Meeting LLR CCGs’ Governing Body meetings Title (meetings ...12ibcm2f1hm941gh4lrvpwk1-wpengine.netdna-ssl.com/wp-content/… · 10/11/2020 · Mr Andy Williams took the report

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Meeting Title

LLR CCGs’ Governing Body meetings (meetings in common) – meeting held in Public

Date Tuesday, 10 November 2020

Meeting no. 7. Time 9:30am – 12:00pm

Chair Prof Mayur Lakhani WL CCG Chair

Venue / Location Via MS Teams

REF AGENDA ITEM ACTION PRESENTER PAPER TIMING

GBs/20/113 Welcome and Introductions Prof Mayur

Lakhani verbal 9:30am

GBs/20/114

Apologies for Absence: • Leicester City CCG:

o • West Leicestershire CCG:

o • East Leicestershire and Rutland CCG:

o

To receive

Prof Mayur Lakhani

verbal 9:30am

GBs/20/115 Notification of Any Other Business

To receive

Prof Mayur Lakhani verbal 9:30am

GBs/20/116 Declarations of Interest on Agenda Topics To

receive Prof Mayur

Lakhani verbal 9:30am

GBs/20/117 To receive questions from the Public in relation to items on the agenda only

To receive

Prof Mayur Lakhani verbal

9:35am

GBs/20/118 Minutes of the LLR CCGs’ meetings in common held on 8 September 2020 To

approve

Prof Mayur Lakhani

A

9:40am

GBs/20/119 Matters arising and actions from the LLR CCGs Governing Body meetings in common held on 8 September 2020

To receive

Prof Mayur Lakhani

B 9:45am

ITEMS FOR DECISION, ACTION AND ESCALATION

GBs/20/120

Report from the LLR CCGs’ Chairs To

receive

Prof Azhar Farooqi,

Prof Mayur Lakhani, Dr Vivek

Varakantam

C 9:50am

GBs/20/121 Accountable Officer’s Corporate Report To receive Andy Williams D 10:00am

GBs/20/122 LLR Winter plan and surge and resilience arrangements 2020/2021

To receive Rachna Vyas E 10:10am

GBs/20/123 Emergency Preparedness, Resilience and Response (EPRR) core standards update

To receive Rachna Vyas F 10:20am

GBs/20/124 Finance Report: Month 6 To receive Nicci Briggs G 10:30am

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REF AGENDA ITEM ACTION PRESENTER PAPER TIMING

GBs/20/125 LLR CCGs’ Performance Assurance Report To receive

Caroline Trevithick /

Hannah Hutchinson

H 10:45am

GBs/20/126 LLR CCGs’ Quality and Performance Improvement strategy

To approve

Caroline Trevithick /

Hannah Hutchinson

I 11:00am

GBs/20/127 Transforming Care in Leicester, Leicestershire and Rutland update

To receive

Rachna Vyas / Paula Vaughan J 11:15am

GBs/20/128

Update on Transition To receive

Andy Williams / Sarah Prema

K (paper to follow or verbal

update)

11:30am

ITEMS FOR INFORMATION

GBs/20/129 Summary report from the Clinical Reference Group (September 2020)

To receive

Prof Mayur Lakhani, L

11:45am

GBs/20/130 Summary report from the Audit Committee meetings in common (September 2020)

To receive

Warwick Kendrick M

GBs/20/131

Summary report from the Primary Care Commissioning Committee meetings in common (September 2020)

To note Nick Carter N

GBs/20/132

Summary report from the Collaborative Commissioning Committee meetings (September 2020)

To receive

Prof Mayur Lakhani O

GBs/20/133 Summary report from the Commissioning Committee meeting (October 2020)

To receive Fiona Barber P

GBs/20/134

Summary report from the Integrated Governance and Quality Committee (September 2020)

To receive Nick Carter Q

11:50am GBs/20/135

Summary report from the Quality and Performance Committee (October 2020)

To receive Wendy Kerr R

GBs/20/136 Summary report from the Performance Finance and Activity Committee (September 2020)

To receive

Warwick Kendrick S

GBs/20/137 Summary report from the Finance and Activity Committee (October 2020)

To receive Zuffar Haq T

ANY OTHER BUSINESS

GBs/20/138 Items of any other business. Prof Mayur

Lakhani Verbal 11:55am

The next meeting of the LLR CCGs’ Governing Body meetings in common will take place on Tuesday, 12 January 2020, virtually.

Prof Mayur Lakhani Verbal 12:00pm

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REF AGENDA ITEM ACTION PRESENTER PAPER TIMING EXCLUSION OF THE PUBLIC

In accordance with the provision of Section 1(2) of the Public Bodies (Admissions to Meetings) Act 1960, to exclude representatives of the press and general public from the meeting due to the confidential nature of the business to be transacted.

A

Blank Page

Paper A LLR CCGs Governing Body Meetings in common

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LEICESTER, LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS GOVERNING BODY MEETINGS

Minutes of the LLR CCGs Governing Body Meetings held in Common on

Tuesday 8 September at 11.45am, via MS Teams

Present: Leicester, Leicestershire and Rutland CCGs: Mr Andy Williams Chief Executive Ms Caroline Trevithick Executive Director of Nursing, Quality and Performance Ms Sarah Prema Executive Director of Strategy and Planning Mrs Rachna Vyas Executive Director of Integration and Transformation Mrs Donna Briggs Interim Executive Director of Finance, Contracts and Governance Mr Richard Morris Deputy Director of People and Innovation (on behalf or Ms Alice McGee) East Leicestershire and Rutland CCG: Dr Vivek Varakantam Interim Clinical Chair Ms Fiona Barber Deputy Chair and Independent Lay Member Mr Warwick Kendrick Independent Lay Member Mr Clive Wood Independent Lay Member Dr Andrew Ahyow Member Practice Representative Dr Nick Glover Member Practice Representative Dr Nikhil Mahatma Member Practice Representative Dr Girish Purohit Member Practice Representative West Leicestershire CCG: Prof Mayur Lakhani Clinical Chair (Chair of meeting) Ms Gillian Adams Independent Lay Member Mr Steve Churton Independent Lay Member Ms Wendy Kerr Independent Lay Member Dr Umar Abdulmajid Locality Lead, South Charnwood Dr Geoff Hanlon Locality Lead, North Charnwood Dr Ash Kothari Locality Lead Dr Fahad Rizvi Locality Lead, North Charnwood Dr Rowan Sil Locality lead, North West Leicestershire Dr Nil Sanganee Locality lead, North West Leicestershire Dr Mike McHugh Public Health, Leicestershire County Council Leicester City CCG: Prof Azhar Farooqi Clinical Chair Mr Nick Carter Independent Lay member Mr Zuffar Haq Independent Lay member Prof Jeffrey Knight Independent Lay member Dr Tony Bentley North and East Health Need Neighbourhood Chair Dr Gopi Boora North and West Health Need Neighbourhood Chair Dr Sulaxni Nainani South Health Need Neighbourhood Chair Dr Raj Than Left Shift / Integration Lead Dr Matthew Trotter Secondary Care Clinician


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In Attendance: Dr Janet Underwood Healthwatch Rutland Mrs Daljit K. Bains Head of Corporate Governance Mr Peter Davies Leicestershire County Council (for item GBs/20/100 only) Mr David Williams Director of Strategy and Business Development,

Northamptonshire Healthcare Foundation Trust (for item GBs/20/100 only)

Mrs Paula Vaughan Head of Commissioning (MH) (for item GBs/20/100 only) Ms Jade Atkin Service Improvement Manager (for item GBs/20/100 only) Ms Hannah Hutchinson Assistant Director of Performance Improvement Mrs Claire Middlebrook Corporate Affairs Support Officer (minutes) Members of the public: there were five members of the public in the meeting.

ITEM DISCUSSION LEAD RESPONSIBLE

GBs/20/90 Welcome and Introductions Prof Lakhani welcomed members of the Leicester Leicestershire and Rutland (LLR) Clinical Commissioning Groups (CCGs) to the meeting of the Governing Body in common meetings. The members of the public were welcomed to the meeting.

GBs/20/91 Apologies for Absences Apologies for absence were received from: Leicester, Leicestershire and Rutland CCGs:

Alice McGee, Executive Director of People and Innovation

Leicester City CCG:

Dr Avi Prasad, Assistant Clinical Chair

Mr Jo Johal, Healthwatch Leicester and Leicestershire West Leicestershire CCG:

Dr Nick Pulman, Vice Clinical Chair

Dr Reema Parwaiz, Locality lead, Hinckley and Bosworth The meeting was confirmed as quorate for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) and West Leicestershire CCG (WL CCG), however was not quorate for Leicester City CCG (LC CCG) due to the absence of Prof Azhar Farooqi at the start of the meeting.

GBs/20/92 Notification of Any Other Business Prof Lakhani informed that he had not received any other items of


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business for discussion.

GBs/20/93 Declarations of Interest on Agenda Topics All GP members declared an interest in items relating to primary care where a potential conflict may arise and also where there are any items concerning the Leicester, Leicestershire and Rutland Provider Arm where GP members’ are minor shareholders. The conflict was noted and will be managed during the discussions as required, it was also noted that the Register of Interests is published on the CCGs websites detailing declarations made by Governing Body members. No specific declarations were made, however, members were reminded to highlight any declarations should they arise as part of the discussion and noted that Mrs Daljit Bains would provide clarity around governance arrangements should this be required. It was RESOLVED to:

RECEIVE the declarations of interest and NOTE the actions being taken.

GBs/20/94 To receive questions from the Public in relation to items on the agenda only It was confirmed that no questions had been received. It was RESOLVED to:

NOTE that no questions were raised on agenda items from the public.

GBs/20/95 Minutes of the LLR CCG’s Meetings in common held on 14 July 2020: (Paper A) The minutes of the LLR CCG meetings in common held on 14 July were accepted as an accurate record. WL and ELR CCGs Governing Body members confirmed their agreement to the recommendation. It was RESOLVED to:

APPROVE the minutes of the LLR CCGs meeting in common held on 14 July 2020.


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GBs/20/96 Matters Arising and actions for the LLR CCG’s Meetings in common held on 14 July 2020: (Paper B) The action log was received and the following updates provided: GBs/20/65 Our Expectations and Clinical Model – learning lessons from Covid-19 – the 10 expectations are still being reviewed and will be brought back to a future meeting. Action ongoing. GBs/20/79 Risk Management Strategy and Policy – a development session on risks and strategic objectives, it was agreed to remove this item from the log, as it is included as part of the wider development programme for Governing Bodies. Action closed. GBs/20/79 Risk Management Strategy and Policy, Risks on the Board Assurance Framework (BAF) – all risks on the BAF have been reviewed and continue to be reviewed. Action ongoing. GBs/20/80/81 ELR and LC CCG Equality and Diversity Inclusion Annual reports – it was agreed to remove this item from the log as it is included as part of the wider development programme for Governing Bodies. Action closed. It was RESOLVED to:

RECEIVE the updates provided.

GBs/20/97 Report from the LLR CCGs’ Chairs (Paper C) Prof Lakhani noted that this report is received for information, no questions or queries were raised. It was RESOLVED to:

RECEIVE the contents of the report.

GBs/20/98 Accountable Officer’s Corporate Report (Paper D) Mr Andy Williams took the report as read, highlighting his congratulations to Mrs Caroline Trevithick, who has been appointed as Deputy Chief Executive of the LLR CCGs. Prof Lakhani added his congratulations to Mrs Trevithick on her appointment. Prof Lakhani reported that Dr Nil Sanganee has been appointed as the new Vice Chair of WL CCG, as this is Dr Nick Pulman’s last meeting, as he is planning to retire at the end of


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September. Dr Pulman was thanked for his contribution to the CCG, for his patient care and leadership and WL CCG members look forward to celebrating in due course. It was RESOLVED to:

RECEIVE for information the Accountable Officer’s report

GBs/20/99 Approval of the Pre Consultation Business Case for the University Hospitals of Leicester NHS Trust Reconfiguration Programme (Paper E) Ms Sarah Prema noted that this paper is part of the £450m plan to reconfigure and consolidate services onto two sites for University Hospitals of Leicester NHS Trust (UHL). At the Leicester Royal Infirmary (LRI) the plan is included the new Accident and Emergency (which is already in place), a new children’s hospital and maternity unit. Glenfield Hospital (GH) will become an elective care site and have a new treatment centre. Both LRI and GH will have expanded Intensive Care Units. The Leicester General Hospital (LGH) will continue to house the Diabetes Centre of Excellence, the Evington centre for Leicestershire Partnership NHS Trust (LPT), stroke rehab and an open access GP diagnostic hub. The consultation also includes the potential for having a community Urgent Care Hub. The public will be asked about what GP service they feel should be available on the site. Land no longer required at the site, will be offered for housing. Prof Farooqi joined the meeting. Mrs Bains confirmed that the LC CCG Governing Body meeting was now quorate. Ms Prema continued and informed that the plan is to have a better clinical model, which is stable. The changes will help deal with the expected increase in births and reduce multi-morbidity. More details are shown in the full paper. There are a few main areas that the CCG needs to consider;

1. Public engagement, section 6.6 of the Pre Consultation Business Case shows that since 2014 the organisations have been consulting with patients and the public regarding this issue. If this paper is approved a formal consultation and engagement process will commence on 28 September 2020.

2. Patient Choice – the impact on patients will be minimal, travel flows have been considered and the public will need


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to be engaged with regarding having a midwife led maternity unit.

3. Clinical evidence – the PCBC has been developed in line with clinicians and has been reviewed by the Clinical Senate. Pathways will be amended in line with national guidance.

4. GP commissioning support – this was originally approved at regional level in October 2019, by the national team in January 2020 and is now part of the public consultation.

5. Bed closures – no bed closures are planned as part of the changes, in fact there has been a small increase in the number of beds to 2033.

The proposed changes will mean that two sites will deal with elective and emergency care, with appropriate ITUs at both sites. This will ease the impact on staff, who will only have to cover two sites, rather than the current three for some specialities. The impact of the pandemic has been considered in the plans. Currently some children have to be sent to Birmingham for care, if there are not enough beds available in Leicester. The proposals include a GP unit at the GH site, which will allow for some minor operations to be carried out. The increase in bed numbers was acknowledged and received with gladness, as the bed numbers have been going up and down for several years; the CCG are finally listening to the patient voice. The changes in maternity services is a major issue, as this will affect 12,000 births per year and it is positive that the problems are being dealt with, however, concern was raised over parking at the LRI site. Support was expressed for the paper, the principle and the opportunity to listen the people of Leicester. There is an overwhelming argument to separate emergency and elective work, by place, town and county, and this proposal stands alone to solve these issues. The investment in Leicester, Leicestershire and Rutland (LLR) is welcomed and overdue; although the lack of commitment to a GP unit at the LGH site was noted, as there will still be diagnostics available. The lack of commitment is disappointing and should be a definite decision. Ms Prema confirmed that the team have listened to the public and car parking has already been considered. All sites will have their car parking capacity increased as part of the plans and UHL have been involved as part of their travel planning. The GP unit at LGH will be shaped following the engagement and


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consultation process, with diagnostics remaining, whatever the outcome. The changes in the paper since the last iteration, in relation to the GP hub are disappointing, as it is a shame that the plans are not more definite. Concern was raised that the Rutland voice is not being heard, as travel from some of the local villages is poor to LRI and GH and if a patient is ill the increase in travel time will be detrimental. The suggestion of a park and ride site in Rutland was made, with travel to all three UHL sites being made available. It was also suggested that as there will still be diagnostics at LGH, some maternity scans could be carried out at LGH, for those patients who this site is more accessible. The future of Rutland Memorial Hospital (RMH) was also mentioned, as the reconfiguration of UHL will put care into community hospitals and if RMH is not available, there would be nowhere in Rutland for patients to access community care. It was acknowledged that there are different nuances for a lot of different areas and these issues will be identified via the consultation process. The aim is to reduce health inequalities and the engagement process will tease out relevant issues. The environmental impact of the travel decisions will need to be assessed and a clear appreciation of the type of journeys to be undertaken to be noted. The transport issue is not limited to Rutland, as the other Park and Ride sites do no always link to UHL sites. There is a commitment from Leicestershire County Council and Leicester City Council to support public transport and reduce the cars queuing on Havelock Street at the LRI site. A suggestion has been made that patients should be able to park to LGH and then use the Hospital Hopper free of charge to travel to LRI or GH. All concerned will need to work together to find a solution to this issue. This is a brilliant opportunity to bring investment into Leicester. Opinions have been expressed about rurality disproportionately affecting patients. The workforce will also need to be transformed as part of the process, to move forward into a 21st century NHS service in Leicester, empowering self-care and care closer to home. The lack of information regarding sustainability was noted, as there is nothing included in the many appendices to the main paper. The progress of the Integrated Care System (ICS) and the 10 principles was noted, these need resolving alongside the issue of the GP site at LGH, as comments have shown that there should be


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a definite commitment to this service being available. Ms Prema noted the comments made and confirmed that she would ask the team to look at the wording in this section of the PCBC. The travel elements will also be considered and the paper changed as appropriate. Some issues will need to be considered at the UHL Programme Board meeting and Ms Prema gave assurance that sustainability will not be ignored and will be in the full detailed business case. This paper is the opportunity to improve care and outcomes for patients, alongside reducing health inequalities, it was suggested that local people should be employed in the building of new facilities. The timeline for the consultation and reassurance from Ms Prema was noted, with the recommendation being highlighted, subject to the comments made regarding the GP facility at LGH. It was agreed that the team need to talk to people regarding the practical issues and not be afraid of the feedback we might receive, as services will be for the community and for the community to make them happen. The principle of the paper was agreed, with some details to be sorted, ensuring an equitable offer for each region is in place. Mr Morris confirmed that the team will reflect on the document and comments provided, noting that the members have given a strong sense that the scheme needs to be delivered, with contributions from the public to be included. NHS colleagues will make the final decisions. The emphasis should be on listening to the public opinion on the plans and strengthening the document if possible, in conjunction with our NHS partners. It was RESOLVED to:

APPROVE the Acute Reconfiguration Pre Consultation Business Case and in doing so APPROVE the commencement of public consultation on the proposals from the 28th September 2020 to 21st December 2020.

