91% of practices were visited in Oct-Dec 2017 89% of practices were visited in Jan-Mar 2018 96% of practices were visited in April–July 2018

A reflection on GP practice visits and wider engagement by the primary care team went to PCSG in April 2018 and IGC in July for discussion

Review of medical support to care homes (Visiting Medical Officer scheme). Following an extensive engagement process with all local stakeholders, we are now implementing long term, improve commissioning arrangements by: Extending the existing VMO arrangements to 31st March 2019 Implementing a new commissioning model for enhanced support to care homes. Through engagement at GP cluster meetings, with

Bromley LMC and at the CCG’s CEG and PCCC meetings, we have now selected an APMS contract model Investing funding from the primary care delegated budget and Better Care Fund to provide the required level of support Completing a provider market engagement on 13th July 2018 Launching the procurement on 13th August, to run until 1st October 2018, after which time the bids will be evaluated and a successful

bidder selected ahead of mobilisation during January-March 2019 and a ‘go live’ start date of 1st April 2019 27

Primary Care (1 of 4)

Primary Care Overview cont.

GP Forward View: Following a local and south east London engagement and development process against short timescales, Bromley CCG has had our two bids for the £2m SCF funding approved. The purpose of this funding is to increase at scale working across general practice to improve resilience, and to promote integration with the wider health system through partnership working. Bromley's bids were: Improving collaboration of practices within localities, supporting practice mergers where there is the appetite and developing Primary

Care Homes by integrating community, voluntary and other services into general practices Increase the pace, scale and depth of a Primary Care Academy for Bromley, building on early developments to include new ways of

working, portfolio opportunities and workforce training Funding should be released in summer 2018, following which time the CCG (and CEPN for project 2) will discuss with local practices, the LMC and other stakeholders their priorities for investment. A delivery structure will also need to be put into place.

Winter resilience schemes for 2017/18: The primary care winter resilience additional schemes for 2018/19 will be additional appointments in the GP access hubs, and

additional ANP home visits. We are working with providers to mobilise these services, and the details of numbers and spread of appointments and general practice/patient access to these will be finalised in September 2018 These will link with the wider winter resilience plans being put into place by the Urgent Care team, including the Hospital at Home

model The housebound flu vaccination programme for 2018/19: Planning meetings are being arranged with Bromley Healthcare, LMC, GP and

Practice Manager representatives and the CCG from May up to winter ‘Liaison GPs’ have been recruited to the Discharge to Assess team at the PRUH. They are undertaking ‘discharge optimisation’ ward

rounds pre-discharge and visiting patients placed in interim care home beds soon after discharge to provide general medical support for the patient

28



Out of Hours Primary Medical Services

Primary care access hubs continue 4pm-8pm opening on weekdays and 8am-8pm opening at weekends (therefore, 8-8, 7/7 has been in place since late January 2017)

Utilisation rates remain high (94% utilisation rate in July 2018) and we are actively tackling the 10% DNA rate with the implementation of text message reminders, which we anticipate will have a particular impact on the weekend appointments.

Utilisation of weekend appointments has grown significantly in recent months, with Saturday utilisation at 97% (Jan-June 2018) and Sunday utilisation at 96%.

The contract with the GP Alliance for the Access Hubs has been extended to 30th September 2019, as the CCG is undertaking a review of all urgent care services, including Access Hubs, Urgent Care Centre's and 111

Bromley’s current Out of Hours GP service runs from 6.30 pm to 8 am, with 24 hour cover at weekends and bank holidays, to ensure

access to Primary Care is available

29




E-Referrals – Outpatient Utilisation

The table below sets out Bromley’s outpatient e-referral utilisation rates over the course of 2017/18 and 2018/19 YTD. Bromley CCG has the fourth highest OP utilisation rates in South East London as of May 2018.

Numbers are draft until published in NHS England's quarterly IAF reports.

The May 2018 data is from the Weekly CCG Utilisation Report from Week ending 27th May 2018.

30

CCG Name Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18

NHS BEXLEY CCG 60.0% 55.4% 58.8% 61.7% 62.1% 67.3% 63.6% 69.0% 63.3% 73.6% 77.3% 77.3% 82.8% 90.4%

NHS BROMLEY CCG 60.6% 66.2% 71.4% 66.8% 68.0% 77.4% 86.3% 89.7% 84.8% 85.2% 84.0% 81.9% 72.4% 78.7%

NHS GREENWICH CCG 46.8% 49.2% 49.0% 53.0% 49.5% 50.2% 45.7% 55.6% 55.5% 67.1% 72.0% 72.1% 72.3% 82.3%

NHS LAMBETH CCG 23.2% 21.7% 23.9% 26.3% 30.3% 43.9% 45.2% 48.9% 49.2% 52.9% 55.5% 58.9% 63.9% 67.2%

NHS LEWISHAM CCG 49.9% 50.8% 50.8% 49.0% 49.9% 47.9% 49.8% 50.6% 55.7% 67.2% 75.7% 79.4% 80.2% 84.2%

NHS SOUTHWARK CCG 26.4% 28.7% 29.9% 30.6% 32.5% 41.5% 45.4% 47.1% 49.9% 54.1% 57.6% 59.5% 63.9% 68.3%

CCG Improvement & Assessment Framework (IAF) Throughout the year we are required to demonstrate delivery against the 2017/18 CCG improvement and Assessment Framework established by NHS England & BCCG achieved an overall Good for period ending 2017/18. . CCG assessment ratings are derived from CCGs’ financial performance, an assessment of the quality of CCG leadership and a CCG’s performance against 48 IAF indictors related to the NHS Constitution; other core performance, health outcome and transformation objectives .

The frameworks covers indicators in four domains:

Better health: how the CCG is helping the health and wellbeing of its populations and reducing demand.

Better Care: focuses on care redesign, performance measured against constitutional standards and outcomes.

Sustainability: how the CCG is remaining in financial balance, securing good value for patients and the public from the money it spends.

Leadership: the quality of leadership within the CCG, the quality of its plans, how the CCG works with partners and governance arrangement.

Q4 Performance Release

This shows BCCG performance against the worst, middle & interquartile range in England.

Although the overall rating for BCCG was good there are a number of areas identified as “worst quartile in England” when compared to England performance and are set out in the table below.

Area Period England Comparison Area of Responsibility

Leadership

1. Progress against the Workforce Race Equality Standard

2017

204/207

Organisational Development

Bettercare

1. Cancer patient experience

2. IAPT Access

3. Completeness of the GP learning Disability register.

4. Dementia post diagnostic support.

5. A& E admission, transfer & discharge from A & E within 4 hours

6. Primary Care workforce

7. 18 weeks RT

2016

2018 02

2016/17

2016/17

2018 03

2017 09

2018 03

159/207

157/207

200/207

167/207

186/207

203/207

180/207

Planned Care

Contracts

Primary Care

Primary Care

Urgent Care

Primary Care

Planned Care

CCG 2017/18 CCG IAF rating (provisional) 2017/18

overall

2016/17

overall Finance (141b) Leadership (165a)

NHS Bromley CCG Green Green Good Good

31

NHS Bromley CCG

Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend

R 102a % 10-11 classified overweight /obese2014/15 to

2016/1730.4% 5/11 46/207 G R 121a High quality care - acute 17-18 Q4 62 5/11 60/207

103a Diabetes patients who achieved NICE targets2016-17 42.6% 3/11 34/207 G R 121b High quality care - primary care17-18 Q4 65 6/11 149/207

103b Attendance of structured education course2016-17 (2015

cohort)7.5% 5/11 75/207 B R 121c High quality care - adult social care17-18 Q4 62 6/11 72/207

R 104a Injuries from falls in people 65yrs +17-18 Q3 1,979 5/11 95/207 R 122a Cancers diagnosed at early stage2016 49.8% 9/11 152/207

R 105b Personal health budgets 17-18 Q4 54.63 1/11 30/207 G R 122b Cancer 62 days of referral to treatment17-18 Q4 82.8% 7/11 109/207

R 106a Inequality Chronic - ACS & UCSCs17-18 Q3 1,088 1/11 11/207 G 122c One-year survival from all cancers2015 73.9% 5/11 32/207

R 107a AMR: appropriate prescribing2018 01 0.859 1/11 24/207 G 122d Cancer patient experience 2016 8.6 11/11 159/207

R 107b AMR: Broad spectrum prescribing2018 01 8.7% 2/11 104/207 R R 123a IAPT recovery rate 2018 02 51.6% 6/11 97/207

108a Quality of l ife of carers 2017 0.62 7/11 144/207 G R 123b IAPT Access 2018 02 3.5% 7/11 157/207