Mr Peter Davies joined the meeting.


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Prof Lakhani noted that the minutes of the meeting (item GBs/20/95) required approval from LC CCG Governing Body’s perspective now that the meeting was quorate. LC CCG Governing Body members confirmed their agreement to the recommendation and approved the minutes of the previous meeting. It was RESOLVED to:

APPROVE the minutes of the LLR CCGs’ meetings in common held on 14 July 2020.

One member of the public left the meeting.

GBs/20/100 Transforming Care in Leicester, Leicestershire and Rutland (presentation by David Williams, Northamptonshire Healthcare Foundation Trust) (Paper F) Mr Peter Davies confirmed that he was the Senior Responsible Officer for the transforming care agenda and the paper was as a result of the Winterbourne enquiry. The local LLR system is currently poor and is therefore being overseen by NHS England, as there is pressure to reduce numbers, reduce over-admitting and have more timely discharges. There is a shortage of providers and facilities for these complex patients. Mrs Paula Vaughan joined the meeting. NHS England has been scrutinising LLRs performance against the target, in August the target was 34, when we had 60 patients in hospital. The approach should deal with the problems across health and social care, with weekly scrutiny of performance and discharge taking place, with data being used more proactively. An integrated approach will focus on the trajectory and performance, especially Mental Health (MH) admissions and deep dives will take place. Mr David Williams joined the meeting. As a system LLR are not meeting the trajectory and the Transforming Care Programme (TCP) has been in place for five years and therefore there needs to be a change to reduce poor performance, with a focus on assessments and quality of providers, whilst raising the profile of the TCP. Mr Williams understands the ask for Learning Disability (LD) and Autistic patients and the need for health checks to be carried out, as per the requirements from NHS England, that all patients have


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an annual health check. In 2019/20 in LLR, only 55% from the target of 65% of patients had an annual health check. This is our opportunity to influence and take forward the plans. Whilst Covid has been a significant challenge, working in partnership to carry out health checks should increase the numbers carried out. The key areas of learning are the medium age of death of these patients which is at 59 years, which is 23-27 years less than the national life expectancy. It was noted that Covid has highlighted these problems and Mrs Paula Vaughan has given a presentation to the Primary Care Cell on how primary care can recover. There needs to be collaborative approach to training for carers, such as a bespoke support group. The team aim to remember and recognise that this cohort of patients cover a wide age range and some are in care homes and therefore conversations with primary care to look at solutions need to take place. During the pandemic the care of LD and Autistic patients has been good, with performance being high and Risk Assessments in place, there is evidence that admissions have been avoided, with strong partnerships in place with care homes. It was acknowledged that the CCGs need to work harder to try and hit the targets, especially as some day care units have closed during the pandemic; which has put additional stress onto families. The system needs to work for all; including looking at what happens if carers die and the support available at this time. Following a query it was confirmed that the team have looked at different areas, to see how they have been carrying out health checks and to look at learning and different approaches, alongside innovation. It was agreed that the profile needs to be raised. Dr Gopi Boora is the clinical lead for the LLR CCGs and confirmed he is happy to be involved in trying to raise the profile, with the Clinical Directors of Primary Care Networks (PCNs). This also needs including in the health inequalities strategy, including patient outcomes and investment. Dr Janet Underwood noted that during the pandemic, some carers have felt abandoned and there was a virtual meeting held in Rutland with local Members of Parliament, the feedback from this meeting will be provided to Ms Prema outside of the meeting. Prof Lakhani read out the recommendations the members are

Janet Underwood


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asked to consider. It was RESOLVED to:

NOTE progress is below our expected trajectory performance

SUPPORT system approach to improve LD annual health checks

SUPPORT system approach to embedding lessons from LeDeR

Mr Davies, Mr Williams and Mrs Vaughan left the meeting.

GBs/20/101 Finance Report: Month 4 (Paper G) Mrs Donna Briggs confirmed that this is the month 4 finance report, which shows a £6.3m overspend; however, £6m of this is Covid spend which should be reimbursed. There is a slight underspend in Continuing Health Care (CHC) and Prescribing, which has been offset by the allocation shortfall. The previous risk associated with non reimbursement of £1.8m for WL CCG cost pressures has now been agreed by NHSE/I. The finance regime for months 5-6 will remain the same, with a focus on developing the month 7-12 financial plan in line with restoration and recovery for the rest of the year. It was RESOLVED to:

NOTE the financial performance at Month 4.

NOTE the adverse forecast position of £6.317m and the breakdown of its various elements.

NOTE the favourable in month variance of £3.878m

NOTE the anticipated receipt of additional allocations from NHSE to support this variance to enable the CCGs to report a breakeven position.

NOTE the remaining risk totalling £1.800m facing WL CCG due to the non-receipt of funding in month 3 to cover acute prior year pressures - this was verbally confirmed in the meeting that this is no longer a risk.


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GBs/20/102 LLR CCGs’ Performance Assurance Report (Paper H) Ms Hannah Hutchinson took the paper as read, highlighting that the Covid status is changing regularly. At the time the paper was written, there were 9282 cases in Leicester, with 875 deaths in LLR. Performance is below standard for Improving Access to Psychological Therapies (IAPT), which is working hard to improve. Within the cancer work stream, some services have resumed (bowel and breast) and cervical screening is being carried out at GP practices. Communication means are being used to highlight that attending hospital is safe. Accident and Emergency (A&E) performance is currently at 83.2%. All six standards are being met by East Midland Ambulance Service (EMAS). Referral to Treatment (RTT) is currently nationally challenged, with LLR being below the midlands and England level, at 2000 patients waiting. The first draft of the plan was submitted to NHS England on 1 September 2020, with an updated plan to be submitted on 21 September 2020, feedback will be received from NHS England. Attention was drawn to the cancer figures shown on page 6 of the report; with a member expressing concern if the public is aware of the problems and the need for seeking care as soon as possible. There should be a local focus on encouraging patients to seek medical help, especially for suspected cancer cases. It was confirmed that the cancer figures were discussed at Performance Finance and Activity Committee (PFAC) and the cancer design group is looking at what can be done, in conjunction with UHL. The group are pushing the message that ‘business as usual’ is happening. It was noted that for IAPT, City is significantly lower than for County. Ms Hutchinson stated that she will raise this with the design group, as it not just for IAPT; cancer is also in the same position. There does appear to be a City / County discrepancy. GPs are in the position to record cases and recommend services which are still available, such as IAPT, which is an early intervention service. The use of social media, such as WhatsApp was discussed and although videos have been produced, there has not been a significant increase in referrals. All communication methods are being considered.


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There is real concern around the cancer figures and therefore a action plan using Covid funding, should be put in place, with a better understanding of primary care access, using data to back the information up. Whilst we try and get things back to normal for cancer patients, highlighting that cancer services are open the message ‘Covid might not get you, but cancer will’ could be used. Some older people are still frightened to go out and this is causing them to lose their mobility. We need to reinforce the use of IAPT and engage with the provider, whilst challenging them to improve. The current performance percentages are good to see, apart from response times for EMAS, which are still below the expected levels. Dr Matthew Trotter noted the interesting figures for 2 week wait (2ww) for LLR and for 62 days wait to start treatment. It would be interesting to understand what has happened in primary care, to reduce the referrals into secondary care. There is a legacy of a backlog of patients attending hospital, with less patients being referred and therefore the perception is that primary care is not open to patients. It would also be interesting to look at the four hour wait targets for A&E for this year, compared to last year. Due to elderly and shielding patients, there has been an increase in diabetes and falls and therefore pre-Covid initiatives need to be pushed again, through Health and Wellbeing Boards. Patients are still being referred to IAPT and there is a 9 month waiting list for MH. Assessments are being carried out in the first few weeks, however, patients then have to wait over a year for focussed support, this means that the provider is not meeting their contract. The cancer figures shown will mean a delay in diagnosis rates; however, they are slowly rising. Whilst RTT patients are being seen, this does not mean that they are treated and therefore we need to understand the detail behind the figures. A deep dive into cancer rates is due to take place next week. Disproportionate lifestyle behaviours create a burden for the NHS, with a potential for delayed presentation for treatment in the more deprived area of the community, which further increases health inequalities. The need to avoid duplication, due to the new groups and projects being created was highlighted; the focus should be on finding a solution. GP access is a national concern and will be looked at by


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the design group. It was acknowledged that the performance report has raised the Governing Body’s awareness of the problems and areas to focus on. The design group is already in place and IAPT is being picked up. Further lines of enquiry will need comparable data and a deep dive into urgent care pathways is due to take place. Issues are also discussed at the leadership group. Any perceived gaps in pathways should be highlighted to Ms Rachna Vyas, noting that clinical leads need to support this work and ensure clinical risk based assessments are carried out. Ms Vyas stated that the design group has 24 pathways to look at and will use data to understand the demand. Capacity plans are in place and work is ongoing with cancer through the Clinical Reference Group (CRG). It was RESOLVED to:

RECEIVE the current performance and actions being taken for areas where performance does not meet the required standard.

DISCUSS additional actions being taken to consider whether further action is required to improve performance.

NOTE the agenda for the August 2020 PFAC meeting.

GBs/20/103 Review of Collaborative governance arrangements (Paper I) Mrs Briggs confirmed that this paper is being presented following the review of governance held in 2019, which the Executive Management Team (EMT) have reviewed. Mrs Daljit Bains confirmed that this has been a detailed piece of work and follows the changes approved in October 2019, when the following three joint committees were established: Performance, Finance and Activity Committee (PFAC), Collaborative Commissioning Committee (CCC) and Integrated Governance and Quality Committee (IGQC). This report outlines the review undertaken to strengthen the arrangements further as shown in appendix 2. It is proposed that the three committees mentioned earlier be changed to Finance and Activity Committee, Commissioning Committee and Quality and Performance Committee. During the review it became apparent that with the changes some areas of reporting no longer aligned to the new joint committees, however aligned better to the executive management team (EMT) meeting and the responsibilities of the executives.


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Therefore the proposal is to establish EMT as a formal group reporting into the Governing Bodies. Feedback received through the process of review is contained in paragraph five of the report. Governing Body members supported the changes and noted that the amended structure was helpful moving forward. Mr Carter raised a query regarding the box on the top left of appendix 1 and the equivalent box on appendix 2. Mrs Bains confirmed that these boxes confirm the reporting required into the Governing Bodies from partner organisations. The blue box on appendix 2 shows system wide meetings. Mrs Briggs reiterated that where appropriate, decisions will be sent to in common meetings, with specific meetings only taking place by exception. A query was raised regarding paragraph 10 of the report and table one, in relation to the risk management elements. Mrs Bains confirmed that the statutory elements are not changing and therefore the functions will remain the same, with reports coming through the Audit Committee. Following a query raised, it was confirmed that EMT have discussed the suggested changes in detail and are assured that the changes are robust. Some concern was raised that the membership will not be taken on the same journey and a question raised as to the plan to address this. It was confirmed that the development session taking place this afternoon, will allow members to look at this in more detail and for GPs to understand the governance framework. There will be a short transition period, whilst the changes are made. Dr Kath Packham highlighted the Terms of Reference for the Quality and Performance Committee (Appendix 5) and suggested that the public health representative may not be able to support this meeting and noting that going forward we may need to consider a single representative whether a member of the County or City representative attend given limited capacity within the public health teams. Dr Packham confirmed that the public health team will in the first instance prioritise attendance at the CCG statutory meetings, that is the Governing Bodies and Primary Care Commissioning Committees as these are priority. The team would have capacity to support reviews etc, however, Dr Packham suggested that regular attendance at the Quality and Performance Committee might not be possible.


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Mrs Briggs confirmed that there has been a lot of thought behind the changes and this is a strong proposal. It was confirmed that EMT will continue to meet every Monday and will have the delegated power to focus on bigger issues. Following a query it was confirmed that Governing Body will have the remit to monitor health inequalities. Mr Williams confirmed that the ICS will ensure greater equity in the transition, with a set of metrics in place to look at equity. This will also be talked about at system level; the details still need to be confirmed. A query was raised as to what the changes answer and what has been made better. It was confirmed that the proposed changes will ensure that the CCGs have a much more clearer and leaner decision making route and reflects the single executive team. It was RESOLVED to:

APPROVE the proposed committee structure at Appendix 2.

APPROVE the disestablishment of the Performance, Finance and Activity Committee (joint committee).

APPROVE the establishment of the Finance and Activity Committee (joint committee) with effect from 1 October 2020, its terms of reference and work programme (Appendices 3 and 4).

APPROVE the disestablishment of the Integrated Governance and Quality Committee (joint committee).

APPROVE the establishment of the Quality and Performance Committee (joint committee) with effect from 1 October 2020, its terms of reference and work programme (Appendices 5 and 6).

APPROVE the disestablishment of the Collaborative Commissioning Committee (joint committee).

APPROVE the establishment of the Commissioning Committee (joint committee) with effect from 1 October 2020, its terms of reference and work programme (Appendices 7 and 8).

APPROVE the establishment of the Executive Management Team meeting as a formal group of the LLR CCGs’ Governing Bodies from 1 October 2020, noting the functions in Table 2.

NOTE the contents of the report and next steps.


10 November 2020

Page 17 of 20


A member of the public left the meeting, Ms Hutchinson left the meeting.

GBs/20/104 WL CCG Equality and Inclusion Annual Report 2019/20 (Paper J) Mrs Briggs took the paper as read, confirming that Ms Gillian Adams has reviewed the report and noting that going forward one LLR report will be produced. It was RESOLVED to:

APPROVE the Equality and Inclusion Annual Report 2019/20 ahead of publishing it on the CCG website.

GBs/20/105 LLR CCGs’ Workforce Race Equality Standards Report 2019/20 (Paper K) Mr Richard Morris took the paper as read, noting that the Workforce Race Equality Standards (WRES) launched in 2018 and looks at ensuring organisations give equal opportunities for all staff. Usually organisations have to report against 9 indicators, however, for this years’ report, indicators 5-8 have been removed. There are positive things to note in the data, in that the workforce has a greater BAME representation, 29.4% than the national average of 21.6%. LC CCG has a higher level of diversity, with good representation from the south Asian community and less staff from black or Somali communities. There has been a small increase in BAME staff in senior posts; although the position shown is as the end on the 2019/20 financial year. If approved the report will be uploaded and submitted to NHS England. Following a query it was confirmed that the report includes GPs and Executives. The LLR CCGs take diversity seriously and will look at the report in detail, using learning from other organisations, such as the police and EMAS to ensure we are not complacent. Whilst the report shows good results for LLR; it is important that all staff are supported to seek promotion as this will benefit all organisations in the long run. Ms Vyas spoke about reverse mentoring, which is a powerful way to move forward. Intersectionality was discussed, as some BAME people do not like to be named as BAME and the gender inequality of the Board was also mentioned.


10 November 2020

Page 18 of 20


It was RESOLVED to:

APPROVE: The WRES report for 2019/20 and the associated action plan for publication on the CCGs websites and submission to NHS England.