Sustainability Period CCG Peers England Trend G R 123c EIP 2 week referral 2018 03 75.5% 7/11 108/207

R 141b In-year financial performance17-18 Q4 Green #N/A #N/A 123dMH - CYP mental health (not available) #N/A #N/A

R 144a Utilisation of the NHS e-referral service2018 02 84.1% 1/11 29/207 ¢ n/appR 123f MH - OAP 2018 02 47.6 7/11 98/207

Leadership Period CCG Peers England Trend 123e MH - Crisis care and liaison (not available) #N/A #N/A

R 162a Probity and corporate governance17-18 Q4 Fully Compliant #N/A #N/A G R 124a LD - reliance on specialist IP care17-18 Q4 61 9/11 125/207

R 163a Staff engagement index 2017 3.76 8/11 123/207 G 124b LD - annual health check 2016-17 56.9% 2/11 45/207

R 163b Progress against WRES 2017 0.20 10/11 204/207 ¢ n/app124c Completeness of the GP learning disability register2016-17 0.28% 11/11 200/207

R 164a Working relationship effectiveness17-18 77.36 3/11 24/207 G 125d Maternal smoking at delivery 17-18 Q3 5.7% 2/11 33/207

R 166a CCG compliance with standards of public and patient participation2017 Green Star G R 125a Neonatal mortality and stil lbirths2016 4.0 5/11 76/207

R 165a Quality of CCG leadership 17-18 Q4 Green #N/A ¢ n/app125b Experience of maternity services2017 82.2 5/11 124/207

Key ¢ n/app125c Choices in maternity services 2017 59.8 7/11 124/207

Worst quartile in England G R 126a Dementia diagnosis rate 2018 03 68.2% 3/11 99/207

Best quartile in England R 126b Dementia post diagnostic support2016-17 76.7% 10/11 167/207

Interquartile range G R 127b Emergency admissions for UCS conditions17-18 Q3 1,899 2/11 36/207

R 127c A&E admission, transfer, discharge within 4 hours2018 03 74.7% 10/11 186/207

G R 127e Delayed transfers of care per 100,000 population2018 03 3.8 1/11 8/207

R R 127f Hospital bed use following emerg admission17-18 Q3 522.8 5/11 142/207

* Patients diagnosed in 2015; # Patients diagnosed in 2014 G R 105c % of deaths with 3+ emergency admissions in last three months of l ife2017 5.57% 7/11 109/207

G 128b Patient experience of GP services2017 83.3% 5/11 142/207

B 128c Primary care access 2018 01 100.0%

R 128d Primary care workforce 2017 09 0.78 11/11 203/207

G R 129a 18 week RTT 2018 03 82.9% 11/11 180/207

¢ n/appR 130a 7 DS - achievement of standards2017 2

G R 131a % NHS CHC assesments taking place in acute hospital setting17-18 Q4 3.6% 1/11 64/207

¢ n/appR 132a Sepsis awareness 2017 Amber

2017/18 Year End Rating: Good

Note: There are no data for NHS Manchester CCG (14L) for the fol lowing indictors : 121a, 121b, 121c,

122d, 125b, 125c, 163a, 163b and 164a

32

BCCG Better Care Fund 2017 – 2019

33

The Better Care Fund 2017 -19 Local Plan was formally agreed by the Health and Wellbeing Board (HWB) on 7th September 2017 and approved by NHS England on 27th October 2017. The Better Care Fund (BCF) grant is ring fenced for the purpose of pooling budgets and integrating services between BCCG and the Local Authority (LA). In order to ensure that local areas are meeting the standard conditions of the BCF it is a requirement to report back to NHS England on a quarterly basis on activity against the planned performance metrics. The BCF has four performance metrics these are:

Reduction in Non Elective Admissions (NEAs) - Data for this metric is sourced from SUS. In 2017/18 there was a total of 25,722 NEAs, which was a 4.15% (1113) reduction against the plan, and this trend continues in 2018/19 YTD where the reduction is 4.15% (273) against the plan.

Rate of Residential Admissions (people aged 65+ )– Data is sourced from the LA, the numerator is the number of admissions and the denominator is the estimated number of Bromley residents aged 65+ yrs and multiplied by 100,000 to establish the rate. The estimated 65+ yrs population size for Bromley in 2017/18 (58,183) and 2018/19 (58, 798) are based on the 2014 Population Projections for Local Authorities in England. Performance shows that in 2017/18 Bromley exceeded its target of 425. 2018/19 Q1 shows improved performance on the same period last year.

Reablement (%)- Data is sourced from the LA. In 2017/18 the percentage of people still at home 91days after discharge was 93.5% (392/419) exceeding the planned target of 90%. 2018/19 Q1 figures are available only for April as there is a 91 day lag in the data being published, this will be updated in Q2.

Delayed Transfers of Care (DTOC) - Performance in 2017/18 was 26.9% (1275) above the year target. 2018/19 YTD performance is 18.1% (167) below the target.

Metric Target

2017/18 2018/19

Q1 Q2 Q3 Q4 Q1

Q2

Q3 Q4

Reduction in Non Elective Admissions This metric has a target for each quarter

Plan 6,486 6,640 6,929 6,780 6,589 6,659 6,956 6,805

Actual 6,587 6,395 6,614 6,126 6,316

Rate of Residential Admissions: Rate of permanent admissions to residential care per 100,000 population (65+) This metric has an annual target. Actual figures are in brackets against the rate per 100,000 population.

Plan Rate

425 (247) 425 (247)

Actual Rate

95.9 (56)

195.3 (114)

298.2 (174)

387.1 (225)

76.73 (46)

Proportion of Reablement (%): Proportion of older people (65+) who were still at home 91 days after discharge from hospital into reablement or rehabilitation services This metric has an annual target and there is 91 day lag to this data being published. Actual figures in brackets.

Plan 90.1% (446/495) 90.1% (445/495)

Actual 92.6% (88/95)

93.0% (172/185)

92.1% (269/292)

93.5% (392/419)

100% (19/19)

Apr

Delayed Transfers of Care (DTOC) - delayed days This metric has a target for each quarter

* The actual DTOC figure was utilised in the BCF plan document.

Plan 1,484* 1,321 991 928 923 919 914 910

Actual 1,484 1,446 1,594 1,475 756

Quality Report

Quality Report Summary Page 35

Kings – Quality Dashboard Page 36

Kings Exception Report Page 37

Kings CQRG Page 38

Oxleas – Quality Dashboard Page 40

Oxleas Exception Report Page 41

Oxleas Bromley Borough CQRG Page 42

BHC CQRG Page 44

BHC Safer Care Presentation Page 46


BCCG QAS Page 54

Authors: Sonia Colwill Director of Quality, Governance & Patient Safety

Gill Holden Head of Quality

Quality Report Summary

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Bromley CCG’s primary responsibility is to ensure providers are delivering safe, high quality, clinically effective services, whilst providing patients with the most positive experience possible. Each provider is required to attend a Clinical Quality Review Group (CQRG) which is a sub-committee of the Contract Monitoring Board of each provider. This is run by the CCG and, in Bromley, supported by NEL Commissioning Unit for acute providers. The CQRG is responsible for receiving data and information from the Trust for scrutiny and challenge. This data is triangulated with information available to the CCG about the provider in the form of complaints or themes via our Quality alert system and also with soft intelligence from patient feedback or through external agencies such as Healthwatch. External scrutiny is provided through CQC inspections and, in the case of Foundation Trusts, through NHS Improvement. Data for this part of the report is taken from: KCH Board reports, KCH website, Oxleas NHS FT, Bromley Healthcare, FFT, CQC and NHS Improvement. There is a vast amount of quality data available and this report seeks to include relevant, up to date and useful information. The report will be developed continually to provide a comprehensive picture of quality within our provider services. The committee is asked to consider any other data and analysis they would like to have present in the quality section of this report.