GBs/20/106 NHS People Plan response (Paper L) Mr Morris confirmed that this paper is in response to the NHS People Plan 2020/21 published in July 2020. The paper provides details of the journey to date and key actions to be taken to ensure delivery, which LLR colleagues are already working through. The report summarises actions LLR need to take and a formal response is due to NHS England on 14 September. It was noted that this is an important topic for a future development session, to make sure all groups are engaged with at place, system and neighbourhood level. It was RESOLVED to:

RECEIVE the report as summary of the actions and plans for the response to the NHS People Plan

Alice McGee / Richard Morris

GBs/20/107 Summary report from the Audit Committee meetings in common (August 2020) (Paper M) The paper was taken as read and no questions or queries were raised. It was RESOLVED to:

RECEIVE the report and SUPPORT the recommendation from the Audit Committees in relation to the chairing arrangements for the Collaborative Commissioning Committee (see paragraph 9 of the report).

GBs/20/108 Summary report from the Primary Care Commissioning Committee meetings in common (August 2020) (Paper N) The paper was taken as read and no questions or queries were raised. It was RESOLVED to:

RECEIVE the report.


10 November 2020

Page 19 of 20


GBs/20/109 Summary report from the Collaborative Commissioning Committee meetings (July and August 2020) (Paper O) The paper was taken as read and no questions or queries were raised. It was RESOLVED to:

RECEIVE the Summary Report from the Collaborative Commissioning Committee held on 16 July and 20 August 2020.

GBs/20/110 Summary report from the Integrated Governance and Quality Committee (August and September 2020) (Paper P) The paper was taken as read and no questions or queries were raised. It was RESOLVED to:

RECEIVE the report and be ASSURED of the actions of the IGQC in respect to monitoring quality and performance and providing assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust across the LLR.

GBs/20/111 Summary report from the Performance Finance and Activity Committee (August 2020) (Paper Q) The paper was taken as read and no questions or queries were raised. It was RESOLVED to:

RECEIVE the summary report and take assurance from the Performance, Finance and Activity Committee held on 30 July 2020 and 27 August 2020.

GBs/20/112 Items of Any other business

Prof Lakhani thanked everyone for their contributions to the complicated meeting, noting that LC CCG colleagues need to reconvene the confidential meeting, immediately following this meeting to approve papers. Mrs Donna Briggs was thanked, as this is her last meeting as Interim Director of Finance, Contracts and Governance.


10 November 2020

Page 20 of 20


Date of next meeting

The next meeting of the LLR CCGs’ Governing Body meetings in common will be take place on Tuesday 10 November 2020, via MS Teams.

The meeting concluded at 2.30pm.

B

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Paper B LLR CCGs’ Governing Body Meetings in common

10 November 2020

Page 1 of 1

Outstanding On-going Completed

Key LEICESTER, LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS

ACTION NOTES

Minute No.

Meeting Item Responsible Officer

Action Required To be completed by

Progress as at November 2020

Status

GBs/20/65 16 June 2020

Our expectations and clinical model – learning lessons from COVID-19

Andy Williams

10 expectations to be discussed at CRG and brought back to Governing Body meeting

September 2020 October 2020

Work in progress. AMBER

GBs/20/79 14 July 2020

Risk Management Strategy and Policy

Stuart Fletcher / Daljit Bains

There are a number of risks on the BAF which have been on for some time and therefore Prof Knight suggested a review of these risks take place.

September 2020 / October 2020

All risks in the LLR CCGs’ BAF have been reviewed and a programme of regular reviews has been scheduled following discussion with the Executive Management Team. ACTION COMPLETE

GREEN

GBs/20/100 8 September

2020

Transforming Care in Leicester, Leicestershire and Rutland

Janet Underwood

Feedback from the meeting held between carers and MP to be provided to Sarah Prema for information

October 2020 Email sent to Sarah Prema on 8 September 2020. ACTION COMPLETE

GREEN

GBs/20/106 8 September

2020

NHS People Plan response

Alice McGee / Richard Morris

NHS People plan to be added to development session plans

October 2020 Plan to be updated. AMBER

C

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Aligned to Strategic Objectives Leicester City CCG West Leicestershire CCG East Leicestershire and

Rutland CCG

Implications a) Conflicts of

interest: None identified

b) Alignment to Board Assurance Framework

Not applicable

c) Resource and financial implications

None identified

d) Quality and patient safety implications

None identified

e) Patient and public involvement

None identified

f) Equality analysis and due regard

Not required

Name of meeting: LLR CCGs’ Governing Body meetings in common

Date: 10 November 2020

Paper: C Public Confidential

Report title:

LLR CCGs’ Chairs’ Report

Presented by: Professor Mayur Lakhani, Clinical Chair, WL CCG Professor Azhar Farooqi, Clinical Chair, LC CCG Dr Vivek Varakantam, Interim Clinical Chair, ELR CCG

Report author: Daljit K. Bains, Head of Corporate Governance In conjunction with the Clinical Chairs

Executive lead: Andy Williams, Chief Executive

Action required: Receive for information only: Progress update:

For assurance: For approval / decision:

Executive summary: The purpose of this report is to provide an overview and update of some of the key constitutional and strategic updates that affect the Governing Bodies and to provide an overview of meetings that attended.

Appendices: • None

Recommendations:

The LLR CCG Governing Bodies are asked to: • RECEIVE the contents of the report.

Report history and prior review:

Not applicable

2

LLR CCGs’ Chairs’ Report Introduction 1. The purpose of this report is to provide an overview and update of some of the key

constitutional and strategic updates that affect the LLR CCGs’ Governing Bodies and to provide an overview of meetings that we have attended.

Meetings 2. Clinical and managerial capacity across the CCGs continue to support the ongoing

response to the COVID-19 pandemic in line with national guidance, and we continue to work remotely.

3. As reported previously, our focus remains on ensuring key meetings continue to take place frequently to ensure clinicians are able to support and provide timely clinical input and advice, for instance, in relation to clinical pathways to support the response to the current situation. We are also maintaining regular contact with our clinical colleagues to ensure they are supported during this period.

4. The ongoing efforts of our NHS colleagues and local partners across Leicester,

Leicestershire and Rutland (LLR) continues to help support in fighting coronavirus and delivering a system wide response in these challenging circumstances.

5. Our staff continue to work incredibly hard to ensure we can continue to support the

system response across LLR and also operate business as usual the best we can during these difficult times.

Meetings over the last couple of months 6. As Clinical Chairs of the three CCGs we continue to work closely in implementing our

strategic approach to managing the response of the CCGs to the pandemic.

7. We have held the following meetings on a regular basis and will review the frequency as the situation evolves: a) The weekly Health Economy Strategic Coordinating Group meetings.

b) Participate in telephone conferences with Dale Bywater (NHS England Midlands

Regional Director), Nigel Sturrock (Medical Director and Chief Clinical Information Officer), and CCG Chairs to receive an update report on the Midlands region.

c) Fortnightly update from primary care leads assigned to the primary care cell.

d) Fortnightly meetings with three representatives from the Clinical Directors of Primary Care Networks in LLR and a monthly Clinical Directors’ forum.

e) System wide clinical directors’ / clinical leads’ call held monthly between medical directors of Derbyshire Health United (DHU), University Hospitals of Leicester NHS Trust (UHL), Leicestershire Partnership NHS Trust (LPT), East Midlands Ambulance Service (EMAS) and clinical chairs of LLR CCGs.

f) Andy Williams, Chief Executive update.

3

8. We will continue to review these meetings and our involvement regularly to ensure that

we are focused on supporting the CCGs and managing the governance.

9. We have also maintained communication with our member practices by supporting the primary care team messages sent in the daily situation update report (SITREP). The team have also developed a website page for practices where all the information is easily accessed from previous SITREPs.

10. Other meetings attended over the last couple of months include the following:

a. The Clinical Leadership Group meeting.

b. The Local Medical Committee liaison meetings now take place monthly.

c. Collaborative Commissioning Committee meetings, the last meeting of which took place in September 2020. The Commissioning Committee has been established in its place in line with the revised internal governance arrangements and we attended its inaugural meeting in October 2020.

d. LLR CCGs’ transition meetings.

e. Clinical Reference Group meetings, an overview of which will be provided under

a separate agenda item on the agenda. f. We met with Sarah Prema with regards to the primary care estates strategy to

help inform the development of this strategy. g. LLR CCGs’ joint Governing Bodies’ development session was held on 27

October 2020 where the Governing Body members had the opportunity to have a discussion about the priorities for the organisational transition programme, and an initial consideration of the strategic objectives for the three CCGs. In addition, we had a training and awareness session on equality and inclusion enabling the Governing Body members to complete their annual refresher training and ensure that equalities and inclusion remains at the forefront of our decision-making and assurance processes.

CCG specific meetings attended and updates 11. In addition, to the above:

a) CCG specific update from Professor Mayur Lakhani:

i. I continue to Chair the End of Life and Palliative Care Task Force and a meeting

took place 10 September to ascertain the priorities during restoration, recovery and resilience as appraised against the ten system expectations. It is important to mention to the Governing Bodies that NHS England has set up a regional Palliative and End of Life Care (EOLC) network to review and support the EOLC work of systems.

ii. Arrangements for engagement and communication for members and GP leaders have been strengthened during the second wave for place and

4

neighbourhood based. The aim is to ensure that primary is fully prepared for the second wave through infection, prevention and control, continuity of provision of services including flu (and potentially Covid) vaccination support for clinically vulnerable patients and optimal utilisation of hub clinics. This includes a primary care leadership forum for West Practices including Primary Care Networks (PCNs) and a members monthly meetings. These are opportunities for updating and also to listen and answer questions on key issues such as preventing and managing local outbreaks. Looking beyond the pandemic, the Primary Care leadership forum discussed amongst other things a strategy for the future models of care of primary care in West including workforce expansion through ARR, e-hubs, inter-practice referrals and out of hospital care services.

iii. My office has coordinated a submission, an expression of interest (EOI) for a pilot

in some West PCNs to the East Midlands Academic Health Science Network (EMAHSN) for a Primary Care Support Package to support people living with Long Term. In England 55% of people with LTCs account for about 50% of all GP appointments, 64% of all outpatient appointments and over 70% in patient bed days. The framework package is based on new pathway development, virtual consultations, digital solutions and optimal use of the wider primary care team. Tools have been developed for asthma, COPD, Type 2 diabetes and hypertension, with AF and lipid management to follow. We are hoping our EOI will be successful.

iv. I am continuing my work on the NHS Midlands STAR Board and one of its

subgroups on restoration to set a direction for the NHS at this critical juncture. I also Chair the Midlands Flu and Covid Immunisation Board. I continue my work on promoting clinical leadership, locally, regionally and nationally. This includes a session at the international conference (now virtual), Leaders In Health (Nov 17-20) which includes a session on primary care leadership that also features one of our PCN CD, Professor Aruna Garcea. A LLR event is also taking place on 26 November on Women in Leadership featuring national and local leaders to encourage more local female clinical leadership.

b) CCG specific update from Professor Azhar Farooqi: i. I have continued to support and maintain regular communication with GP

Practices locally throughout the current challenging period. Communication with patient groups has also been key during this period.

ii. Meetings I attended include: • Protected Learning Time (PLT) meeting with over 100 attendees from GP

Practices. • Virtual meetings with individual practices and GPs. • Regional STAR board meetings including the regional health inequalities

subgroup. • LLR Diabetes Delivery group meetings and national Diabetes clinical

Network meetings, we have been developing the LLR diabetes pathway in an ICS, national toolkit to assess COVID risk in diabetes and restoration planning.

• Chairing LLR Alliance board, including a meeting planning the LLR COVID vaccination plan (required by first week of December).

5

• I have started to explore mechanisms for a better working relationships and coordination between PCNs and Provider Company Limited (PCL) who effectively have the same membership.

• I have been invited and attended a national NIHR research committee looking at health inequalities.

• I have had meeting with local authority leaders on developing the concept of “place” in the city

c) CCG specific update from Dr Vivek Varakantam:

i. Since my appointment as interim Clinical Chair for East Leicestershire and Rutland CCG, I have held a series of introductory meetings to strengthen partnerships with stakeholders, providers, local authority colleagues, and the LLR CCGs’ Executive Management Team. Since my previous update I have met with Chair and representatives from Healthwatch Rutland, Ms Janet Underwood and Tracey Allan-Jones.

ii. In addition to the meetings mentioned earlier in the report, I have attended the following during September and October 2020:

• The new and well received monthly East Leicestershire and Rutland CCG

member practice virtual meetings, held between the GP Governing Body members, the Executive Management Team and the member practices.

• Andy Williams and I have held meetings with Primary Care Networks

(PCNs) across East Leicestershire and Rutland CCG to establish a two-way dialogue, meetings attended were as follows:

• 10 September 2020 – Rutland PCN • 8 October 2020 – Cross Counties PCN • 27 October 2020 – North Blaby PCN • 28 October 2020 – South Blaby and Lutterworth PCN • 29 October 2020 – Oadby and Wigston PCN

• On 29 September I joined the East Midlands Chairs’ development network

event during which we had an opportunity to review current situation relating to COVID-19 and the NHS reset.

• I am also pleased to announce that at the time of writing this report the

ballot for the appointment of the new Member Practice Representative post has closed. Once the votes have been verified I will be able to confirm the outcome of the Membership’s vote.

Recommendations The Leicester, Leicestershire and Rutland CCGs Governing Bodies are asked to: • RECEIVE the contents of this report.

D

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Rutland CCG


interest: No conflicts of interest have been identified.


Not applicable.


There are no financial implications.


None identified.


Not applicable.


Not applicable.



Paper: D Public Confidential

Report title: Accountable Officer’s Corporate Report

Presented by: Andy Williams, Chief Executive

Report author: Daljit K. Bains, Head of Corporate Governance In conjunction with the Executive Management Team

Executive lead: Andy Williams, Chief Executive

Action required: Receive for information only: Progress update: For assurance: For approval / decision:

Executive summary: The purpose of this report is to inform the Governing Bodies of key activities with which the Executive Membership Team and Chief Executive have been involved in since the last meeting of the Governing Bodies. The report includes updates on items not covered elsewhere in the Governing Body papers, as well as details of achievements and other items of interest.

Appendices: None Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE for information the Accountable Officer’s report.


Not applicable

2

ACCOUNTABLE OFFICER’s REPORT INTRODUCTION 1. This report sets out to the Governing Bodies some of the key activities with which the

Executive Management Team (EMT) and I have been involved in across Leicester, Leicestershire and Rutland (LLR) since our last meeting of the Governing Bodies. It includes updates on items not covered elsewhere in the Governing Body papers, as well as details of achievements and other items of interest.

COVID-19 Update 2. With the current lockdown commencing on 5 November, our collective efforts continue

across the NHS in Leicester, Leicestershire and Rutland (LLR). We continue to work incredibly had with our partners within the Leicester, Leicestershire and Rutland Local Resilience Forum (LRF) and through the Strategic Co-ordination Group in response to the COVID-19 outbreak.

3. The Health Economy Strategic Co-ordination Group, which I chair, is meeting weekly to support and coordinate the complex response across the partners. This group plays a key role in the local arrangements as part of the Local Resilience Forum, which is the multi-agency partnership made up of representatives from public services including the emergency services, local authorities, the NHS and others.

4. The response of the NHS in LLR to the Covid-19 outbreak demonstrates the NHS at its best. The focus has entirely been on doing what is best for our patients and ultimately to save lives by working in partnership through a multi-agency response structure.

5. Thank you once again to all our staff and NHS colleagues and local partners across LLR

for their continued contributions, commitment and support through these challenging circumstances.

Flu vaccination programme update 6. It is important to maintain high flu vaccination coverage. However the delivery of this

year’s programme is going to be more challenging because of the impact of COVID-19. This includes flu vaccinations taking longer because of the need to observe social distancing rules and the need for clinicians to change personal protective equipment (PPE). There is no one right way of maximising flu vaccinations, it will take effort from everyone. All organisations need to act as advocates for vaccination of their staff where eligible and emphasise the importance of this on overall system resilience.

7. The flu vaccination programme for this year was expanded and there is an increased

number of people who are eligible for a vaccination. The early requests for the flu vaccine have been higher than in recent years. Although many people have been vaccinated, some people may have to wait as some GP practices and pharmacies have used their early supplies of flu vaccine to prioritise certain groups and the increased level of demand.

8. At this early stage of data monitoring it is noted that notification of vaccine distribution

was provided to general practice at slightly different times and that practices received their vaccines at different times. Individual general practices have different flu plans in

3

place depending on their area of prioritisation, their practice population, available estate and available workforce.

9. The overall CCG summary data as at week 43 indicates that the current focus across

LLR is the over 65 age group with coverage in this group being higher than at this time last year. We are conscious that there is a range of coverage from 15% to 82% in the over 65s for example and we need to understand the reason for this and see what support can be provided.

10. Whilst workforce has not been cited as a specific issue at this point in time we are

mindful that this may impact as COVID rates raise.

11. A primary care flu group has been established which reviews the data to identify where there is lower uptake. Equally practices are encouraged to inform the CCGs of any concerns they may have in delivery.

12. Additional Flu funding has been made available by NHS England /Improvement. The

LLR CCGs are including in the claiming process a requirement that each practice confirms their 75% delivery trajectory.

13. There will be a rolling cycle of data review and practice contact throughout the flu

season. Initial contact maybe by email, but when a practice does not respond to email, identifies specific support/assistance needs, and or continues to show data that appears to be counter to their expressed delivery plan trajectory; contact and engagement will be through Flu Ops Group and Primary Care Network (PCN)/Locality Leads in collaboration with relevant CCG Clinical Leads and PCN Clinical Directors.

14. From a communications perspective the following is being explored:

• Local amplification of national campaign on Flu • Targeted check with practices on what communications they have undertaken with

patients and determine what support can be provided • Target public communications in the area of those practices with low uptake. This

will include media and hyperlocal social media channels. • Target seldom heard groups • Work directly with voluntary and community organisations to send information to their

networks – we will target those cohorts with low uptake e.g. Age concern for elderly, support groups for those with long – term conditions

• Engage the PPGs to cascade information wider through their networks • Continue to push messages out through local authority channels • Continue general communications across LLR: media, social media etc.

15. Whilst this update focusses on accessing the flu vaccination programme within general

practice it needs to be recognised that this year’s flu programme is challenging and all organisations across Leicester, Leicestershire and Rutland are working hard to maximise uptake.

Integrated Care System (ICS) Governance 16. As previously report, it is expected that all systems will become Integrated Care Systems

by 1 April 2021 and there are two opportunities for a system to go through an approval process with NHS England and NHS Improvement: one in November 2020 and one in February 2021. Following a meeting with the NHS England / NHS Improvement local team and the Chief Executives of University Hospitals of Leicester NHS Trust (UHL),

4

Leicestershire Partnership NHS Trust (LPT) and the LLR CCGs it was agreed that LLR would go through the February 2021 process.

17. To support this process it was agreed that an independent Chair would be appointed for the ICS and governance arrangements would be established across the system.

18. Appended to this report is the system level governance arrangements that have been

agreed in October 2020. These arrangements will support the development of an integrated system to drive service transformation, collective action and accountability to deliver improved outcomes for the population of LLR and deliver the requirements of the NHS Long Term Plan. The structure will enable the necessary relationships to be established to support collaborative decision making as we mature as a system.

Hinckley 19. Prior to the start of the COVID-19 pandemic West Leicestershire Clinical Commissioning

Group had plans to redevelop services in Hinckley which proposed the relocation of:

• Endoscopy and Day case Services to Hinckley and Bosworth Community Hospital from Hinckley and District Hospital

• some services, namely X-Ray and diagnostics from Hinckley and District Hospital to Hinckley Health Centre

• of some beds from Hinckley and Bosworth Community to Loughborough Hospital. 20. However these plans have been revisited in light of our experience from the COVID-19

pandemic to understand if our plans would change as a result. The findings from this review indicates that we need to assess the impact of the future of virtual outpatient appointments; reassess space requirements in light of infection, prevention and control measures; and how we might use the beds at Hinckley and Bosworth Community Hospital in the future. As a result we have concluded that we need to revisit the option appraisal stage of our proposals to determine the right solution in a post COVID-19 situation. The revised option appraisal will explore the possibility of delivering a solution that is based around the current Hinckley and District Hospital and Hinckley Health Centre sites, working with wider partners. This work is likely to take about six months and during this time we will be engaging with the local population about our plans.

Lutterworth 21. Lutterworth is due to grow over the next few years with the development of 2,750 new

homes on the Lutterworth East site. In order to ensure that health services can met this increased demand the CCG and Harborough District Council have committed to work together to develop a plan for the Lutterworth area which will include both primary care services and community based services. Work will be ongoing over the next six to twelve months and we will be engaging with the local population and local groups to take this work forward.

Update from the Executive Management Team (EMT) meeting (October 2020) 22. Members of the Governing Bodies will recall that last month EMT meetings were formally

constituted as a group accountable to the Governing Bodies. It was agreed that the formal route of reporting would be through this report.

5

23. In addition, to the items covered elsewhere in this report and also on the agenda of the Governing Bodies’ meeting, the following provides an overview of some of the other key areas considered by EMT during October:

a. Innovation Event “12 days of Christmas” - the idea generated locally by Nicci Briggs, provides an opportunity to develop and submit new innovative ideas that may not otherwise progress due to lack of resources. The innovative ideas generated and put forward should help LLR to deliver one of the following aims: quality improvement, improving patient experience, improving staff health and well-being, and transformative innovations. Staff and colleagues from primary care are encouraged to take up the challenge and come up with great ideas that will be implementable by 31 March 2021 and be a one-off cost.

b. Deputies / Direct-reports Group - EMT has established the Deputies and Direct-reports Group as a sub-group and approved its terms of reference. The Group will be instrumental in supporting the day-to-day operational management of the running of the CCGs.

c. A regular update on risk management arrangements was presented. EMT were

assured that positive progress has been made to establish directorate / team level operational risk registers and work continues to ensure the LLR CCGs’ Board Assurance Framework (BAF) is regularly reviewed. It was recognised that the BAF will continue to evolve over the next few months as we work through organisational transition arrangements.

d. Quarterly workforce metrics report was received highlighting staff sickness

absence and uptake of mandatory training required further review once the management of change process is complete.

Management of Change 24. The management of change process for posts at Bands 8b -2 is progressing to plan and

on track to conclude by the end of the calendar year. The 30 day consultation process started on 12 August and closed on 11 September. A staff briefing to communicate the outcome of consultation took place on 22 September and with the exception of Medicines Optimisation and Operational Finance, new structures were confirmed and have been published. The process for appointing to the new structures at bands 8b-2 is being managed in two phases, the first phase for posts at bands 8b-7 is complete and the second phase for posts at bands 6 – 2 commenced on 4 November and is planned to finish on 23 December. Some vacant posts at bands 8b-7 have been advertised externally where these have not been filled internally.

25. For the Medicines Optimisation and Operational Finance teams, further work was required to review the feedback and agree next steps. For Medicines Optimisation the final structure has been agreed and recruitment to posts has commenced. For Operational Finance, a new consultation process for posts at bands 9 – 2 commenced on 27 October and will close at midday on 10 November. The Corporate Governance and Contracting teams are not affected by the new consultation process and the timescales for appointing to the new operational finance structure will be confirmed at the close of consultation.

6

Delivering a ‘Net Zero’ National Health Service 26. The NHS has already made progress to reduce its carbon footprint, but more remains to

be done. In October 2020, Delivering a ‘Net Zero’ National Health Service was published https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/ . The report provides a detailed account of the NHS’ modelling and analytics underpinning the latest NHS carbon footprint, trajectories to net zero and the interventions required to achieve that ambition. It lays out the direction, scale and pace of change. It describes an iterative and adaptive approach, which will periodically review progress and aims to increase the level of ambition over time.

Recommendation The Leicester, Leicestershire and Rutland CCG Governing Bodies are asked to: • RECEIVE for information the Accountable Officer’s report.

https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/

https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/

0 | P a g e

LEICESTER, LEICESTERSHIRE AND

RUTLAND INTEGRATED CARE

SYSTEM GOVERNANCE ARRANGEMENTS

ICS

Governance

Final Version

2nd November

2020

1 | P a g e

CONTENTS

1. Introduction

2

2. Proposed System Governance Diagram

3

3. High level summary of groups

5

4. Terms of Reference for System Leaders Group

9

5. Terms of Reference for NHS Executive Group 17

6. Terms of Reference for System Operational Group

24

2 | P a g e

1. Introduction

This document sets out Leicester, Leicestershire and Rutland (LLR) Integrated Care System’s (ICS)

governance structure which:

Will support the development of an integrated system to drive service transformation,

collective action and accountability to deliver improved outcomes for the population of LLR

and deliver the requirements of the NHS Long Term Plan.

Provides a structure to build the necessary relationships, alignment, development and

decision making as we mature our Integrated Care System over the next 18 months.

Provides a structure for the local NHS organisations to work collaboratively together on

issues that are NHS in nature.

Sets out how we will work at place as well as system level.

The ICS governance structure is designed to be a vehicle to enable closer collaboration with enabling

governance and simplified structures to ensure the system and NHS partners can work effectively

together. It is not replacing the statutory responsibilities of each organisation.

Partners in Leicester, Leicestershire and Rutland have worked collaboratively together on

transformation for number of years, through the Better Care Together Programme and the Better

Care Fund, and have developed a vision for delivery of integrated care focused on managing and

improving population health; community based integrated health and social care; and acute

provision no bigger than needed.

In the context of the national direction of travel, for all areas to be mature Integrated Care System

by April 2021, it is timely to consider our governance arrangements to support us achieving this and

also to take the learning from the way the system has managed the recent COVID-19 emergency.

The key finding is to develop a governance structure that supports continued collaboration and

partnership working at pace, which is agile and as streamlined as possible. This is reflected in our 10

System Expectations and associated actions under the enabling culture expectation.

All systems will become Integrated Care Systems by 1st April 2021 and the NHS is being increasingly

held to account as a NHS system for finance, performance and delivery. Therefore it is important

that within any revised governance structure there is NHS system ownership of all these areas.

The proposals are embedded in patient and public engagement and insight together with strong

clinical input and leadership. Transformation and delivery will be driven through Design Groups

which will work on an integrated pathway basis and through the Place Based Groups who will ensure

delivery and integration at a place level.

The System Leaders Group will be responsible for the overall delivery of the strategy. It will set the

strategy, plans and outcomes for the system to deliver against. A NHS Executive Group will drive

forward collaboration and delivery of NHS business across partners including operational planning;

finance and performance. Both groups will be chaired by an ICS Independent Chair.

Overseeing development and delivery is the System Operational Group which will be supported by

the LLR Chief Finance Officers Group; the LLR System Planning Operational Group; LLR Clinical

Executive and the LLR Quality and Performance Group.

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Work has been undertaken to explore the options in relation to the decision making powers of joint

groups. Given that current legislation does not enable a joint committee of providers and

commissioners then any decision making required would need either to be done within the

individual members delegated authority or by referring matters to statutory bodies. This may change

over time and as such governance arrangements will be reviewed as and when required.

2. Proposed System Governance

The goverannce structure has been designed to enable to Design and Place Based Groups to drive

forward innovation, transformation and integration to improve outcomes for the LLR population.

The System Leaders Group will set the priorities for the sytem yearly and ask the Design Groups to

deliver agianst these with the NHS Executive Group in the longer term allocating resources to Design

Groups.

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Place Based Groups

The governance for each of the Place Based Groups is detailed below:

Leicester City

Leicestershire County

Rutland County

In addition to this formal structure the NHS Chief Executives and the elected leaders of the Upper

Tier Local Authorities have committed to meet on a regular basis to enable collaboartive working to

take place across local government and health.

Design and enabling groups

The following groups have been set up to drive transformation across Leicester, Leicestershire and

Rutland. They will be multi-disciplinary teams.

3. High level summary of group

Design Groups Integrated Cancer Pathways Integrated Elective Pathways Integrated Primary and

Community Care Integrated Medicines

Optimisation Acute and Tertiary Services Children and Young People

Pathways Maternity Services All age Mental Health

Services Integrated Learning Disability

Services

Enabling Groups System Communications and

Engagement Estates Digital System Business Intelligence Population Health Management Prevention and Health

Inequalities Infection, Prevention and

Control LLR People Board

Health and Wellbeing Board

Joint Integrated Care Board

Integrated System of Care Group


Health and Wellbeing

Operational Board


Integration Executive

Integration Delivery Group

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3. Responsibilities

The following sets out high level responsibilities for each group.

Group Responsibility System Leaders Group Meets 2 -3 times a year (1 x planning conference and 1-2 meetings pa) Independent Chair

Set the strategic direction (Long Term Strategy), vision, yearly priorities and outcomes for integrated care in Leicester, Leicestershire and Rutland (LLR).

Ensure the strategic plans are adequate to address health inequalities across LLR.

Ensure collaboration between organisations across the system to deliver the strategy and enable LLR to work as an integrated care system.

Oversee the delivery of an integrated approach to service transformation and delivery within LLR.

Ensure delivery of the system plan and outcomes. Manage escalations from the System Operational Group. Collective problem-solving and consideration of system wide issues. Ensure that there is sufficient patient voice and insight into the development of

the LLR strategy.

NHS Executive Group Meets 6 times a year Independent Chair

Approve the yearly system operational plan for the NHS organisations. Oversight of the delivery of the NHS operational plan in year. Approve the NHS short, medium and long term financial plans and the NHS

system financial regime. Oversight and collective delivery of the NHS system financial resources including

the NHS system financial control total and allocations to sectors; Design Groups and Places.

Collective problem-solving and decision-making for NHS system-wide issues.

Manage any escalations from the System Operational Group. Oversight and monitoring of NHS performance against planned outcomes and

agree actions to address any variances from plan. This will include financial, quality and operational performance targets.

Ensure that there is sufficient patient voice and insight into the development of proposals to transform services.

Manage escalations from the System Operational Group.

System Operational Group Meets monthly Chaired by LLR STP Lead

Develop the Long Term Strategy for LLR on behalf of the System Leaders Group, via the System Planning Operational Group.

Develop the NHS Operational Plan each year and recommend this to the NHS Executive that delivers the plans set out in the system strategic plan; the LLR 10 System Expectations; and any local and national priorities, via the System Planning Operational Group.

To coordinate efficiency plans and opportunities between organisations to ensure there is no duplication in count and or effort.

Develop the NHS system financial plans and financial regime for recommendation to the NHS Executive Group, via the Chief Finance Officers Group.

Confirm and challenge the proposals from the Design Groups to meet the system clinical model, strategy and operational plans and approves Business Cases and or investments within the delegation of the group or recommends these to constituent organisations for recommendation.

Monitor delivery of Design Groups plans.

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Group Responsibility Monitor delivery of the system Strategy, Operational and Financial Plans. Manage NHS system performance including activity, target performance and

quality, via the NHS System Quality and Performance Group. Manage escalations from the Design Groups and other reporting groups.

Design Groups SRO from one of the system partners

Develop proposals for specific models of care and pathways that met the strategy, the LLR 10 System Expectations and operational plans and national requirements.

Implement approved proposals, models of care and pathways. Manage performance in specific areas including activity, target performance,

quality and efficiencies. Review implementation to inform future proposals. Contribute to the development of system strategies and operational plans. Manage any allocated budgets. Accountable for delivery of plans, performance and where allocated budgets.

Enabling Groups

Provide specialist and expert advice and support to the Design Groups. Develop strategy and plans for specialist areas contributing to the development of

system strategies and operational plans.

Place Based

Groups

Develop integrated care at place level.

Implementation of the Design Group’s proposals at a local level.

Ensure Place Based Plans meet the needs of the local population and address the

specific health inequalities of each place.

Work with health and wellbeing boards to set priorities and respond to local need

including issues wider than just health.

LLR Chief

Finance

Officers

Creates an affordable longer term financial planning framework and financial

regime for the NHS organisations in the system.

Develops the short, medium and long term financial plans for the NHS system.

Manages all system finance issues and oversees the delivery of the yearly financial

plan including the delivery of the system financial control total.

Proposes and advises the NHS Executive Group on allocative strategies for sectors,

Design Groups and Place.

LLR System

Operational

Planning

Group

Development of yearly NHS Operational Plan and supporting programmes.

Development of strategic direction for the system including the system Long Term

Plan.

Support Design Groups with identification of opportunities.

Demand and capacity modelling at a system level.

Co-ordinate system level planning returns required by NHS England/Improvement.

LLR Quality

and

Performance

Group

Systematically bring together different parts of the health and care economy to routinely and methodically share information and intelligence about quality and performance.

Provide a forum for local health economies to work openly and honestly together to identify quality outcomes for the local populations, monitor quality and performance information and identify opportunities for improvement across the

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Group Responsibility system.

Ensuring a shared understanding of risks to quality through sharing intelligence. Acting as an early warning mechanism of risk about poor quality to develop

system solutions where required. Provide opportunities to coordinate actions to drive improvement whilst

respecting statutory responsibilities of and ongoing operational liaison between organisations.