Provider Quality Dashboard KCH May 2018

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4 Kings - Denmark Hill Kings - PRUH

Clinical Effectiveness Month Target

MAY APRIL Month Target

MAY APRIL

(SHMI) latest current data is Dec 2017 <100 85.6 - <100 99.1 -

Emergency Re-admissions within 30 days 5.9% 4.6% 5.2% 5.9% 7.0% 7.5%

Patient Safety

MRSA – Number of Cases 0 0 0 0 0 0

C-Difficile – Number of Cases 5 2 6 3 0 0

Never Events 0 3 0 0 0 0

Safeguard Adults Level 2-5 80% 82.8% 81.8% 80% 84.6% 81.9%

Safeguard Children Level 3 80% 74.9% 78.5% 80% 82.0% 75.0%

Serious Incidents 0 12 12 0 11 11

Hospital Acquired Pressure Ulcers – grade 3 or 4 0 1 2 0 0 1

Falls resulting in Moderate harm 0 1 1 0 3 0

Falls resulting in Major harm 0 1 1 0 5 3

VTE Risk Assessments 95% 98.3% 97.0% 95% 91.8% 88.9%

Patient Experience Cancelled Operations – 28 day rule 0% 32.7% 30.4% 0% 11.4% 0.0%

Outpatient Cancellations < 6 weeks notice (hosp) 2775 3611 3064 1777 2395 2022

Complaints 52 52 52 26 30 30

Complaints Response > 25 working days 35 33 29 15 15 5

Staffing

Staff Vacancy Rate - DATA FROM IPR (M1) REPORT 5-8% 9.2% march 9.1% feb 5-8% 11.9% march 11.3% feb

Mandatory & Statutory Training & Induction TRUSTWIDE DATA FROM

IPR (M2) REPORT

80% 83.4% 83.7% 80% 83.4% 83.7%

Governance

SINGLE OVERSIGHT FRAMEWORK– TRUST WIDE 1

NO POTENTIAL SUPPORT NEEDED

4 SPECIAL MEASURES

4 SPECIAL MEASURES

1 NO POTENTIAL

SUPPORT NEEDED

4 SPECIAL MEASURES

4 SPECIAL MEASURES

CQC status – “Requires Improvement” Note: This dashboard shows a selected number of indicators, however, the Trust report on a significant number of other indicators which BCCG have oversight via CQRG.

Safe

Mortality: delay in publication of mortality data by ONS means the latest data is for December – Trust wide position is 90.9. (DH 85.6: 253 fewer deaths than expected; PRUH 99.1: 14 fewer deaths than expected by the SHMI model). Trust continues to undertake monthly ward level mortality monitoring including case reviews and looking at outcomes in terms of avoidable/unavoidable deaths with a process in place for escalation of findings.

Infection control: 2 C.diff cases at DH. A task and finish group will be established to develop and implement reduction strategies

Never Events and Serious Incidents: 3 NEs declared at DH: overdose of insulin, retained wire, wrong side angiogram. 30 SIs in total: PRUH 13, DH 17 - investigations in progress with finding presented at QARC

Falls and Pressure Ulcers: decrease in the number of grade 3 & 4 HAPUs reported in May - the Trust reported one incident at DH. Trust reported 221 falls incidents with an increase to 134 at DH and a decrease to 87 at PRUH. DH reported 1 fall resulting in moderate harm and one fall resulting in major harm. PRUH reported 3 falls resulting in moderate harm and 5 falls resulting in major harm

Responsive

Complaints: 82 complaints in May (DH 52 and PRUH 30). Number of complaints not responded to within 25 days at DH is 33 and PRUH 15 which is an increase is within the monthly target. There is an organisational emphasis on quality and timeliness of complaint handling reinforced by the Board.

Care

FFT: Trust wide ED rating ‘recommended’ remains static and’ not recommending’ has reduced from 10% to 8.6%.

Inpatient FFT ‘recommended’ slightly decreased to 94% (DH 95% PRUH 94%); ‘not recommended’ increased slightly to 1.8%

Outpatients FFT ‘recommended’ slightly increased to 90% (DH remained static at 90% and PRUH improved to 89%). Beckenham Beacon and Dental outpatients increased to 93%. Outpatient transformation work continues with a planned patient workshop to test Trust’s new customer care standards, information boards and overall service standards.

Well-led

Appraisal rate increased to 50.9%. Statutory and Mandatory compliance decreased slightly to 83.3%. Sickness rate is 2.8% (a decrease of 0.1% - the fourth month reduction). Trust actively manages both long and short term sickness cases with oversight from directorate teams and workforce. Currently no April or May data for vacancy rates as budget FTE have not yet been released

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KCH Dashboard Exception Report May 2018

Matters Arising Business plan to increase I-Mobile at PRUH was not accepted at investment board, revised plan submitted. Update will be

provided at next CQRG Case review of high/serious complaints: Complaints received throughout the year are categorised by upheld/not upheld. There may be a spike in events complained

about but no spike in the number of incidents where patients came to harm. Issue of discharge is a recurring them; discussions around pathway of care acknowledge that getting integrated care right will

have an impact on discharges. Complaints team are working with Transformation team Main agenda item – CIP CIP development summary process is standard: used by all Trusts. Engagement does not involve patient reps but the Trust suggested ways that patient/carer involvement could be built in –

possibly at patient experience committee, members events or “How are we doing?” Trust survey. Main agenda item – Infection Control Outbreak of Candida Auris (CA) – particularly in Cardiac, with strong clinical leadership to address. CA does not cause high

mortality or morbidity but spreads and requires a concerted effort to control. Aim is to close ward; deep clean and then reopen. Actions also include staff awareness and re-emphasising the importance of hand washing

Dual strain of CPE identified in a transplant patient (DH) Standing items M1 Performance Report (Safety) ED at PRUH & DH are utilising ED safety checklist. PRUH undertake safety huddles 8 x a day to ensure staff are aware of all

patients. Children’s ED at DH use the checklist from admission and documentation review shows daily completion of the checklist. Adult ED is less responsive. This needs to be sustained practice in adult ED.

4 hour performance at PRUH is improved: DH had a difficult the weekend leading up to CQRG, partially due to UCC having 8-hour waits despite being staffed

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KCH CQRG June 2018 (1 of 2) DRAFT

Standing items Diagnostic waits – compliance with cancer but non-compliance with general diagnostic rates. Endoscopy unit at PRUH has long

waits. Trust to direct patients to Croydon University Hospital and Shirley Oaks - new provision yet to commence Trust looking into Falls classification and working with NHSI as nationally there is little consistency around this. Once report is

completed the Trust will comply Bring Forward: Trust agreed

to validate on antibiotic stewardship at PRUH to validate data on VTE at PRUH to present formal report regarding medical staffing at PRUH

AOB Trust to present a plan on how they will be addressing patients “lost to follow up” to CQRG. Date of next meeting: 17th July 2018 Safer Care Forum: Additional Information on Falls Actions at PRUH

The bedrails policy has been updated and is awaiting review by Director of Nursing at PRUH.

The bedrails risk assessment on EPR is to be changed to mirror the one previously used by the Trust (by end of August).

Recent documentation and environmental audit carried out on 100 patients chosen at random (on 10 wards) showed disappointing results in some areas. Results were sent out of relevant ward managers, matrons and physiotherapy leads. However, the results may have been affected by the transition from paper to EPR, therefore a re-audit is planned for Sept/Oct.

Recording of lying and standing blood pressure on EPR has improved and will continue to be monitored by the falls team via audit.

A new falls risk assessment and care plan is to be established on EPR once the content has been reviewed by the Directors of Nursing.

Work with EPR continues to establish a falls medication review alert which will be flagged to the doctors when prescribing medication to patients on admission. The process has been devised and a pilot will take place on a medical ward at PRUH.

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KCH CQRG June 2018 (2 of 2) DRAFT

Quality & Safety Indicator Description Target Trust wide inc

Forensics

Bromley May

Bromley April

Serious Incidents 0 8 2 4

7 Day follow ups – patients discharged on new CPA 95% 100.0% 100.0% 100.0%

48hr post-discharge follow-up 100% 96.8% 100.0% 93.3%

Safe staffing levels – Registered (actual against planned) >100% 96.1% 90.3% 89.3%

Safe staffing levels – Unregistered (actual against planned) >100% 118.7% 114.2% 119.1%

Number of reported medication errors - 49 2 4

Vacancy rate <14% 11.0% 12.9% no data

Complaints received 0 23 5 5

Delayed Transfers of Care <7.5% 3.5% 2.5% 6.1%

Referral to treatment for Allied Health Professionals 95% 98.1% 98.0% 95.6%

4 Must Do’s – Treated with Dignity and Respect 90% 99.1% 99.3% 93.8%

CPA Reviews at 6 months 95% 95.1% 93.6% 93.0%

Compliance with S132 of the Mental Health Act 100% 88.8% 82.0% 96.4%

Compliance with S58 of the Mental Health Act 100% 100.0% 100.0% 100.0%

% of Early Intervention Psychosis (EIP) referrals seen within 2 weeks 50% 64.7% 66.7% 66.7%

Supervision completeness >80% 81.0% 80.0% 82.0%

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Provider Quality Summary Oxleas May 2018

Safe Staffing levels - Registered and Unregistered (Actual against planned) Registered staff fill rate 90.3% Unregistered staff fill rate 114.2% There are a number of examples of where a low fill rate for Registered nurses has been mitigated by a higher fill rate for HCAs. Overall the actual staff fill rate for both registered and unregistered total staff was 100%, meeting the Trust target of 100% Ensure patients detained under the MHA are provided with info as stated – recorded on Rio S132 Bromley provided 28/34 patients with information regarding their section. Breaches: 3 on Betts ward, 1 on Goddington ward, 1

on Norman ward and 1 for a client who was brought to the 136 suite at Green Parks House.