Collectively consider and triangulate information and intelligence to safeguard the quality of care. In particular:

What the data and emerging intelligence is indicating about where there might be concerns regarding the quality of services and patient outcomes.

Where they are is most worried about the quality and performance of pathways.

Whether further action is required to address concerns, or collect further information.

Where is there a lack of information and so a need for further consideration and/or information gathering.

Undertake ‘deep dives’ into areas indicated as causing concern.

Clinical

Executive

Group

Using organisational positions to inform & drive system strategy. Empowering clinical leads/unblocking barriers:

Support for design group clinical leads to lead design groups

LLR Academy Leadership/endorsement. Endorsing the strategic direction:

Ratifying the developments from the wider clinical leadership group. Oversight & approval of clinical pathways:

Managing interdependencies between Design Groups

Formal Clinical sign off and recommendation to System Operational Group/System Executive

Oversight of the system clinical risk register. TCS Process oversight:

Managing the interface between primary and secondary care.

Clinical

Leadership

Group

Develop the strategic direction for clinical leadership. Ensure wide involvement across clinicians to develop the clinical leadership

strategy. Become the Engine Room for ICS clinical innovation. Focus on problem solving across organisations/pathways/professions relating

to system working. Support the Transferring Care Safely work by sourcing appropriate task and

finish group members to resolve issues. Engage with organisational clinical forums on ICS priorities e.g. CCG Clinical

Reference Group, UHL Clinical Senate, LPT Clinical Groups, AHP Forums. Lead system OD/Clinical Leadership Development through the LLR Academy. Develop the OD plan for person-centred leadership. Drive clinical culture change across LLR. Develop clinical champions in health and care.

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Group Responsibility Patient and

Public

Assurance

Group

Deliver a strategic ‘critical friend’ functions to LLR partners in respect of the public

and patient involvement.

Maintain strategic oversight of the public and patient involvement work.

Maintain strategic oversight of the business intelligence and insights gathered from

the involvement to assure them that it has been used to design, organise and

commission health services, in line with the commissioning cycle.

Provide a transparent and evidenced based judgement in respect of the assurance

they provide on the public and patient involvement and the impact of business

intelligence and insights gathered.

Raise and escalate any concerns around assurance to the System Operational

Group or System Leaders Group, as appropriate.

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4. Terms of Reference Leicester, Leicestershire and Rutland System Leaders Group

Purpose

The Leicester, Leicestershire and Rutland System Leaders Group will oversee the joint collaborative

working arrangements across the system to deliver transformation in care to the Leicester,

Leicestershire and Rutland (LLR) population. It brings together the NHS, Upper Tier Local Authorities

and patient representative organisations and or groups to provide system-wide strategic leadership

and oversight to the strategic direction within LLR. This will include:

Setting the strategic direction (Long Term Strategy), vision, yearly priorities and outcomes for integrated care in Leicester, Leicestershire and Rutland (LLR).

Ensure the strategic plans are adequate to address health inequalities across LLR. Ensure collaboration between organisations across the system to deliver the strategy and

enable LLR to work as an integrated care system. Oversee the delivery of an integrated approach to service transformation and delivery within

LLR. Ensure delivery of the system plan and outcomes. Collective problem solving and consideration of system wide issues. Ensure that there is sufficient patient voice and insight into the development of the LLR

strategy. Manage escalations from the System Operational Group.

Responsibilities

The duties of the System Leaders Group will include the following:

Overseeing the development and implementation of the Leicester, Leicestershire and

Rutland Long Term Plan, including the LLR 10 System Expectations, setting out how the

system will work together to deliver improved outcomes to patients; reduce variation

and health inequalities; and respond to the priorities set out in the NHS Long Term Plan.

Drive forward the collaboration and partnership working within LLR so that we can meet the required maturity level expected within the NHS Long Term Plan for integrated systems by April 2021 and to continue to deliver thereafter.

Identify and work collectively to resolve barriers and issues that are impacting on implementation or progress in developing the system collaborative approach to resolution.

Consideration of significant system wide service and pathway changes, making necessary decisions or recommendations (depending on members’ delegated authority) and to consider, confirm and challenge the ambition and vision of plans, particularly with regard to integration of services.

Take collective responsibility to resolve issues escalated from the System Operational

Group.

Consideration of materials for local consultation exercises where there are implications for the wider system, prior to approval by individual organisations.

Consider regular reports on the level of patient and public engagement that has taken place to develop and implement proposals.

To co-ordinate communication messages from the System Leaders Group to the

individual organisations in the system.

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Membership

Leicester, Leicestershire and Rutland System Leaders Group membership is:

Independent Chair Chief Executive from each NHS Provider Trust (University Hospitals of Leicester, Leicestershire Partnership Trust, East Midlands Ambulance Service and DHU Healthcare) Chief Executive Leicester City, East Leicestershire and Rutland West Leicestershire Clinical Commissioning Groups Elected Executive representation from each of the Upper Tier Local Authorities and or nominated representative One Officer from each Upper Tier Local Authority Chairs of Leicester City, East Leicestershire and Rutland West Leicestershire Clinical Commissioning Groups Primary Care Network Clinical Directors x 3 Chairs from each NHS Provider Trust (University Hospitals of Leicester, Leicestershire Partnership Trust, East Midlands Ambulance Service and DHU Healthcare) Chair of Leicester, Leicestershire and Rutland Patient and Public Assurance Group Healthwatch Leicester and Leicestershire Healthwatch Rutland

Attendees

The meeting will also be attended by other senior officers responsible for specific aspects of work

as required by the agenda items.

Officer support to the Chair will be provided by the Executive Director Strategy and Planning

Leicester, Leicestershire and Rutland Clinical Commissioning Groups.

Quoracy

For decision-making purposes, a quorum shall be one representative from each of the NHS

organisations, one representative from the Primary Care Networks, one representative from

each Local Authority and one patient representative.

Given the need to foster relationships it is expected that the membership will be consistent

and members will attend all the meetings but when this is not possible than a deputy may

attend who has sufficient authority to act for the organisation.

A list of current membership is appended as Annex A to this document.

Role of members

Members will work together to develop relationships that will enable the system in LLR to mature

as an integrated care system and deliver improved patient outcomes; reduce variation and health

inequalities. This will include mutual scrutiny and challenge, holding each other to account and

working cooperatively. The expected behaviours are set out in Annex C.

Members of the System Leaders Group represent their organisations and the views of their

governing bodies, groups, committees and or boards. It is expected that, where necessary,

members shall ensure that recommendations presented to the System Leaders Group for decision

11 | P a g e

are considered by the appropriate body within their own organisation, to establish the shared view

of the organisation which they represent when attending the System Leaders Group.

Members shall also provide visibility within their own organisations of the considerations of the

System Leaders Group and ensure that issues and proposed solutions are discussed by the

appropriate bodies within member organisations.

Chair (role)

The System Leaders Group Chair will be an independent appointment, the Leicester, Leicestershire and Rutland Integrated Care System Chair. The role of the Chair is to convene the System Leaders Group, work with organisations to achieve consensus and to identify areas where escalation may be required to boards, governing bodies, relevant committees or external regulatory or assurance organisations as appropriate.

Where the Chair is unable to attend the meeting, the meeting shall be chaired by the Chief Executive

of Leicester, Leicestershire and Rutland Clinical Commissioning Groups as the Sustainability and

Transformation Lead for LLR.

Decision making

When making decisions the members of the System Leaders Group will work constructively and

pragmatically to reach a consensus position where all agree (i.e. voting arrangements will not apply

to the decision-making of the System Leaders Group).

Decisions of the System Leaders Group shall be made under an individual’s delegated authority from

their organisation.

Members shall ensure that their own constitutions and schemes of reservation and delegation

provide members of System Leaders Group with sufficient authority to take decisions on behalf of

their organisations on matters presented to the System Leaders Group.

Where an issue presented to the System Leaders Group for consideration is outside of an

individual’s authority then each member will make necessary arrangements within their own

organisations to ensure that decisions which require approval by Boards are taken in a timely

manner.

Where a decision has been made by the System Leaders Group, it shall be reported to the individual

organisations Boards, as appropriate.

Meetings

The System Leaders Group shall meet three to four times a year to coincide with key milestones.

One of these meetings will be a yearly conversation to set the coming years priories and plans. This

will involve a wider membership drawn from other public and voluntary sectors of the LLR system.

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Where an additional meeting is required outside of the established meeting pattern it shall be for

the Chair to convene the meeting, providing five clear working days’ notice.

Papers will be circulated one week in advance, to enable organisations to consider the implications

for their own operations in advance of the System Leaders Group. Where this is not possible, any

later circulation must be agreed with the Chair in advance. Late circulation may affect

organisations’ ability to reach a consensus at that meeting.

Meeting administration will be through the LLR CCGs Chief Executives office.

Conflicts of Interest

The meetings of the System Leaders Group will be supported by a screening panel. The panel will

review agendas and papers in advance of each meeting of the System Leaders Group to identify

those items where a decision may be required and confirm whether the decision sought is within

the powers of the System Leaders Group via the delegated authority of the decision-making

members. Any possible conflicts of interest will also be identified by this panel and communicated

to the chair in advance of the meeting and clearly documented (including how the conflict was

managed).

The meetings will make the distinction between items for discussion and those where a decision is

required, to allow conflicted members and attendees to withdraw if necessary.

Accountability

The System Leaders Group does not usurp or replace any existing statutory accountabilities of

member organisations. Individual member organisations retain their statutory accountabilities to

their respective regulatory and oversight bodies.

Reporting into the System Leaders Group will be the System Operational Group.

A diagram showing the governance structure is attached as Annex B.

Review

The Terms of Reference will be reviewed at six months from the first meeting of the System Leaders

Group. Thereafter they will be reviewed every year or sooner should be the need arise.

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Annex A

Members and Named Deputies

Organisation Member Role

Independent Chair

Elected Executive Member Leicestershire County Council and or nominated representative

Elected Executive Member Leicester City Council and or nominated representative

Elected Executive Member Rutland County Council and or nominated representative

Officer Leicestershire County Council

Officer Leicester City Council

Officer Rutland County Council

Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Andy Williams LLR CCGs Chief Executive Officer

LLR Sustainability and Transformation Lead

Leicester City Clinical Commissioning Group Professor Azhar Farooqi Clinical Chair

West Leicestershire Clinical Commissioning Group Professor Mayur Lakhani Clinical Chair

East Leicestershire and Rutland Clinical Commissioning Group

Dr Vivek Varakantam Clinical Chair

University Hospitals of Leicester NHS Trust Rebecca Brown Interim Chief Executive Officer

University Hospitals of Leicester NHS Trust Karamjit Singh Chair

Leicestershire Partnership NHS Trust Angela Hillery Chief Executive Officer

Leicestershire Partnership NHS Trust Cathy Ellis Chair

East Midlands Ambulance NHS Trust Richard Henderson Chief Executive

East Midlands Ambulance NHS Trust Pauline Tagg Chair

DHU Healthcare Stephen Bateman Chief Executive

DHU Healthcare David Whitney Chair

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Primary Care Network Representative Dr Aruna Garcia City PCN Representative

Primary Care Network Representative Dr Hilary Fox Rutland PCN Representative

Primary Care Network Representative Dr Anu Rao Leicestershire PCN Representative

Patient and Public Assurance Group Evan Rees Chair

Healthwatch Leicester and Leicestershire

Healthwatch Rutland

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Annex B

System Governance Structure

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Annex C

Behaviours to support collaborative working

To enable the system to work effectively the following behaviours are expected of members.

We are committed to working collaboratively to meet the health and care needs of the people served by our System, provide high-quality services and improve health outcomes. To do this we will work together in the following ways: We will work together collaboratively providing whatever support and assistance we can

to each other to do so. We will act with utmost good faith towards each other.

We will seek solutions and agree and take actions which offer the most effective and

efficient use of our resources in the best interest of our System and the people we serve,

even where those solutions and actions may not be in the immediate best interests of any

one or more of us individually.

We will be as open and transparent with each other as we are within our own

organisations. We will, on an open-book basis, provide each other with all information

that is reasonably required and to enable appropriate mutual scrutiny and challenge.

We will hold each other to account. We will scrutinise and challenge each other, and we

will each be open to scrutiny and challenge by others. We will support each other in

meeting those challenges.

We will engage and co-operate with all partners in our System giving due consideration

to their views and suggestions. We will use our reasonable endeavours to ensure that we do not have a negative impact on other Systems.

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5. Terms of Reference Leicester, Leicestershire and Rutland NHS Executive Group

Purpose

The role of the Leicester, Leicestershire and Rutland NHS Executive Group is to oversee the joint

collaborative NHS working arrangements across the system to deliver transformation in care;

financial sustainability; the yearly operational plan; and improved health outcomes for the

population of LLR.

Responsibilities

The duties of the NHS Executive Group will include the following:

Driving forward the collaboration and partnership across the NHS within LLR to deliver improved outcomes to patients; reduce variation and health inequalities.

Identify and work collectively to resolve barriers and issues that are impacting on implementation or progress in developing the NHS system collaborative approach.

Oversee, test and approve any NHS system Operational Plans ensuring that it will meet priorities set in the system Long Term Plan; the LLR 10 expectations; and national and local priorities.

Oversee, test and approve, both the long and short term NHS financial plans including

the use of investments and transformation funding and the robustness of efficiency

plans.

Oversee the delivery of the yearly NHS financial system plan, taking action to mitigate

risk of non-delivery.

Plan and oversee the NHS system capital allocations and consider business cases for major capital expenditure prior to approval by individual NHS governing bodies and boards.

Oversee the delivery and take collective action to ensure key NHS performance targets can be delivered and take action where necessary to recover performance.

Take collective responsibility to resolve NHS system issues and those escalated from the

System Operational Group.

Consider regular reports on the level of patient and public engagement that has taken place to develop and implement proposals.

Membership

Leicester, Leicestershire and Rutland NHS Executive Group membership is:

Independent Chair Chief Executive from each NHS Provider Trust (University Hospitals of Leicester, Leicestershire Partnership Trust, East Midlands Ambulance Service and DHU Healthcare) Chief Executive Leicester City, East Leicestershire and Rutland West Leicestershire Clinical Commissioning Groups Chairs of Leicester City, East Leicestershire and Rutland West Leicestershire Clinical Commissioning Groups Primary Care Network Clinical Directors x 3 Chairs from each NHS Provider Trust (University Hospitals of Leicester, Leicestershire Partnership Trust, East Midlands Ambulance Service and DHU Healthcare)

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Attendees



Officer support to the Chair will be provided by the Executive Director Strategy and Planning

Leicester, Leicestershire and Rutland Clinical Commissioning Groups.

Quoracy

For decision-making purposes, a quorum shall be one representative from each organisation

and one representative from Primary Care Networks.

Given the need to foster relationships it is expected that the membership will be consistent

and members will attend all the meetings but when this is not possible than a deputy may

attend who has sufficient authority to act for the organisation.

A list of current membership is appended as Annex A to this document.

Role of members

Members will work together to develop relationships that will enable the NHS system in LLR to

mature as an integrated care system and deliver improved patient outcomes; reduce variation and

health inequalities; deliver and sustain performance and deliver a sustainable financial plan. This

will include mutual scrutiny and challenge, holding each other to account and working

cooperatively. The expected behaviours are set out in Annex C.

Members of the NHS Executive Group represent their organisations and the views of their

governing bodies and or boards. It is expected that, where necessary, members shall ensure that

recommendations presented to the NHS Executive Group for decision are considered by the

appropriate body within their own organisation, to establish the shared view of the organisation

which they represent when attending the NHS Executive Group.


NHS Executive Group and ensure that issues and proposed solutions are discussed by the


Chair (role)

The NHS Executive Group Chair will be the Leicester Leicestershire and Rutland Integrated Care System Independent Chair. The role of the Chair is to convene the NHS Executive Group, work with organisations to achieve consensus and to identify areas where escalation may be required to boards, governing bodies or external regulatory or assurance organisations as appropriate.

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Where the Chair is unable to attend the meeting, the meeting shall be chaired by the Chief Executive

of Leicester, Leicestershire and Rutland Clinical Commissioning Groups as the Sustainability and

Transformation Lead for LLR.

Decision making

When making decisions the members of the NHS Executive Group will work constructively and


to the decision-making of the System Executive Group).

Decisions of the NHS Executive Group shall be made under an individual’s delegated authority from

their organisation.


provide members of NHS Executive Group with sufficient authority to take decisions on behalf of

their organisations on matters presented to the NHS Executive Group.