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Oxleas Bromley Exception Report May 2018

Main Agenda Item: Mental Health, Alcohol and Drugs A new policy has been provided by PHE and commissioners : ‘Mental health, alcohol and drug use’. Trust has a working

partnership with Bromley Drug and Alcohol Service (BDAS) where information and data is shared when there are any untoward incidents. Guiding principles were explained and confirmation that LBB and Trust were working together on these.

Patients will receive an assessment of their mental health irrespective of their drug and alcohol use and there is parity with patients who do not have drug or alcohol issues

PHE policy is “no wrong front door”: any patient attending any service should be supported and leave with an appropriate appointment. PHE guidance has changed term to “co-occurring mental health issues”

Audit – conducted throughout 2016 looking at access to services for patients with co-occurring problems. Face to face assessments were offered and the clinics explored patients history, current drug and alcohol use, patients perception of use and the barriers to engage with the MH treatment plan

Patients seen in clinic will have their GP informed with a detailed letter. At this early phase the service is working to get the data in real time and this should be in a couple months

Information from this presentation to be included in CCG’s GP bulletin

Dementia Diagnosis Acknowledgement of challenges of continuing to achieve the diagnosis target in Bromley. As of March 2018 Bromley has

surpassed the target; best practice has been shared with Bexley and Greenwich teams. Dementia awareness week went well and PRUH referral form has been adapted to help with awareness Challenges

Re-inforcing the benefits of seeking a dementia diagnosis to GPs this being to allow assistance for patients via Dementia Hub following diagnosis

Recording clinical coding is different between Oxleas and GPs Engaging with Care Homes

Successes Oxleas express thanks to a BCCG staff member who was instrumental in pushing diagnosis increases through Outcomes of diagnosis for patients opens up services to them

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Oxleas Bromley CQRG June 2018 (1 of 2) (DRAFT)

Homicide Action Plan Review Coroners report due in October, potential to include additional actions Any cross-organisational issues/learning to be taken to 3-Borough Quarterly Oxleas CQRG and any updates of actions should

come back to Bromley-only CQRG in September

Review of Green Parks House complaints (May 2017- May 2018) Complaints are a very small proportion when compared to the number of patients that go through GPH. Complaints have been

grouped into: environment, clinical care, staff attitude, and method of communication. The change to single sex wards has resulted in decreased amounts of “environment” complaints

Many complaints relate to disagreements about medication between clinicians and patients. In this case patients are offered a meeting to discuss any medication concerns

Standing items Actions from RCAs – Discussion on Monitoring CCG require assurance of RCA action plans being completed and audits being conducted and best way to approach was

discussed. Oxleas to bring briefing paper of quarterly embedded learning event Quality Dashboard and Local interpretation of Exception Report Oxleas to clarify FFT data Assurance provided on sufficient qualified staff levels but not necessarily the right mix of qualified/unqualified staff due to on-

going recruitment issues Risks on the wards are managed as long as there are no less than 2 qualified nurses amongst other HCPs. Oxleas provided

assurances regarding the provision of 2 qualified nurses - staffing levels reviewed daily Issues for Escalation to 3 Borough Quarterly Oxleas CQRG August 2018 Presentation on new crisis care developments for young people across Bexley, Bromley and Greenwich Cross-organisational issues and/or learning from Homicide Action Plan Review CQC Warning Notice for Oak Tree – action plan Date of next Bromley meeting: 11th July 2018 Date of next 3 Borough meeting: 29th August 2018

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Oxleas Bromley CQRG June 2018 (2 of 2) (DRAFT)

Bromley Healthcare CQRG June 2018 (1 of 2)

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CQRG has Quality oversight of all contracts held by BHC: within a 12 month period all contracts will be reviewed for quality, patient safety and clinical effectiveness. Safer Care Presentation – May 2018 See slides 13-14 Questions were asked about incidents appearing out of the norm within Orpington Hub – BHC are assured all PUs are reported;

work being conducted around UTIs and catheter care. Work is carried out within the safety meeting. BHC confirmed that all patients are being put onto EMIS and are fully reviewed as a result. CCG asked for assurance that missed medication incidents are considered against safeguarding criteria – assurance was received

Medicines Management Report A merged 2016/17 and 2017/18 report was presented as the CCG had not received the older report Highlights: Paediatric medicine spend is a challenge which can be attributed to: increase in activity over four years; appointments backed up;

patients not sent out for shared care quickly enough; increased referrals over the last four years. 149 medication incidents in 2017/18 a decrease from 154 in 2016/17 Increase in percentage of poor discharge from acute sector – many involved medication issues Medicines management report to be presented at December CQRG December report to highlight new quality premium targets BHC to decide which audits will go in December report Mouth Care Presentation The aims of the Adult SLT service is to increase awareness with an aim to reduce the numbers of poor oral hygiene cases and produce clearer written advice for patients. BHC and St Christopher’s are involved in the project and it is hoped an acute provider will be involved for the next step in service provision. Next steps: Finalise advice leaflets given to patients Leaflets added to “just in case” boxes Protocol reviewed Encourage other providers in Bromley to stop using pink mouth sponges as per the CAS alert A draft Bromley-wide mouth care protocol was presented and the pathway routes were demonstrated

Bromley Healthcare CQRG June 2018 (2 of 2)

45

Bladder & Bowel: Discussion and Outcomes Measure Template provided to go to panel within CCG and then for presentation at a future CQRG

National Audit of Intermediate Care Presented at CMB and positively received

AOB Recognitions were conveyed to BHC about open, transparent and responsiveness to CCG requests Date of next meeting: 19th July 2018

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BHC Safer Care Presentation May 2018 (1 of 2)

Incidents 268 incidents reported in May 2018 – 181 of these were BHC incidents 2 moderate harm: 1 missed insulin, 1 incorrect dressing Top 5 reported incidents – (themes remain the same as reported for March and April) Pressure ulcers – no avoidable PUs reported as SIs in May 2018 Admin or supply of a medicine from a clinical area Abuse – other (related to assaults on staff at Hollybank) Implementation of care or on-going monitoring Slips, trips, falls and collisions Key Learning points First assessments of patients to be undertaken by substantive staff to ensure all aspects of care are considered – variation of

quality of assessment if undertaken by agency staff Trial of a new progress note for agency staff to complete – July 2018 All new assessments to be allocated to substantive staff Medication incidents 15 x admin or supply of a medicine from a clinical area, 1 x advice, 2 x medication errors during prescription process, 1 x

patients reaction to medication and 1 x possible delay or failure to monitor Areas of concern: Beckenham and Orpington DN teams have seen an increase in the number of medicine incidents. Beckenham

errors relate to incorrect dose of medication given, lack of medication available and failed visits due to patients not being available. Orpington errors relate to predominately mis-scheduled visits relating to insulin. Daily audit underway

Poor Discharges (from acute sector) 3 x inappropriate discharges, 21 x discharge planning failure and 1 x patient discharged with complications Planning failure reasons: no referral to a service on discharge, no discharge summary, no medication and patient unable to transfer

on discharge

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BHC Safer Care Presentation May 2018 (2 of 2)

Falls 2 x moderate harm (short term harm caused), 3 x low harm (minimal harm caused), 7 x no harm caused Moderate Harm (2) No harm caused by BHC – 1 patient collapsed in leg ulcer clinic but was already being investigated for previous episodes Discharged home from hospital and fell 30 mins after discharge CAS Alerts 100% of safety alerts were acknowledged within the 48 hour deadline; 100% of alerts have now been closed; 100% closed

before the deadline and of the 13 CAS alerts that have been closed/completed, none required further action Quality Alerts 2 x red: prefilled posiflush syringe; late discharge. 1 x amber: referral to CMHT & IAPT Complaints 2 closed complaints, both were upheld and responded to in 25 days. Learning: staff reminded of inappropriateness of

discussing budgets and funding with patients and carers + ensure there is adequate supply of dressings at home and staff attend with relevant dressings and equipment

Compliments – 64. Three positive stories posted to Care Opinion

48

This report aims to pull together information on the quality of primary care from Primary Care Steering Group reports and intelligence collected by the CCG Quality Team. Current data and information is limited and often only available annually. The CCG will seek to improve the level and quality of information collected as the commissioning relationship develops. Primary Care Steering Group Notes May 2018 Sustainability and Resilience Tool Spreadsheet is useful and contains important elements - all data is updated monthly by NHSE. Comments made: the tool can be used to look at resilience, consider premises, trend in QOF, impact of losing money and

sustainability; sometimes info is updated at differing times and sometimes inaccurate; data will allow learning from best performing practices.