Where an issue presented to the NHS Executive Group for consideration is outside of an individual’s

authority then each member will make necessary arrangements within their own organisations to

ensure that decisions which require approval by Boards are taken in a timely manner.

Where a decision has been made by the NHS Executive Group, it shall be reported to the individual

organisations Boards, as appropriate.

Minutes of the NHS Executive Group will be taken to individual organisations Public Board meetings.

Meetings

The NHS Executive Group shall meet six times a year. Where an additional meeting is required

outside of the established meeting pattern it shall be for the Chair to convene the meeting,

providing five clear working days’ notice.

Papers will be circulated one week in advance, to enable organisations to consider the implications

for their own operations in advance of the NHS Executive Group. Where this is not possible, any

later circulation must be agreed with the Chair in advance. Late circulation may affect

organisations’ ability to reach a consensus at that meeting.

Meeting administration will be through the LLR CCGs Chief Executives office.


The meetings of the NHS Executive Group will be supported by a screening panel. The panel will

review agendas and papers in advance of each meeting of the NHS Executive Group to identify

those items where a decision may be required and confirm whether the decision sought is within

the powers of the NHS Executive Group via the delegated authority of the decision-making

members. Any possible conflicts of interest will also be identified by this panel and communicated

20 | P a g e

to the chair in advance of the meeting and clearly documented (including how the conflict was

managed).

The meetings will make the distinction between items for discussion and those where a decision is

required, to allow conflicted members and attendees to withdraw if necessary.

Accountability

The NHS Executive Group does not usurp or replace any existing statutory accountabilities of

member organisations. Individual member organisations retain their statutory accountabilities to

their respective regulatory and oversight bodies.

The NHS Executive Group will be accountable to the boards and governing bodies of its members.

Reporting into the NHS Executive Group will be the System Operational Group who will report on

financial, strategy, planning, programme and quality and performance issues.


Review

The Terms of Reference will be reviewed at six months from the first meeting of the NHS Executive

Group. Thereafter they will be reviewed every year or sooner should the need arise.

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Annex A



Independent Chair

Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Andy Williams LLR CCGs Chief Executive Officer

LLR Sustainability and Transformation Lead

Leicester City Clinical Commissioning Group Professor Azhar Farooqi Clinical Chair

West Leicestershire Clinical Commissioning Group Professor Mayur Lakhani Clinical Chair


Dr Vivek Varakantam Clinical Chair

University Hospitals of Leicester NHS Trust Rebecca Brown Interim Chief Executive Officer

University Hospitals of Leicester NHS Trust Karamjit Singh Chair

Leicestershire Partnership NHS Trust Angela Hillery Chief Executive Officer

Leicestershire Partnership NHS Trust Cathy Ellis Chair

East Midlands Ambulance NHS Trust Richard Henderson Chief Executive

East Midlands Ambulance NHS Trust Pauline Tagg Chair

DHU Healthcare Stephen Bateman Chief Executive

DHU Healthcare David Whitney Chair

Primary Care Network Representative Dr Aruna Garcia City PCN Representative

Primary Care Network Representative Dr Hilary Fox Rutland PCN Representative

Primary Care Network Representative Dr Anu Rao Leicestershire PCN Representative

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Annex B


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Annex C

Behaviours to support collaborative working

The following behaviours are expected of members and which forms part of the standard NHS

Contract for 2020/21.

We are committed to using our collective resources as efficiently and effectively as possible to meet the health and care needs of the people served by our System, provide high-quality services and improve health outcomes. To do this we will work together in the following ways: We will work together collaboratively providing whatever support and assistance we can

to each other to do so. We will act with utmost good faith towards each other.

We will seek solutions and agree and take actions which offer the most effective and

efficient use of our collective resources in the best interest of our System and the people

we serve, even where those solutions and actions may not be in the immediate best

interests of any one or more of us individually.

We will ensure that our respective operational plans and plans for spending within the

System for 2020/21 and beyond are aligned so that successful delivery of each

operational and spending plan is a success for all of us and contributes towards achieving

our Objectives.

We will be as open and transparent with each other as we are with our own board

members/Regional leadership. We will, on an open-book basis, provide each other with

all information that is reasonably required and to enable appropriate mutual scrutiny and

challenge.

We will hold each other to account. We will scrutinise and challenge each other, and we

will each be open to scrutiny and challenge by others. We will support each other in

meeting those challenges.

We will engage and co-operate with other commissioners and providers of health and

care services for the people served by our System (including commissioners and providers of primary care and social care services), giving due consideration to their views and suggestions. We will use our reasonable endeavours to ensure that we do not have a negative impact on other Systems.

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6. Terms of Reference Leicester, Leicestershire and Rutland System Operational Group

Purpose

The Leicester, Leicestershire and Rutland System Operational Group will oversee the delivery of the

systems transformational plans. This will include:

Setting and monitoring the yearly financial plan and the long term financial plan and regimes for the NHS system;

Develop on behalf of the System Executive the system Long Term Strategic Plan; Develop on behalf of the NHS Executive the yearly Operational Plan; Oversee the programme and project assurance arrangements to deliver the yearly financial

plan and strategic programmes;

Manage escalations from the Design Groups;

Oversees the NHS performance at a system level.

Responsibilities

The duties of the System Operational Group will include the following:

NHS Finance:

Develop the system NHS Long Term financial plans and financial regime on behalf of the NHS Executive and gain approval from NHS members Boards and NHS England/Improvement.

Develop the NHS system yearly financial plans and financial regime on behalf of the NHS Executive and gain approval from NHS members Boards and NHS England/Improvement.

Monitor, take action as necessary and report on the NHS system financial plans to the NHS Executive and NHS member Boards.

Consider all investments and efficiency Business Cases that impact on the NHS system Financial Plan or refocus resources. Approve where the proposal is within delegation of the individual members of the group and if not make recommendations to the relevant approving committee or board.

Oversee and make decisions about the use of any in year NHS contingency funds that have

been built into the NHS System Financial Plan.

Manage any risk and gain share arrangements across commissioners and providers and

make any necessary recommendations to the relevant board or committee.

Monitor, on a monthly basis, financial delivery of all efficiency programmes that form part of

the yearly and the Long Term Financial Plans ensuring that efficiency models such as

RightCare, Model Hospital and Getting It Right First Time are utilised in developing plans.

Reporting on progress, both milestones and financial targets, to the NHS Executive Group

and individual organisations.

To develop any in year financial recovery plans to enable the system to deliver its financial

plan for the year.

Strategy:

Develop and recommend Long Term Strategy for LLR on behalf of the System Leaders Group.

Ensure that health inequalities are addressed in plans.

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Monitor implementation of the actions set out in the Long Term Strategy and the LLR 10

System Expectations for LLR.

Attendees



Quoracy

For decision-making purposes, a quorum shall be one representative from each organisation.

Members shall be entitled to send a nominated deputy. Deputies shall be nominated in

advance. A list of current membership and deputies is appended as Annex A to this document.

Role of members

Members will work together to ensure that the NHS system in Leicester, Leicestershire and Rutland

can deliver its strategic, operational and financial plan.

Members of the System Operational Group represent their organisations and the views of their

governing bodies and/or boards. It is expected that, where necessary, members shall ensure that

any decisions required to be made by organisations are done so in a timely manner.


System Operational Group and ensure that issues and proposed solutions are discussed by the


Chair (role)

The System Operational Group will be chaired by the Sustainability and Transformation lead for

Leicester, Leicestershire and Rutland.

The role of the Chair is to convene the System Operational Group, work with organisations to

achieve the responsibilities set out in these Terms of Reference and to identify areas where

escalation may be required to the System Executive Group.

Where the Chair is unable to attend the meeting, the meeting shall be chaired by one of the

Directors of Finance or Directors of Strategy and Planning.

Decision making

When making decisions the members of the System Operational Group will work constructively and


to the decision-making of the System Operational Group).

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Decisions of the System Operational Group shall be made under an individuals’ delegated authority

from their organisation.


provide members of System Operational Group with sufficient authority to take decisions on matters

presented to the System Operational Group on behalf of their organisations.

Where an issue presented to the System Operational Group for consideration is outside of an

individuals’ authority then each member will make necessary arrangements within their own

organisations to ensure that decisions which require approval by Boards or Committee are taken in a

timely manner.

Meetings

The System Operational Group shall meet monthly, where an additional meeting is required outside

of the established meeting pattern it shall be for the Chair to convene the meeting, providing five

clear working days’ notice.

Papers will be circulated five working days in advance, to enable organisations to consider the

implications for their own operations in advance of the System Operational Group meeting. Where

this is not possible, any later circulation must be agreed with the Chair in advance. Late circulation

may affect organisations’ ability to reach a consensus at that meeting.

Meeting administration will be through the LLR CCGs Director Strategy and Planning office.


Members must ensure that they abide by their own organisations Conflict of Interest policy.

Members of the System Assurance Group should report any Conflict of Interests on agenda items at

the beginning of each meeting. The Chair will then decide how the item will be handled – this may

include the member(s) with the conflict to be excluded from either or both of the discussion and

decision.

Accountability

The System Operational Group will be accountable to the System Leaders Group for system issues

and to the NHS Executive Group for NHS issues. It will provide a regular report to both groups.

Reporting into the System Operational Group will be the LLR Chief Financial Officers Group; the

System Planning Operational Group; and the LLR Quality and Performance Group.


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Review

The Terms of Reference will be reviewed at six months from the first meeting of the System

Operational Group. Thereafter they will be reviewed every year or sooner should the need arise.

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Annex A


Role and Organisation Member

Chief Executive Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups LLR Sustainability and Transformation Lead

Andy Williams (Chair)

Operational Lead University Hospitals of Leicester Debra Mitchell

Executive Director Finance, Contracting and Governance Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Nicci Briggs

Chief Financial Officer University Hospitals of Leicester NHS Trust

Simon Lazarus

Director Finance Leicestershire Partnership NHS Trust

Dani Cecchini

Deputy Director Finance, Contracting and Governance (System Finance) Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Spencer Gay

Executive Director Strategy and Planning Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Sarah Prema

Director Strategy and Communications University Hospital of Leicester NHS Trust

Mark Wightman

Director of Strategy and Business Development Leicestershire Partnership NHS Trust

David Williams

Executive Director Integration and Transformation Leicester City, East Leicestershire and Rutland, West Leicestershire Clinical Commissioning Groups

Rachna Vyas

Executive Representation from DHU Healthcare

Executive Representation from East Midlands Ambulance Service

Chair System Quality and Performance Committee

Where a named deputy is also unable to attend then the organisation may nominate a suitably qualified alternate.

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Annex B


E

Blank Page


Rutland CCG


interest: None identified


Supports the objectives around quality of urgent care, ED waiting times and ambulance handover times, and EPRR


No financial implications noted.


Ensuring that the urgent care system operates as smoothly as possible over winter is vital to ensuring that patients who need emergency care are seen with no delay.


The LLR winter planning arrangements were presented to JHOSC in September.


N/A


Date: 10th November 2020

Paper: E Public Confidential

Report title:

LLR Winter & Surge and resilience OPEL Plan

Presented by: Rachna Vyas, Executive Director of Integration and Transformation

Report author: Tamsin Hooton, Assistant Director of Urgent and Emergency Care

Executive lead: Rachna Vyas, Executive Director of Integration and Transformation



Executive summary: The purpose of this report is to provide an overview and update on the LLR Winter and surge and resilience OPEL plan.

Appendices: • Appendix 1 – LLR Winter Plan

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE The LLR Winter and Surge and resilience plan


• Urgent and Emergency Care Cell 06/10/2020 • Earlier draft received by the LLR Governing Bodies in confidential session

in October 2020.

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LLR Winter plan and surge and resilience arrangements 2020/2021 Introduction 1 The LLR winter plan for 20/21 has been developed to provide a clear overview of

actions in place to cover the winter period. This year the plan takes into account the additional complexities caused by the COVID pandemic.

2 Winter planning for 2020/21 brings with it added complexities, due to: • the likelihood of further outbreaks of COVID-19; • an expected increase in non-elective activity pressures due to seasonal

illness • reduced capacity as a result of cohorting and IPC requirements; and • the need to restore elective activity and deal with a growing back log of

routine and planned care

3 Whilst traditionally a separate winter plan is required to be submitted to NHSE/I, for 20/21 due to the additional pressure of COVID 19 and the overlap between winter planning and COVID recovery planning the regulators felt that winter resilience could be covered as part of the phase 3 return. However, system partners agreed that it would be of use to have a stand-alone plan summarising our winter resilience arrangements bringing together our OPEL surge and escalation plans along with a description of additional capacity and schemes to support winter resilience.

4 The arrangements for winter in the attached plan reflect the plans in the LLR phase 3 COVID recovery submission, which also covers the same period. The development of the plan has been led by the Urgent and Emergency Care cell, with input from all system partners.

5 The Emergency care team have attended an assurance meeting with a

delegation of subject matter expects from NHSEI and concluded that our planning for winter preparedness was proportionate and detailed in response to the key risks that face the system over the coming 6 months.

6 The plan summarises the way that system partners will work together to manage

system pressures and maintain effective services over the coming six months. Key schemes to manage demand for urgent care and reduce hospital attendance or ambulance conveyance are described in the report.

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Surge and Resilience Plan

7 This year the Emergency care team has reviewed the LLR surge and resilience plan which builds on and responds to Operational Pressures Escalation Level (OPEL) reporting and governs the actions taken by each system partner/organisation to manage pressures in the system at different levels of escalation. The outcome of this review felt it necessary to streamline the plan and produce action cards for each provider dependant on level of escalation reporting.

8 The plan describes the clear organisational and system actions required by each provider in order to de-escalate and spread the level of risk across the system ensuring that patient safety and care is paramount. In addition, there are separate COVID action plans which are not included in this document but which support the COVID cells in responding to changing levels of COVID alert, enacting plans to manage the level of virus in healthcare settings including stepping down non-essential activity and mutual aid to maintain essential workforce.

9 This year, we have included primary care escalation levels and actions within the surge and resilience plan for the first time. This is an important development that recognises the importance of resilient primary care within the health care system Alongside this the OPEL plan also details the actions that will be taken to support primary care resilience and the actions that primary care will take in support of the wider system at different levels of pressure. Consistent reporting of primary care pressures in real time is new development for LLR and the UEC cell is working with the primary care cell to take this forward.

Recommendations The LLR CCGs’ Governing Bodies are asked to RECEIVE the LLR winter and surge and resilience plan for 2020/2021.

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Leicester, Leicestershire and Rutland Health and Social Care Economy

Winter planning arrangements

November 2020 – March 2021

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Leicester, Leicestershire and Rutland Winter Plan 2020/2021 1. Introduction This document summarises the arrangements in place within the Leicester, Leicestershire and Rutland (LLR) system to enhance capacity and to maximise our resilience to respond to winter pressures. Winter is defined as the period from November to the end of March and is traditionally the period when health and social care services are under greatest pressure.

This plan relates to the work of the following system partners:

Leicestershire Partnership Trust East Midlands Ambulance Service University Hospitals of Leicester Primary Care Networks GP Federations DHU Health Care TASL Patient Transport Leicester City Council Social Care Leicestershire County Council Social Care Rutland County Council Social Care East Leicestershire and Rutland CCG West Leicestershire CCG Leicester City CCG

Winter planning for 2020/21 brings with it added complexities, due to:

• the likelihood of further outbreaks of COVID-19; • anticipated COVID-19 vaccination programme • 2nd wave of COV-19 there will be more cohorts of patients being identified and

added to the Shielded Patient List (SPL) • an expected increase in non-elective activity pressures due to seasonal illness • reduced capacity as a result of cohorting and IPC requirements; and • The need to restore elective activity and deal with a growing back log of routine and

planned care. 2. Governance and Escalation processes We have developed a surveillance group called SAGE that monitors a range of metrics in real time, including COVID infection rates and both COVID and non-COVID related activity, in order to establish the level of pressure that the system is under and assess the likelihood of increases in COVID putting pressure on the ability to maintain safe services delivery and restore services. The SAGE alert level is reviewed at least weekly in response to changing rates of COVID across the system and informs actions across the system, including primary care, such as the stepping up or down of COVID capacity and the pace of elective restoration. SAGE links to the Health Economy Tactical and Strategic groups as well as the LRF Recovery Group.

Winter planning, including the management of the system surge and escalation plan, will be overseen by the Urgent and Emergency Care Cell. This group was set up during the level 4

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incident to respond to the need to rapidly amend how urgent and emergency care services were set up as well as to oversee overall levels of pressure across the UEC system. As part of the recovery arrangements the cell has absorbed some of the functions of the previous AEDB including responsibility for maintain performance within the UEC system and the operation of the system surge and escalation plans. Ensuring a continued holistic whole system response the UEC cell continues to work closely with and be aligned to the Primary Care Cell. The UEC cell reports into both the tactical and strategic groups of the Health Economy resilience arrangements.