Action: Decide how to bring together the information establish a group and turn into an action plan then bring back to the PCSG then on to IGC.

Friends and Family Test – Bromley Overview There is a contractual requirement to provide BCCG with a data submission. 4 practices had not been submitting regular data to reach the 0.5% target based on list size. Request was made as how to manage surgeries who do not submit and action to discuss with Primary Care Team for practice visits Draft Policy on Communicating with Patients and GPs On-going work regarding quality of letter writing, clinical input has been provided, discharge problems and poor discharge

summaries had been considered. Policy welcomed. London Primary Care Commissioning Operating Model Group had been asked to review the revised Model and related documentation prior to PCCC meeting for ratification.

Documents endorsed by NHS England Primary Care Management Board Date of next meeting: 21st June 2018

Primary Care Quality Report

49

The Friends and Family Test (FFT) –April 2018 18 practices did not submit data: South View Partnership, Dysart, Derry Downs, Summercroft, Station Road, Charterhouse,

Cornerways, Elm House, St James’, Robin Hood, Ballater, Gillmans Road, Highland Road, Wickham Park, Bank House, Cross Hall, Crescent, and Cator Medical centre

2 practices submitted data but the number of responses was less than 5 so the results were suppressed: Manor Road and Bromley Common

Friends and Family Test development project 2018-19 NHS England is carrying out a project to improve some areas of the way the Friends and Family Test works across the country. The work will result in publications of refreshed FFT Guidance by April 2019. Outline proposals for the work were given the green light by NHSE Chief Executive in the autumn and also supported by the Department of Health. The ambition is to ensure the FFT can be a more effective tool in gathering patient feedback that helps to drive local improvements in healthcare services. Stakeholder surveys NHS England are inviting providers, commissioners and FFT suppliers to complete a survey to tell us how they currently use the FFT and how they might be impacted by any changes to the current guidance. Individuals are welcome to complete this as we have not restricted it to one response per organisation. We understand it may be used and experienced differently by different professionals and it is useful to have a range of perspectives. Responses will provide vital information to the project team to help shape decision-making. The surveys are open until 31 July and the Commissioners Survey can be accessed here https://www.engage.england.nhs.uk/survey/2018-fft-development-project-commissioners/


https://www.engage.england.nhs.uk/survey/2018-fft-development-project-commissioners/











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GP Survey The GP Patient Survey measures patients’ experiences across a range of topics, including: Making appointments Perceptions of care at appointments Waiting times Practice opening hours Out-of-hours services Each month the report will focus on a specific area. This month’s report will focus on “Out of Hours Services” Previous reports have focussed on “Making appointments, Overall experience of GP surgeries and Satisfaction with opening times” The table below details the age breakdown of respondents to the survey. The pie chart alongside sets out when survey respondents last saw or spoke to a GP.

Age Band Number of Respondents %

18 to 24 years 374 8

25 to 34 years 773 16

35 to 44 years 915 19

45 to 54 years 950 20

55 to 64 years 727 15

65 to 74 years 591 12

75 to 84 years 372 8

85+ years 169 3

Primary Care Quality Report - GP Survey The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients’ experiences of their GP practices. The data in this report is based on the July 2017 GPPS publication. The 2018 GP Patient Survey data will be available in early August. The following data represents some of the key results for Bromley CCG. In Bromley CCG 12,321 questionnaires were sent out and 4,937 were returned completed. This represents a response rate of 40%.

Primary Care Quality Report - GP Survey

51

The out-of-hours service questions are only asked of those who have recently used an NHS service when they wanted to see a GP but their GP surgery was closed. As such, the base size is often too small to make meaningful comparisons at practice level; practice range within CCG has therefore not been included for these questions. (Ipsos MORI Social Research Institute)

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Primary Care Quality Report - GP Survey

53

MONTH TOTAL RED AMBER GREEN OVERVIEW

NOV 6 2 2 2 Inappropriate referral requests x3; Prescribing/Medication x 1 Appts: follow up x 1; Clinical care x 1

DEC 4 2 2 Clinical Care x 2; Test results: missing information

JAN 4 1 2 1 Appts: correspondence x 1 & follow-up x 1 & delay x 1 Prescribing/medication x 1

FEB 6 3 3 Clinical Care x1; Prescribing/Medication x1; Test results x 1 Inappropriate referral requests x 2; Appts: delay x 1

MAR 8 3 2 3 Prescribing/Medication x 2; Inappropriate referral requests x 4; Appts: correspondence x 1 & delay x 1

APR 6 2 2 2 Prescribing/Medication x 2; Appointments: delay x2; Discharge issues and Test results

MAY 7 7 Appts delay; clinical care; test results; discharge issues x 3; inappropriate referral request

JUNE 8 3 3 2 Prescribing/medication x 3; appts correspondence x 2; test results x 1; appts delays x 1; discharge issues x 1

REVERSE QUALITY ALERTS Response within 7

days

Response within 14

days

Response within 28

days

Reverse Quality Alerts Analysis In line with other South East London CCG’s, BCCG started to roll out reverse quality alerts (RQA’s) in April 2017. This offers providers the opportunity to comment on issues arising in primary care and for practices to make improvements based on this feedback


Bromley CCG QAS June 2018 (1 of 3)

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Matters Arising Oxleas Serious Incidents Report – a decrease in the number of SIs reported by the Trust in Bromley borough, a substantive report

would be provided at the next meeting and was already included in the yearly planner

Continuing Healthcare Report The November report identified a number of areas that required improvement and an action plan had been created to them. The CCG’s internal auditors had reviewed the service and had echoed the concerns highlighted by the team and had given a “partially assured” rating Key themes were: Staffing – on-going vacancy for Nurse Assessor; the team had a higher than average sickness level with work underway to engage

and motivate staff and identify emerging trends Contracts – need for timely contracts to be put in place with providers of CHC placements. Only 3 care homes have signed the AQP

contracts noting that the London Purchase Healthcare Team found it challenging engaging with the remaining care homes in Bromley to persuade them to join the AQP contract. The team were working closely with Bromley Council, who hold the domiciliary care contracts, to review all the clients. Assurance was provided there was an action plan in place to manage the piece of work.

Policy & Process – work has begun on internal processes, a new complaints policy has been presented and approved at QAS, a robust process for requests, referrals and assessment have now been implemented. With an increase in the number of assessments it is becoming challenging to ensure full MDT meetings were taking place within required 28 days.

Complex Case Management meetings - TORs now created ensuring all identified processes were followed and adequate oversight for vulnerable cases with clinical supervision and support in place.

Internal Audit focus – on people with mental health or learning disabilities diagnosis. Assurance was provided that two action plans are running concurrently to ensure all actions were implemented

Adverse Incident Continuing Healthcare Anti-virus software deployed across the CCG resulted in fax messages being blocked leading to six faxes being delayed none of

which resulted in harm to patients. Assurance was provided the incident had not occurred through negligence or lack of oversight. In response the CHC’s business continuity arrangements had been reviewed and an additional process had been added to ensure no delay. CCG are promoting use of NHS email which is a secure mode of communication. Assurance was provided that BHC had checked all systems and no others services had been affected


Quality and Governance Risk Register 2 new risks added: Tailored Dispensing Service, assurance in place to manage transfer of patients; and risk of CCG not achieving

CHC assessment performance indicators – assurance provided that risk was being discussed with Bromley Council for resolution 2 risks have been deleted: one because funding for post of Independent Domestic Violence Advisor was received, IT changes

within diagnostics had reduced to acceptable level following EPR implementation 2 risks had their rating reduced: change of Healthwatch provider and IAPT waiting time Monthly Quality Report Oxleas The decrease in SI reporting would be raised at Bromley Borough CQRG meeting CHC team thanked for supporting Oxleas improve their Delayed Transfer of Care patients