Throughout winter, the UEC Cell will maintain existing, effective methods of managing the urgent care system and responding to raised OPEL levels. This includes daily system calls to review the OPEL level in both individual organisations, including primary care and the system, agree any actions to de-escalate higher OPEL levels and provide cross system support to maintain effective flow. The weekly UEC cell meeting maintains senior oversight of system actions to respond to pressures and maintain performance and patient safety.

The system surge and resilience plan has been refreshed for Phase 3 to incorporate learning from phase 1, to reflect additional triggers related to COVID outbreaks and to incorporate additional surge capacity and actions to maximise system capacity and resilience that have been developed by system partners over the past 5 months. This is described in more detail in section 5.

2.1 Aims of the Winter Plan The key objectives of partners’ plans for winter are to:

• Reduce demand for unnecessary presentation at primary care, ED and other

emergency pathways through providing alternatives and increasing non conveyance rates;

• Reduce overcrowding in ED and urgent care sites; • Enable demand to be managed within the footprint of defined, existing bed capacity

and other capacity, setting out available core and surge capacity • Mitigate and manage situations whereby care provided in corridors occurs ensuring

risk and harm is avoided/mitigated; • Mitigate the risk that pressures within ED impact on ambulance handover, minimising

lost time and avoiding unseen risk in the community • Operate clear organisational and system-wide surge and escalation management

protocols, with the management of system escalation levels led by the CCG UEC team and primary care cell;

• Provide assurance that all services have and maintain priority actions and resilience plans;

• Support the primary care and community flu vaccination programme and increase health and social care staff take up;

• Build relationships across the system for providers to manage pressures effectively in collaboration;

• Ensure that patient flow is optimised and free up maximum bed capacity to cope with anticipated bed pressures;

• Provide assurance of how UHL’s ED is prepared to meet expected demand; • Describe plans for use of additional escalation bed capacity in both UHL and LPT

when required in response to admission rates and occupancy levels;

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• Describe plans in out of hospital services to increase capacity and/or manage demand to prevent admission/discharge step down to maintain flow

• Describe any additional plans required in response to COVID, in relation to IPC, surge and escalation.

• Ensure the continued delivery of high quality, safe care to patients by the whole system • Improve patient experience by removing unnecessary delays in care and delivering

care with a ‘right first time’ approach • Minimise the risk of excess deaths through supporting patients to access appropriate

care in the right setting, with appropriate PPE and IPC arrangements • Reduce unnecessary presentations and enable demand to be managed

through a whole system promoting self-care, signposting, use of Care Navigators and pharmacy first, self-referrals to physiotherapy, podiatry etc. and appropriate use of 111.

• Support primary care to remain resilient and sustainable 3. Arrangements to maximise capacity and manage demand for services over winter Appendix 1 summarises the current capacity across the LLR UEC system and sets out what additional capacity or demand management initiatives partners have in place for winter. This supports the wider system resilience approach to Phase 3. Initiatives in place for winter are discussed in more detail throughout this document.

Key actions include:

• Increasing capacity in the UEC model for urgent telephone and face to face contacts to restore the opening hours and range of service locations previously in place before COVID. During the emergency response to COVID in March and April, a number of sites were temporarily closed in response to the dramatic reduction in face to face activity. The increased capacity in the system over the 7 days of the week is summarised in Appendix 2. In total, this will expand the available clinical capacity for appointments by 31%.

• Changes to access arrangements at ED and other walk in sites put in place in response to COVID will be maintained within the NHS triage and COVID screening (including calls to NHS 111) before patients are seen.

• Continuing to deliver separate ‘hot’ clinics for patients who have either confirmed or suspected COVID and need to be seen urgently face to face, in addition to the existing urgent care sites across LLR. We have the ability to flex this capacity up or down very rapidly in response to the community infection rate, linked to the LLR COVID SAGE escalation level. From October, the delivery of hot clinics will change, with weekday delivery being managed by PCNs. The revised sites and access arrangements will be confirmed by the beginning of October.

• Strengthening the service delivered through NHS 111 to make sure that patients are seen in the right place at the right time, aiming to reduce unnecessary attendance and crowding in emergency departments and other site. Support NHS 111 to direct book into Hot and Cold sites and practices and use of alternative services, e.g. self-care, signposting, Care Navigators and community pharmacy.

• More support for care homes and East Midlands Ambulance Service crews responding to patients in care homes, with on call specialist consultant advice to agree the right approach to care and to keep patients in their place of residence wherever possible, ensuring alignment to the primary care Care Home programme.

• Investment to increase capacity in the Home First service, to recruit up to 44 additional community nurses, therapists and social care staff to work in partnership with primary care. This will support us in speedier discharge of patients, meeting new discharge guidance requirements, and avoiding admissions where patients

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can be kept at home with increased support through a crisis. • Increasing bed capacity in University Hospitals of Leicester to care for the

expected numbers of additional admissions over winter. An additional 75 winter beds are planned.

• Availability of 36 ‘surge’ beds in Leicestershire Partnership Trust which could be opened in case of a significant second COVID surge, or unmanageable winter pressures, conditional on staffing.

• Work with the three Universities in LLR to communicate the right access routes to healthcare to students including access to testing, encouraging GP registration and promoting wellbeing and mental health.

• Enhanced plans for flu vaccinations as part of our Flu Plan • The system has developed strengthened workforce plan in response to COVID

which includes mutual aid between organisations and effective monitoring of the workforce situation across health and social care. The workforce group has developed plans to support care homes as a vital part of the health and care system

• Ensuring system partners are aware of, able to access and fully utilise all referral routes, other than through Primary Care, for Mental Health services,

• Adherence to the 10 LLR System Principles / Expectations • Ensuring our staff and patients remain safe • Alignment of the Central DoS with Local Authority DoS and use of the mobile Dos

application • Improved and increased general signposting or Care Navigation to the public - well

before individuals pick up the phone for 111 or present at ED .4. Winter initiatives to manage demand and maximise flow This section summarises in some greater depth a number of initiatives across the LLR system to deliver the objectives of our winter plan, increase capacity and manage demand in ways that reduce pressures on ED and ambulance conveyance.

The impact of these initiatives on non-elective bed use and ED attendances is summarised in Appendix 2.

4.1 Reducing Inflow Demand

NHS 111 First

LLR has a strong track record of clinical assessment and navigation of patients calling 111 and 999. Currently LLR have direct booking between 111 and 95% of the LLR GP practices and 100% to our urgent care/primary care hub sites. We also transfer a significant volume of lower acuity ambulance calls to clinical assessment, with proven outcomes in reducing ambulance on scene activity and ED conveyance. We are building on this by developing an expanded 111 First model. We are a fast follower site for the Midlands and will be launching our expanded 111 First model from the 28th September, using a phased approach. We have established a 111 First project structure and programme plan, including a communications and engagement plan and demand and capacity modelling. Work has identified an expanded cohort of clinical conditions that can be transferred to clinical triage from 111, aiming to reduce ED dispositions. From the end of September 111 our clinical navigation hub will book ED patients into a timed slot within ED. Patients who self-present to ED will be triaged before being treated in ED and may be asked to contact

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111 to get an appointment in an alternative service if they do not need emergency care. The ED front door will have the capability to book patients into alternative sites and we will maintain a dedicated clinical resource to protect capacity in our system to take bookings from ED (1 GP, currently situated in Westcotes but this may move to Merlyn Vaz).

We will enable direct booking into SDEC, Hot Clinics and UHL specialities to bypass ED, taking a phased approach between September and November, with GPAU becoming bookable via bed bureau from the end of September. As additional pathways and alternative services are determined, the DoS will be profiled accordingly.

A key risk has been identified in relation to the possible increase in clinical assessment activity and/or an increase in referrals in alternative pathways without additional funding for 111 First and primary care in terms of the workforce and financial pressure across services. We are undertaking modelling work to asses this. At present, DHU have sufficient spare capacity in our UTCs, hot clinics and visiting services to absorb the modelled increase in face to face treatment arising from 111 First although we are assessing this for any unmitigated gaps against the reasonable worst case modelling. Clinical capacity will be flexed across all areas including clinical navigation to meet an increase in demand in matching a return to winter 19/20 levels, There is also an anticipated increase in 111 call handling which we expect to be offset by national funding and an increase in baseline activity to reflect the phase 1 COVID activity.

The 111 First work will result in more referrals direct to SDEC and the Emergency floor units, reducing patients who pass through ED, reducing congestion and demand in ED. An expanded SDEC facility is planned at LRI using COVID capital funding which will allow for more rapid flow/better cohorting accommodation although this does not increase the net number of beds. There is a challenge to get this facility opened in time for winter. This is being overseen by a UHL planning group.

Other work to reduce unnecessary urgent care demand includes a project focussed on the three universities in LLR, encouraging registration and access to non ED healthcare pathways, including mental wellbeing support.

Further mitigations to reduce demand on ED and urgent care sites will include maximising self-care, and trying to address patients’ needs via initial telephone/video consultation thus avoiding a need for a second F2F attendance. There may be scope to move staff into different settings of care, to reflect the shift in where patients are presenting.

In addition 111 First have the ability to direct booking into Hubs and practices. If primary care direct bookable appointments are fully utilised, consideration should be given to o the use of urgent care centres, self-care, and signposting and Care Navigators or community pharmacy.

We have carried out a full EIA and identified a risk that access may be lower for some groups due to language barriers in some communities in LLR. The current 111 service does provide interpretation and we will use data to identify key target population groups and put in place plans to ensure that barriers to accessing care are addressed. Communication approaches publicising 111 will be developed targeting different populations and translated into the main languages used in LLR.

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LLR has relatively high rates of non-conveyance historically (circa 50%). LLR is participating in an ambulance improvement collaborative supported by NHS E/I.

There are a number of existing pathways in place to reduce inappropriate conveyance and we are continuing to develop these to manage patient care in the community. EMAS crews have access to the Healthcare Professional Line which is part of our Clinical Navigation Hub, and supports on scene paramedics with clinical advice and access to alternative pathways.

4.2 Low Acuity Ambulance Triage We have recently implemented a new pathway for Cat 3 and 4 EMAS calls to be clinically triaged in our CAS which is proving to reduce conveyances and ED attendances (71% of EMAS calls triaged in CNH avoided ambulance dispatch and 46% did not result in any form of ED referral) . This model will be built on and expanded prior to winter. Further work includes expanding the range of ambulance clinical codes which are passed for assessment, to maximise the impact and automating the transfer of calls into 111.

4.3 Pre Transfer Clinical Discussion and Assessment pilot This scheme is aimed at reducing EMAS conveyance to hospital from care homes and was piloted as part of our phase 1 COVID response. The scheme involves the following interventions

• Pre-transfer clinical discussion with a consultant geriatrician or geriatric

emergency medicine consultant to support decision-making around admission and exploring safer alternatives. This includes supporting the interpretation of ReSPECT documents and guiding discussions with patient/families and the person’s usual GP.

• Follow-up visit from a GP or Geriatrician with Special Interest in Care Home Medicine if a particularly rapid response is needed, if the situation is complex or time-consuming, or if the usual GP cannot provide the appropriate response within a clinically appropriate timescale. The visit includes initiation of treatment or referrals for follow-up treatment, initiation or updating of ReSPECT documents and support for care home staff in undertaking necessary next steps for care and monitoring of the patient.

• Structured Feedback to the usual GP practice (using Registered GP’s clinical System where possible).

This scheme was introduced during COVID and has been successful in avoiding conveyance in 80% of calls. It is planned to extend the scheme to run 7 days a week, 14 hours per day by October 2020. System finance to support this continuation and expansion is being confirmed as part of the phase 3 finance plan. There is potential to look at the scheme also supporting patients in their own homes as part of the home first model.

A further scheme is being trialled in partnership between EMAS and UHL, involving a physician accompanying an EMAS car to attend cases where it is considered that an additional on scene presence will be able to see and treat the condition.

The work to improve handover times and to reduce overall demand is part of our response to this. We are developing some alternatives to blue light responses for instance for falls, including response from Home First teams.

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Primary Care will continue to ensure that all complex patients receive regular reviews and have documented, up to date care plans. For End of Life patients this includes increasing the coverage of completed RESPECT forms reflecting discussions with patients and carers.

4.4 Bed capacity for Winter The table below summarises the system bed plans for winter 2020/2021.

Provider Current beds Winter capacity Efficiencies

UHL 1565 75 beds 67

LPT 222 (47 COVID) 36 (COVID) surge beds

System 53

LLR 1789 111 120

In addition to the above we have access to the following non acute bed capacity:

• 14 block purchased reablement beds in the Sovereign unit • Discharge to assess framework spot purchased beds in care homes across

LLR. The number of beds used is not capped, and we have not identified any capacity issues in the care home market. The normal range of D2A bed use is between 30 and 50 beds occupied at any one time.

• The opportunity to recommission Grey Ferrers as a COIVD +ve step down residential facility with 17 beds.

The bed capacity plan includes the reprovision of the current Hampton suite rehab facility into LPT wards by November. To enable this there is a proposal to review the use of Hinckley hospital as a COVID +ve facility for 47 beds and to convert one wards to COVID – ve. This can be flexed as required and will ensure that we are using capacity flexibly in response to different COVID levels, to optimise utilisation of beds.

The discharge cell reviews capacity issues in pathways 1-3 on a weekly basis and makes recommendations in relation to surge capacity required.

4.5 Maintaining flow and rapid discharge processes System partners put new discharge processes in place in response to the COVID-19 discharge arrangements guidance. A single integrated discharge hub, based at the Leicester Royal Infirmary, is supported by a multi-disciplinary team drawn from all system partners. The hub oversees and manages discharge planning across the system. We have developed a single real time discharge tracker which enables improved situational awareness and better resolution of any process or capacity issues across the system as well as enabling performance monitoring of the discharge system.

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To support flow, the integrated discharge hub holds twice daily MDTs to review all patients waiting for discharge across the system. Daily discharge SITREP escalation calls are held in addition to the routine MDTs which act as a point of escalation to ensure that actions are in train to discharge all patients medically fit for discharge as swiftly as possible.

There are three key medically led quality improvement projects at UHL that aim to increase the number of patients going home; reduce the time from the medical optimisation date to discharge destination and, earlier referral of those patients with more complex discharge needs to the discharge coordination hub. The projects focus on our medical wards at the Leicester Royal Infirmary and involve a revision of existing board round practices, including Reason to Reside classification, estimated date of discharge, timely Home First referral, COVID -19 swabbing for discharge ,electronic discharge medication tracking , transport coordination, and improvements to nerve centre data collection and live flow tracking. There is a focus on reducing Long length of stay patients and on the operational workings of the discharge hub and pathways.

We are working very closely with Local Authority partners through our design groups and strategic arrangements to ensure that we implement revised discharge guidance, building on the COVID discharge model, to ensure that we discharge patients as swiftly as possible using a discharge to assess and Home First approach.

Overall, capacity in out of hospital services met demand in phase 1 of COVID, both bed based and home based pathways, but we expect demand and bed occupancy to be higher as we move through winter. As a system, we are aiming to discharge more patients home rather than to bed based pathways, with 95% of patients going home, and 75% of patients going home on the day that they are agreed to be medically fit for discharge.

Current capacity within ASC services is being enhanced in some areas (see below for details) but there are continuing challenges in relation to capacity in some sectors and at times of peak pressure to meet any increased demand. In particular, there are acknowledged pressures on capacity for domiciliary care and crisis response, particularly in rural County localities. This is mitigated by bridging solutions, including support from LPT to cover short delays in packages of care starting, and work with the independent sector as well as ongoing recruitment campaigns.

The existing Home First model is being enhanced with non-recurrent funding as part of the Ageing Well programme and we have begun a joint recruitment initiative to get more staff in post before winter, aiming to have as many new staff as possible starting by December.

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Recruitment plans include a further 20 therapy and nursing staff within LPT and an increase of 24 additional crisis response staff in Leicestershire, as well as additional night time response capacity and equipment services in the City, which will support winter pressures through preventing admission and enabling rapid discharge flow. We will mitigate any recruitment shortfalls by using bank and agency HCAs.

City Social Services are increasing capacity for winter by recommissioning a ‘holding’ team which will supplement ICRS capacity to make same day discharges home.