Kings Vacancy rates remain a challenge Building work at DH had negatively affected Endoscopy performance, assurance provided that by next month the department

would be working as normal The policy on bed management within Critical Care had been implemented to ensure those needing care would receive it and

the Trust were looking at innovative ways to support patients that meet the criteria for Critical Care. Trust reported a patient death (SI) with incident being reviewed by Coroner who commended Kings positively on the way the

incident had been dealt with. Primary Care Following a request to review/improve quality reporting to PCCC it was expected a different approach would be taken with a

reliance on soft intelligence and link into primary care needs assessment. Duty of Candour: 6-monthly update Oxleas – assurance provided no themes or concerns had been raised with the info provided; BHC will complete template and

update at June CQRG, KCH felt their reporting at CQRG was sufficient; assurance was provided that smaller provider’s DoC was satisfied through SI process as CCG had sight of incidents through RCA report

55


Review: NHS Staff Survey Kings: number of staff completing survey has increased, overall the Trust performed poorly against similar Trusts and a number

of areas were identified for improvement. Concerns were: number of appraisals completed; discrimination, harassment from patients and relatives and flexible working. Noted that although performance was poor this year it was an improvement on last year, assurance provided there are a number of measures in place – to be discussed further at CQRG

Oxleas: number of staff completing the survey had decreased, Trust performed well in many areas compared to peers but areas for improvement were identified around witnessing harmful errors and confidence in reporting them, additionally poor performance when benchmarked against similar Trusts for harassment, abuse and violence from patients and relatives

Bromley Healthcare: not required to undertake NHS Staff Survey – will undertake a similar survey later in the year.

Endoscopy Briefing Quality Team had reviewed QAs and SIs from April 2016–2018 to establish any emerging themes and trends (48 QAs & 17 SIs)

the Trust had used endoscopy to manage the flow of patients during winter period which had a negative effect on the service evidenced by the incidents and alerts raised. However, since April 2018 no SIs reported and only two QAs. Previously there had been no collection of adverse incident data at PRUH endoscopy – since rectified. Assurance was provided that the dept. had not been used as an overflow area; planned investment in estates and endoscopy would be moved back to original area. Quality Team to continue monitoring and report any concerns if they arise

Direct Access Adult Hearing Service and ear care guidelines Guidelines ratified Warfarin Monitoring Template Approval was sought for the template to be shared with practices within the borough; resolved – approved for roll-out subject to

endorsement by the Prescribing Medicines Management Group

Date of next meeting: 12th July 2018

56

CCG Finance Report 2018/19 Month 3 (Period to end of June 2018)

Finance Report

Financial Performance Duties Page 59

Summary of Position at M3 Page 60

CCG Programme Budget Summary Page 61

CCG Runnings Costs Summary Page 62

Acute Financial Position Page 63

Notes on Acute Budgets Page 64

Client Group Financial Position Page 65

Notes on Client Group Budgets Page 66

Community Health Services Page 67

Notes on Community Health Services Page 68

Primary Care & Prescribing Financial Position Page 69

Notes on Primary Care & Prescribing Budgets Page 70

Primary Care Co-Commissioning Page 71

Notes on Primary Care Co-Commissioning Page 72

Earmarked Budgets and Reserves Page 73

Running Costs Page 74

Better Care Fund Page 75

Capital Page 76

QIPP Monitoring Page 77

Financial Risks & Mitigations Page 78

Cash Position Page 79

Better Payments Practice Code Page 80

Aged Debtors (Receivables) Page 81

Financial sanctions imposed by the CCG Page 82

Revenue Resource Limit Page 83

Recommendations Page 84

58

Author: David Harris, Head of Finance

Financial Performance Duties

Notes: The above duties correspond to those reported in Note 22 of the 2017/18 Annual Accounts, and

represent the statutory duties of NHS Bromley Clinical Commissioning Group (‘the CCG’).

The CCG is forecasting to make a surplus of £10,490k, which is the annual in year target surplus of £644k

plus the 2017/18 brought forward surplus of £9,846k which has been returned to the CCG in the form of

a non-recurrent allocation.

The revenue resource position includes the programme and running costs allocations. The programme

allocation includes the surplus target of £10,490k.

The CCG is has not received any capital allocations to date.

To support the delivery of the above, an in-year QIPP programme of £18,650k has been established, and

is being delivered in full. QIPP monitoring information is included later in this report. 59

DutyYTD Target

£'000

YTD

Performance

£'000

RAGAnnual Target

£'000

Forecast

Performance

£'000

RAG

Achieve planned surplus (Expenditure no to

exceed income) - in year£161 £161 £644 £644

Capital resource does not exceed the allowance £0 £0 £0 £0

Revenue resource does not exceed the

allowance (programme + running cost + surplus)£125,296 £122,653 £501,186 £490,651

Capital resource use on specified matters does

not exceed the allowanceN/A N/A N/A N/A

Revenue resource use on specified matters

does not exceed the allowanceN/A N/A N/A N/A

Revenue administration resource use does not

exceed the allowance£1,829 £1,738 7,315 6,953

Summary of position at Month 3

The CCG was underspent at the end of Month 3 by £2,643k year to date. This is £20k above the planned surplus target.

The CCG is forecasting to meet the annual target surplus of £10,490k. This consists of the brought forward surplus of £9,846k from 2017/18 adjusted for a planned 2018/19 in-year increase of £644k.

The CCG is currently holding £24,870k of earmarked budgets and reserves which includes: £2,456k relating to the 0.5% contingency reserve. £16,843 NET joint CCG and LBB funding relating to Better Care Fund. £923k relating to Bromley’s contribution to the SEL PMO which is hosted by Southwark CCG. £1,826k relating to Bromley’s contribution to the SEL 111 contract hosted by Bromley CCG. £525k Bromley’s 0.15 % contribution to the Healthy London Partnership programme. £2,297k other earmarked budgets including M3 non recurrent, market rent increases, LAC MH

costs etc.

Bromley CCG “Running Costs” are treated as a separate allocation so are shown as separate in the summary. Cross subsidisation of Running Costs by underspend on Programme Budgets is not permitted.

60

CCG Programme Budget Summary 2018/19 – Month 3

61

Progamme BudgetAnnual Budget

(£000s)

Variance to

Month 3

(£'000s)

Predicted

End of Year

Variance

(£'000's)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Acute250,326 (1,296) (2,874) (2,874) (5,750)

Client Groups69,630 54 (126) 292 (676)

Community45,776 30 119 121 (244)

Primary Care & Prescribing (excl DPC)49,242 29 0 0 (500)

Delegated Primary Care43,537 180 723 723 543

Earmarked Budgets & Reserves24,870 933 1,841 2,429 1,841

Planned Surplus (brought forward and in year)10,490 2,623 10,490 10,490 10,490

TOTAL 493,871 2,552 10,173 11,182 5,703

Reserves not yet ulitised in above position 588

Reserves not yet ulitised in above position (prior month for comparison) 2,456

Drawdown of prior year surpluses in 2018-19 0

Note : a red negative sign indicates budget overspend

CCG Running Costs Summary 2018/19 – Month 3

Notes:

The running costs allocation is separate from the Programme budget and should be

monitored

separately.

The recurrent running costs budget has increased in 2018/19 by £29k compared to 2017/18.

In line with national requirements, the running cost allocation per head of population has

reduced from £25 in 2013/14, to £21.75 in 2018/19. Although there is a reduction in funding

per head of population in 2018/19 there is an increase in the Bromley population size

resulting in a slightly increased budget.

62

Running CostsAnnual Budget

(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000's)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Running Costs7,315 90 362 455 270

Mth 2 (for comparison) 172 172 172

Acute Financial Position 2018/19

63

Acute ContractAnnual Budget

(£000s)

Variance to

Month 3

(£'000s)

Predicted

End of Year

Variance

(£'000's)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

King's College Hospital NHS Foundation Trust179,590 0 0 0 (2,000)

Guy's and St Thomas' NHS Foundation Trust19,361 (280) (399) (399) (676)

London Ambulance11,424 (13) (53) (53) (71)

Lewisham and Greenwith NHS Trust10,982 (622) (1,026) (1,026) (1,254)

Other contracts and non-contracted activity22,145 (374) (1,396) (1,396) (1,649)

Locally led Acute6,823 (6) (0) (0) (100)

TOTAL250,326 (1,296) (2,874) (2,874) (5,750)

Mth 2 (for comparison) 250,326 0 0 0 (5,433)

Notes on Acute Budgets

The year to date position has been reported as £1,296k and is based upon Month 2 flex information.

The following areas are currently overspending. GSTT £280k – the overspend relates primarily to critical care which is volatile area in terms of spend, LGT £622k – this overspend relates primarily to emergency activity and this activity is not expected to continue at this level throughout the year, BMI £255k – this overspend reflects a continuation of the increasing activity trends which have been seen over the last few years.

The predicted year end likely position for Acute budgets is £2,874k overspent. The 3 largest forecast

overspends are at the same providers as mentioned above. It should be noted that there is an

expectation that these early trends will slow during the year and the forecast is not based upon a

straight line projection of the Month 3 position.

The Kings position includes £10m QIPP target of which £5m is CCG risk. It is too early in the year to

assess the performance against this target. In 2017/18 the CCG had a similar target of which £5m

was CCG risk, the CCG achieved £1.5m of the £5m target.

The Other contracts year to date overspend of £374k includes: BMI £255k (as reported above);

Dartford & Gravesham £94k and Non contracted activity £68k.

64

Client Group Financial Position 2018/19

65

Programme BudgetAnnual Budget

(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000's)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Oxleas (MH)32,327 (40) (121) (81) (151)

IAPT2,960 (0) 0 0 0

South London & Maudsley1,950 (50) (100) (75) (125)

CAMHS1,196 (0) (1) (1) (1)

Other Mental Health3,881 84 244 244 183

Oxleas (LD)1,825 0 0 0 0

Other Learning Disabilities859 48 81 81 61

Sub Total 44,998 41 103 168 (34)

Continuing Healthcare Adult16,346 (149) (598) (374) (747)

Continuing Healthcare Children935 (86) (344) (215) (430)

FNC4,521 155 619 619 464

Sub Total 21,802 (81) (323) 30 (713)

Other Client Groups 2,830 94 94 94 70

Sub Total 2,830 94 94 94 70

Total 69,630 54 (126) 292 (676)

Mth 2 (for comparison) 69,630 (104) 76 76 (550)

Notes on Client Group Budgets

Mental Health

The year to date Oxleas position has been reported at £40k overspent in relation to UEA

expenditure. This is based upon an estimate based upon last years position as no information has

been received to date from the provider.

The South London and Maudsley year to date position is £50k overspent as a result of Bromley

currently having 2 clients in the National Autism Unit (NAU). The contract is cost and volume and the

number of Bromley clients in this unit over the previous 2 years was lower than at present.

Mental health and Learning Disabilities cost per case placement contracts are currently

underspending by approximately £140k. This position can change quickly as these placements are

low volume/high cost.

Continuing Health Care

The YTD position at M3 is a £81k overspend with a forecast year end position of £323k overspent.

There are four CHC QIPP Schemes with a target to deliver £350k savings over the year. At M3 no

achievement was made against this target.

The CHC children’s budget is overspending by £75k due to an increase in the number of clients

compared to the budgeted position. These clients often have complex packages.

Other Client Groups

These budgets include Integrated Care Systems, Safeguarding and pregnancy advisory services.

66

Community Services Position 2018/19

67


(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000s)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Bromley Healthcare32,971 0 0 0 (330)

St Christophers Hospice2,729 0 (0) (0) (1)

Specsavers1,250 0 (0) (0) (0)

Lewisham Hospital NHS Trust1,108 (1) (6) (4) (7)

Other Community Contracts 7,718 30 125 125 94

45,776 30 119 121 (244)

Mth 2 (for comparison) 45,776 19 19 19 (444)

Notes on Community Services

Bromley Healthcare CIC Community Contract. This contract was awarded to BHC our previous

provider from December 2017. The contract is split into 3 Lots, Children, Adult and Integrated Rapid

Response and Transfer of Care Services. The total contract value is £32.9m. The YTD position at M3

is breakeven.

St Christopher’s Palliative Care Contract. Bromley hold two contract with St Christopher’s, the first is

a Consortia Contract with Lambeth, Lewisham, Southwark and Croydon CCG’s with Bromley leads

and the other is a Bromley only contract covering support of care homes, bereavement, personal

care and a 24 hour care co-ordination service. The total value of the two contracts is £2,729k. There

is a pharmacy/pathology service being provided by King’s to support St Christopher’s in providing

medication to this patient cohort, the funding for this service sits within the King’s block contract.

The other four CCG’s are recharged a share of this value. The YTD position is breakeven.

AQP Hearing. This service is being provided by a number of branches under the Specsavers group as

well as Hearbase and Complete Eye Wear Ltd. The annual budget is £1,250k and the YTD position is

breakeven.

Crystal Palace Physio Group. This contract was awarded in April 2018 to the previous provider. The

annual value of this block contract is £3,634k. The YTD and forecast position at M3 is as planned

showing no adverse variances. These costs are included within other community contracts.

Other community contracts have an annual budget of £7,718k. The YTD position is showing a £30k

underspent forecast to £125k. The main driver of this underspend is the Medicines Optimisation

Service (MOS) and the community mobilisation/implementation budget. 68

Primary Care & Prescribing Financial Position 2018/19

69


(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000s)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Prescribing46,217 0 0 0 (500)

Local Enhanced Services768 0 0 0 0

Medicines Management666 29 0 0 0

Other Local1,591 (0) 0 0 0

Sub Total 49,242 29 0 0 (500)

Delegated Primary Care43,537 180 723 723 543

Sub Total 43,537 180 723 723 543

Total 92,779 209 724 724 43

Mth 2 (for comparison) 92,779 26 0 0 (500)

Notes on Primary Care & Prescribing Budgets

Prescribing

PPA prescribing data for April has been received however the position has been broken even as

one months data is not reliable enough to use for reporting . In addition to this the PPA does not

include a forecast position within the April figures.

The annual Prescribing budget is £46,217. This reflects cost pressures in relation to new drugs

and devices but also includes a QIPP savings target of £2m.

Enhanced Services

GP services currently commissioned locally are Visiting Medical officer, Transgender, Adult ADHD,

DMARD, Phlebotomy, Zoladex, Safeguarding for both children and adults. Within the annual

budget of £768k there is also our planned spend of £345k for year 2 of transformation funding (£3

php). The current position is breakeven.

Medicine Management

The total annual budget for this establishment is £666k. YTD position at M3 was a £29k

underspend, due to staffing vacancies, with a forecast breakeven position.

Other

Included within other Primary Care Budgets are Home Oxygen, GP I.T. and Commissioning

Schemes. The annual budget for these areas is £1,591k. The YTD and forecast position at M3 is to

plan with no adverse variances being reported.

70

Primary Care Co-commissioning

71


(£000s)

Variance to

Month 3

(£'000s)

Predicted

End of Year

Variance

(£'000's)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Core Contract32,636 0 0 0 0

QOF3,780 0 0 0 0

Enhanced Services991 0 0 0 0

Premises Reimbursements4,276 0 0 0 0

PCO administered975 0 0 0 0

Other Medical Services879 180 723 723 542

43,537 180 723 723 542

Mth 2 (for comparison) 43,892 0 3 3 3

Notes on Primary Care Co-commissioning

As of the 1st April 2015, the CCG entered into Level 2 co-commissioning of primary care with NHS

England.

There were 3 levels available to CCGs with regard to co-commissioning:

Level 1: Greater involvement in primary care decision-making.

Level 2: Joint Commissioning – enables decisions.

Level 3: Delegated Commissioning – enables decisions.

The CCG has moved to Level 3 for the 2017/18 financial year.

Level 3 is an opportunity for CCG to take on full responsibility for the commissioning of general

practice services.

The primary care medical budget for 2018/19 is £43,537k. Budgets are currently reported at

breakeven with the exception of the 0.5% contingency and non-recurring reserve which have been

released into the position. The M3 position is £180k underspent and the forecast is £723k

underspent.

72

Earmarked Budget & Reserves 2018/19

Part of the 0.5% contingency reserve has been released into the position to

offset the overspends elsewhere in the CCG.

Other budgets include overseas visitors and market rents

73


(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000s)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

HLP 0.15% Reserve 525 0 1 1 1

Better Care Fund16,843 0 0 0 0

0.5% Contingency Reserve2,456 940 1,868 2,456 1,868

NHS 111 1,826 0 0 0 0

PMO923 (0) (0) (0) (0)

Other2,297 (7) (28) (28) (28)

24,870 933 1,841 2,429 1,841

Mth 2 (for comparison) 24,540 (13) (267) (267) (267)

Running Costs 2018/19 (separate allocation)

This is the separate allocation of £21.75 per head of population for running costs.

Staff costs are underspending by £78k year to date due to vacancies.

Other non pay costs include Audit Fees.

74

Running Costs BudgetAnnual Budget

(£000s)

Variance to

Month 3

(£'000s)

Predicted End of

Year Variance

(£'000s)

End of Year Best

Case Variance

(£000s)

End of Year

Worst Case

Variance (£000s)

Staff Costs4,636 78 314 393 236

CSU Recharge1,385 14 56 70 42

Other Non Pay Costs1,294 (2) (8) (8) (8)

7,315 90 362 455 270

Mth 2 (for comparison) 7,315 82 172 172 172

Better Care Fund 2018/19

Better Care Fund Description Budget

£'000

Reablement services Reablement capacity 853

Intermediate care services Winter Pressures Discharge (LBB) 1,027

Intermediate care services Winter Pressures Discharge (CCG) 646

Assistive Technologies Integrated care record 433

Intermediate care services Intermediate care cost pressures 473

Assistive Technologies Community Equipment cost pressures 422

Personalised support/ care at home Dementia universal support service 520

Personalised support/ care at home Dementia diagnosis 620

Improving healthcare services to

care homes

Extra Care Housing cost pressures 418


care homes

Health support into care homes 259


care homes

Health support into extra care housing 55

Assistive Technologies Self management and early intervention (inc Vol sector) 1,047

Support for carers Carers support - new strategy 633

Risk Pool Risk against acute performance 1,347

Risk Pool Transfer of Care Bureau 611

Risk Pool IC LBB 152

Personalised support/ care at home Protecting Social Care 4,483

Support for carers Carers Funding 527

Reablement services Reablement Funds 952

Reablement services Reablement Funds 315

Personalised support/ care at home DoH Social Care grant 4,494

Total 2017/18 CCG Funded Recurrent Budget - Gross 20,287

2018/19 uplift - 1.9% 385

Total 2018/19 CCG Funded Recurrent Budget - Gross 20,672

Planned Recharges -3,829

Total 2018/19 CCG Funded Recurrent Budget - Net 16,843

75

The BCF budget has been uplifted by 1.9% in 2018/19

Monitoring information is produced quarterly by the LBB team and will be included here when

available.

Capital 2018/19

As at Month 3, no capital funding has been released to the CCG for Bromley capital

schemes.

76

Capital ProjectsAnnual

Budget £000s

Actual Spend

to Month 3

£'000s

Variance at

Month 3

£'000s

Predicated

End of Year

Variance

£'000s

End of Year

bast case

variance

£'000s

End of Year

bast case

variance

£000's

No allocation at M3 N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

Mth 2 (for comparison)

QIPP Monitoring

77

Annual Plan

£'m Plan £'m Actual £'m Variance £'m RAG Outturn £'m Variance £'m

Acute Services10.76 2.84 2.84 0.00 10.76 0.00

Community Health Services1.57 0.58 0.58 0.00 1.57 0.00

Continuing Care Services0.20 0.05 0.05 0.00 0.20 0.00

Primary Care Services2.00 0.50 0.50 0.00 2.00 0.00

Other Programme Services3.86 0.97 0.97 0.00 3.86 0.00

Running Costs0.25 0.06 0.06 0.00 0.25 0.00

Total 18.65 5.01 5.01 0.00 18.65 0.00

ForecastYear to date

The QIPP has been reported as breakeven as it is to early in the year to accurately assess the

position.

The acute QIPP includes £10m relating to Kings of which £5m is Trust led and £5m is CCG led

and if not delivered will impact upon the CCGs financial position (maximum exposure is

£5m). In 17/18 a similar arrangement was in place and the CCG delivered £1.5m of the £5m

target.

Financial Risks & Mitigations

The position above was reported to NHSE at Month 3.

The position is being regularly updated.

The acute risk relates to the possibility of QIPP not being delivered along with overspends on

contracts such as GSTT, LGT and BMI which have been highlighted earlier in this report.

78

RISKSPotential Risk

Value £'mCommentary

Acute Services 3.143 Primarily QIPP non delivery plus GSTT & BMI O/S

Mental Health Services -

Community Health Services 0.100 Possible changes to BHC contract

Continuing Care Services 0.100 Additional growth

Primary Care Services -

Primary Care Co-Commissioning -

Other Programme Services -

Running Costs -

Unidentified QIPP -

TOTAL RISKS 3.343

MITIGATIONS

Expected

Mitigation

Value £'m

Non recurrent measures 1.347

TOTAL MITIGATIONS 1.347

NET RISK 1.996

Cash Position 2018/19

At Month 3, the YTD cash drawdown was £106.5 million which is 23.72% of MCD

(slightly below the average for the percentage of months completed in financial year,

25.0%).

The actual month end cash balance for June was £288k and within 1.25% target.

79

Cash Drawdown

Monthly

Drawdown

£'000s

Cumulative

Drawdown

£'000s

Proportion of

Annual Cash

Resource Limit

(%)

KPI - 1.25% of

cash balance as

drawdown

£'000s

Actual month

end cash balance

£'000s

Apr-18 33,500 33,500 7.46% 419 473

May-18 39,000 72,500 8.69% 488 153

Jun-18 34,000 106,500 7.57% 425 288

Forecast

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

Annual Total 106,500

Better Payments Practice Code (BPPC) 2018/19

The CCG has achieved the target of >95% in April, May and June.

80

BETTER PAYMENT PRACTICE CODE

2018-19

NHS NON-NHS TOTAL NHS NON-NHS TOTAL

NUMBERS FOR THE MONTH

Total number of invoices paid in the month 218 970 1,188 131 1,104 1,235

Number of invoices paid within target 213 962 1,175 131 1,085 1,216

Numbers %age for the month 97.71% 99.18% 98.91% 100.00% 98.28% 98.46%

VALUES FOR THE MONTH (£000s)

Total va lue of invoices paid in the month 23,805 18,181 41,986 23,896 11,519 35,415

Value of invoices paid within target 23,658 18,089 41,747 23,895 11,437 35,332

Value %age for the month 99.38% 99.49% 99.43% 100.00% 99.29% 99.77%

CUMULATIVE NUMBERS TO THE MONTH

Total number of invoices paid YTD 422 1,786 2,208 553 2,890 3,443

Number of invoices paid within target 416 1,771 2,187 547 2,856 3,403

Numbers %age Cumulative 98.58% 99.16% 99.05% 98.92% 98.82% 98.84%

CUMULATIVE VALUES TO THE MONTH (£000s)

Total va lue of invoices paid YTD 46,775 29,438 76,213 70,671 40,957 111,628

Value of invoices paid within target 46,629 29,338 75,967 70,524 40,775 111,299

Value %age Cumulative 99.69% 99.66% 99.68% 99.79% 99.56% 99.71%

May-18 Jun-18

Aged Debtors (Receivables) 2018/19

56% of the outstanding receivables relates to the 1-30 day period.

The Non-NHS debt of £127k that is greater than 181 days old relates to London Borough of Bromley invoices relating to Section 75 and BCF invoices.

The NHS debt of £694k relating to the 91-120 day period included £523k relating to NHS England. This invoice has been settled since reporting the Month 3 position.

81

Customer

Account

Group

Total AR O/S

amount

AR Ageing 1-

30 days

AR Ageing

31-60 days

AR Ageing

61-90 days

AR Ageing

91-120 days

AR Ageing

121-180 days

AR Ageing

181+ days

£'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS 1,795 443 529 0 694 113 16

NON-NHS 1,844 1,591 6 72 23 26 127

Total 3,639 2,034 535 72 717 139 143

Financial sanctions imposed by the CCG

Information is available of a quarterly basis and will be reported in future

financial reports.

82

Revenue Resource Limit 2018/19

83

Revenue Resource Limit Admin Programme Total

(£'000s) (£'000s) (£'000s)

Programme Allocation 2018/19 479,351 479,351

Running Costs Allocation 2018/19 7,315 7,315

2017/18 Brought Forward Surplus 9,846 9,846

Additional resource 2018/19 3,656 3,656

2018/19 opening allocations 7,315 492,853 500,168

In year allocations:

18/19 Paramedic allocations - non recurrent 260 260

Market Rent - non-recurrent 23 23

Market Rent - recurrent 328 328

HSCN - non recurrent 77 77

GP WIFI Maintenance 2018/19 23 23

CHP Void subsidy charges 68 68

Liaison and Diversion /CYP Co-commissioning network 89 89

IPS Wave 1 Transformation Funding (Q1 & Q2) 80 80

2018-19 CYP IAPT Trainee staff salary support funding 12 12

Allocation for IUC pharmacist - Payment 1 of 7 (1st 2 quarters of a 2yr programme) 58 58

Total confirmed allocation at Month 3 7,315 493,871 501,186

Recommendations

Malcolm Hines Director of Finance

NHS Bromley CCG July 2018

To note the budgets and position for the ‘Programme’ and ‘Running Costs’ budgets.

To note the forecast position for the year for both ‘Programme Budgets’ and ‘Running Costs’

To note the risks and mitigations.

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