4.6 Primary Care In response to COVID, Primary Care has adapted, adopted and operated within the following principles:

• Patient cohorting • Telephone triage and remote consultations • Offering face to face appointments when and where clinically safe and appropriate to

do so • Adhering to the principles of patient shielding • PPE / IPC • Ensure patient and staff safety • BAME risk assessment and risk mitigation for all staff • Preventing the spread of other community infections though the continuation of the

immunisations and vaccinations programme. Primary Care has been and continues to remain open and operational delivering services, when appropriate though alternative routes, e.g.

• Enhanced home visiting service, delivery by DHU • Hot Clinics for COVID positive or suspected COVID patients, currently delivered by

DHU and moving to PCN delivery week commence 12th October • Provision of same day bookable appointments via the LUCC, City and ELR sites • Walk in Centres across LLR • Development of a secondary blood collection, to commence week commencing 19th

October and community phlebotomy service, to commence week commencing 12th October, to allow more patients to access practice phlebotomy services which is due to be operational during October.

• Use of Innovation PIDs, to allow practices and PCNs to rapidly develop new initiatives for different ways of working that will enable practices and/or PCN to maintain service delivery in the longer-term pandemic recovery period.

• Creation and adoption of a layered approach to neighbourhood and place based business continuity planning. Commencing with the development of 133 individual practices BCP and building into 25 PCN BCPs.

Primary Care has aligned service restoration to the LLR SAGE / COVID escalation levels. At Levels 5 and 4 Primary Care operates at an essential service delivery level and at Level 3 all high priority (green) and priority (amber) services restoration commencing.

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5. Operational Resilience and Escalation process LLR has in place a system to provide daily capacity and performance monitoring of operational pressures, across providers throughout the year (not just the winter and Easter periods).

LLR manages surge and capacity utilising a whole system approach, which acknowledges predictable peaks in demand, for example over the Christmas and New Year period (As well as unusual peaks in demand as experienced throughout the year). Our commitment is to ensure that we have adequate ‘system wide’ resilience plans, to respond to operational difficulties in parts of the system, occurring in isolation or as a building pressure across LLR.

A common escalation policy has been agreed with each organisation to aid consistency and communication. We have reviewed the resilience and escalation plan in response to COVID, with the inclusion of additional actions which reflect the new operating model for services developed post COVID. The plan also has a greater emphasis on system wide actions and mutual aid, although the plan still centres on the core element of each organisation’s response to different escalation levels.

We have reviewed the resilience and escalation plan in response to COVID, with the inclusion of additional actions which reflect the new operating model for services developed post COVID. The plan also has a greater emphasis on system wide actions and mutual aid, although the plan still centres on the core element of each organisation’s response to different escalation levels. The plan is attached as Appendix 3.

The OPEL Surge and Escalation Management Plan seeks to have in place:

• Clear identification of the escalation process, agreed by all partners • Key organisational contacts are identified • That potential risks have been identified and contingency measures agreed • That the provision of high quality patient services is maintained through periods of pressure • That national targets and finance are managed during pressured periods • That processes are in place to meet local and National reporting requirements

The underlying principle is that sufficient capacity has been planned to be in place to enable providers, under expected levels of planned activity and within expected levels of tolerance, to provide emergency care services and planned elective capacity in accordance with agreed targets.

Each organisation within LLR has developed their own internal Surge and Capacity and winter resilience plans and provides detailed confirmation of their preparedness across a number of areas.

Any organisation within LLR is able to ‘call’ for a health economy wide alert, but it is the responsibility of the CCGs as the lead commissioners for health services to ‘declare’ the health economy status.

Without prior discussion, no action will be undertaken by one constituent part of the system, which may undermine the ability of other parts of the system to manage their core business. The CCG will communicate system pressures to NHS England.

To support all organisations in the safe management of patients in times of high escalation, the LLR system wide escalation protocol enables a multi organisational approach to risk sharing.

12

5.1 LLR Surge and resilience plan incorporating the Operational Pressures Escalation Levels (OPEL) Framework LLR:

The LLR Surge and escalation plan is based upon an integrated status report, which details differing levels of capacity availability and trigger indicators which produce an overall System OPEL level. Once the OPEL level is calculated at organisation and system level the CCG will then initiate a system wide call to check actions of which are listed in the Surge and Resilience actions cards.

Focus has also been given on actions to specifically reduce pressure on inflow from all streams and ensure patients receive the right care at the right time. Specific discharge related actions are also listed to ensure safe and timely flow into home first or community services at each OPEL level. Actions to ensure domiciliary and care home resilience are also included in the plan.

This year, the surge and escalation plan includes for the first time an approach to reporting primary care escalation levels and contains actions both to support primary care and to capture the contribution that primary care make to managing enhanced levels of pressure in the health and care system. This is a developmental part of the plan which recognises the important role that primary care play in the system of care. There is more work still to be done to confirm confirm the process to report on primary care OPEL levels as part of the overall daily system OPEL management.

The updated plan is attached as Appendix 3.

6. Flu Plan Health and social care partners plan a large scale flu vaccination campaign each year, which is more important than ever this year as we need to minimise the impact of influenza alongside COVID. The flu vaccine remains one of the best defences available against flu however the delivery of this year’s programme is going to be more challenging because of the impact of COVID-19. This includes flu vaccinations taking longer because of the need to observe social distancing rules and the need for clinicians to change personal protective equipment (PPE). The expansion of the programme to an increased number of eligible groups such as people over 50 years, despite the plans for phased approach, also creates practical challenges around vaccine supply and storage and on primary care workload and capacity. This year we are aiming for 75% coverage of at risk groups and 100% offer of the vaccine to front line health and social care workers. Patient vaccinations will be delivered by GP practices and pharmacies and by health care providers to their front line staff.

The LLR Flu Plan has been developed by the Flu Board and is attached as Appendix 4. Although we do not yet have confirmation of when a vaccine against COVID19 will be made available, NHS systems have been asked to work up plans for COVID vaccination on the basis of this being available before Christmas. The COVID-19 pandemic poses a specific set of challenges to achieving high volume through-put when vaccination becomes available. NHSEI are exploring options for delivery and further information will be made available as this becomes known. The Flu Board will also oversee this work and will build on successful flu vaccination delivery mechanisms, adapting these where appropriate for the scale of COVID vaccination.

13

7. Communications Plan 7.1 Planning and co-ordination Our winter communications activities will be underpinned by multi-agency working to a single plan and set of activities and fully integrated with operational planning and activities e.g. the escalation framework to ensure communications is responsive to service pressures and work with our LLR partners to co-ordinate a response.

As in previous years we will ensure our communications are evidence – based and data driven, e.g. to understand service usage and target those groups for enhanced communications activities. In particular we will be undertaking specific insight work related to NHS111 First and using this to shape our communications.

The prevalence of COVID means communications will add complexity to our messaging and in particular the importance of accessing services appropriately.

We will re-activate our Winter Communications and Engagement Network (WCEC) with core membership drawn from the following organisations:

• DHU Health Care • East Leicestershire and Rutland CCG • East Midlands Ambulance Service • Leicester City CCG • Leicester City Council • Leicestershire County Council • Leicestershire Partnership NHS Trust • Rutland County Council • University Hospitals of Leicester • West Leicestershire CCG • Primary Care Networks • GP Federations

As in previous years we will ensure a joint protocol is in place for media handling.

As well as the taskforce we will ensure that winter activities draws on other partners in the LRF who can support delivery of our activities. The WCEC is plugged into the overall governance arrangements and related groups:

14

7.2 Activities

All Communications will be planned and co-ordinated through the WCEC. The WCEN will ensure the following activities are delivered:

As part of the LRF, continue to support national and local public health

campaigns for COVID e.g. Rising Tide Communications strategy Amplification of national campaigns incorporated within a single schedule of

activities to form the LLR winter communications plan shared and owned by all partners;

• Continuing to encourage uptake of the flu vaccination by the eligible groups and possibly new 50 – 64 years cohort subject to availability of the vaccine;

Promotion of NHS111 First and in particular the amplification of the national campaign;

• Ensure the public is aware of their service options including self – care and guide them to the right service at the right time and in the right place. This will include publicising the opening times and service availability; Protecting the reputation of and promoting confidence in NHS services over the winter period. This year we will need to ensure people are confident to use services in response to the increased prevalence of COVID. We must ensure people feel able to use NHS services; and An agile communications response to service pressures linked to the operational resilience and escalation process described in section 5.

Our experience with COVID – 19 and in particular the extended lockdown in Leicester has seen the development of strengthened links with BAME communities in particular. We will provide information in other languages and in a range of formats.

Urgent & Emergency

Care Cell

Winter speciffic

groups e.g. cold weather

Local Resilience

Forum

LLR Comms

NHS 111 Project Board

Sytem Escalation

(OPEL)

Flu Project Board

15

7.3 Communications channels We will ensure the full range of our established channels are are used to support our communications including:

7.4 Stakeholder engagement

• Series of briefings to stakeholders e.g. MPs, Healthwatch, Citizen Panel, JHOSC etc.

• Effective arrangements for pro-active and reactive media handling • Reactive briefings in response to events to system partners: GPs, care homes • Engagement with Voluntary and Community Sector to extend reach to

targeted groups • Engagement of specific groups to reach out to specific communities e.g. Council

of Faiths • PPGs support to deliver messages • CCG patient and public involvement group • Patient and public communication as to signposting, Care Navigators, self care and

how best to use NHS and what to expect over the Winter period Media

• Press releases • Community Radio Stations • Social Media • Videos • 5 on Friday – CCG stakeholder bulletin • CCG websites • PCN’s patient webinars and videos

Partner communications

• Residents’ newsletters e.g. Your Leicester • Sharing social media • Syndicated content for websites etc.

7.5 Feedback

We will obtain feedback on the impact of our winter communications activities through the Citizen Panel.

8. Workforce

• There is an LLR system workforce plan which sets out the actions that will be taken by individual providers and at system level to strengthen workforce resilience in phase 3 and over winter. Key risks include staffing gaps and sickness levels as a result of COVID in any part of the system compromising the ability to continue to deliver safe care, keep people out of hospital and manage flow in the UEC system. Risks include testing capacity, the risk of not being able to staff additional wards and community team roles critical care and diagnostics alongside staff availability and required funding.

16

• Mitigations include increased mutual aid, a tiered response plan for care homes with ability to flex staff across providers through workforce sharing agreements, deployment of dental trainees and volunteer peer programmes to support flu vaccination plans, workforce sharing utilising Bring Back Staff programmes, use of bank and agency staff and effective health and well-being and retention support programmes to maintain existing staffing level.

• Another key element will be Primary Care workforce reporting, including BAME staff to identify staffing gaps and sickness levels as a result of COVID which may compromise the ability to continue to deliver safe qualities care and keep people out of hospital.

17

Appendix 1 – system capacity and surge capacity plans

1

Appendix 1 – system capacity and surge capacity plans Organisation

Sub-division

Summary of Current capacity

Additional planned capacity for winter (Nov-Mar)

Surge capacity that could be created

How will any surge capacity be staffed? What additional initiatives or actions will be taken to manage demand/do things differently over winter to meet pressures?

Key risks or dependencies Additional comments

Beds

Other (please specify appointments/patients/hours of operation etc using relevant measure of capacity)

Beds


Beds


LPT

Adult Community Services

Commissioned beds = 222 Bed Stock = 224 (including 47 Covid positive beds at H&B, 15

additional covid negative beds on Coalville Ward 4 (Surge Ward) to offset impact of ringfenced beds at H&B on system

flow, & excluding 10 temporarily closed beds at Feilding Palmer hospital)

All CHS Adult services are reviewing their capacity as part of their Recovery and Restoration Planning

All beds currently commissoned and staffed are open

LPT Estate Provision = 36 (excluding Coalville Ward 4)

LPT - Staff will need to be redepolyed fom the temproary closure of non-essential services as per the Covid 19 clinical prioritisation document INDEPENDENT SECTOR- beds are staffed and could be

converted from elective (see dependencies)

Telephone and video consultations

LPT - Lack of system agreement ref recurrent CSR investment to expand community services Independent Sector - converting beds from elective to rehab will impact on UHL elective

restoration plans

Note that the previous IS surge beds are now not considered to be viable

due to isolation requirements

Mental Health

acute and PICU - 148 rehab - 58 Total - 206

0

10

Overtime, bank and agency staff or re- distribution of existing staff

Intention to continue with Central Access Point and Mental Health Urgent Care Hub that were implemented during Covid-19 to support admission avoidance

Key dependencies are with UHL ED and the police/ EMAS - streamlining of pathways. Key risks are continued impact of covid-19 and any increases over winter

CAMHS

10

No specific winter revision of services planned

10 (bed capacity changes to 15 November onwards due to opening of Beacon ward)

N/A

No surge capacity planned

N/A

Not normally any winter pressures within CAMHS services

MHSOP

88 + 15 (Wakerley)

0

15 already mobilised on Wakerley

Intention to continue with Central Access Point and Mental Health Urgent Care Hub that were implemented during Covid-19 to support admission avoidance

Additional dependencies with care homes/ social care

Children's and Young People

N/A

2 WTE respiratory physiotherapists prevent acute admission to UHL

N/A

Respiratory Physiotherapy prioritises acute emergency work in the wnter months

There are additional physiotherapists in other teams who are trained in respiratory physiotherapy if required

There are not normally any winter pressures within Children's Community services and in patients is in UHL

LD

12

12 Pods 4 & 5 can be made available 4 beds in each pod

bank and agency

UHL Emergency Department

SDEC abmbulatory capital development. Consultant input to physician unit supporting admission avoidance.

Reliance on demand management and inflow work including 111 First to reduce attendances and enable flow

Inpatient wards

Total Trusts beds 1565

75

Additional efficiences including admission avoidance, SDEC, LOS improvements equating to 289 beds

The additional beds are dependent on being staffed/funded. A number of the efficiencies are also dependent on funding and/or the success of admission. avoidance schemes etc .

DHU Face to Face appointments

Below shows capacity in line with current sites that are open: Mon - Fri 470 Patients Sat 785 Patients Sun 765 Patients LUCC - Full Hours Merlyn Vaz - Full Hours Westcotes - Full Hours Oakham ; Centre Surgery ; Saffron - W/end only OOH GP Overnight - LUCC - Full Hours LRI ED Primary Care located in Westcotes - Full Hours

Hot Clinic LUCC Mon - Sun 6 Hours per Day Hot Clinic New Parks Mon - Sun 12 Hours per Day

Mon - Fri 665 Patients Sat 1208 Patients Sun 1124 Patients

Phased restoration through September & October resulting in full contractual capacity delivery from November across commissioned sites: West - LUCC / Hinckley / Coalville / Centre Surgery / Rosebery East - Oadby / Enderby / Oakham / Mkt Harb / M Mowbray (query Lutterworth) City - Merlyn Vaz / Westcotes / Saffron / Brandon OOH GP Overnight - LUCC - Full Hours LRI ED Primary Care located in Westcotes - Full Hours

Hot Clinic LUCC Mon - Sun 6 Hours per Day Hot Clinic New Parks Mon - Sun 12 Hours per Day *Hot clinic provision to be further reviewed in line with CCG/ System requirement / provision

• Hot clinic provision to be further reviewed in line with CCG/ System requirement / provision. • We have the ability to support any dynamic review with system partners / CCG to provide help. We have a successful track record of doing this dependant on therequirement.

• Flexiblemovement of additional staffing from other areas if needed to help to support • Resources will be increased in specific areas of the operation at predetermined times in linewith predicted demand levels • Sickness is closely managed in line with DHU Policy to ensure maximum attendance of resource with plans for staff returns prior to peak periods. • An active list of Doctors who are willing to be contacted at short notice. A more formal process of on-call enhancement, rota fulfilment / remuneration is in place in order to robustly manage GPs rota fulfilment

• Additional resources will be planned for all Bank Holidays, including associated weekends, and consideration is given in regards to staff availability following these periodsofincreased requirement. • Continued recruitment drive for more staff on bank contracts in order to support additional hours • Continued recruitment drive for clinical staff in keys areas to reduce reliance on agency • GP Clinical Leads within the Service covering key peak periods will support with productivity, clinical support and advice for Clinicians working within the Service. • Continued growth in skill mix (use of ANPs and other practitioners) • Annual leave embargo over peak times • Bank holidays will be fully operational at all sites • Flexibility within the HVS service to undertake increased COVID testing if required. • A plan currently being developed looking at Flusupport.

• Financial constraints • Any surge in demand that will require additional support may be limited by additional space requirements and IT support. • Lead in times will be key particularly with the current 'downtime' in relation to clinical staffing. Therefore longer lead in times will support the sourcing and training of clinical staff.

Home Visiting/AVS Commissioned additional In hours provision currently +10 visits per day M-F Provision to be further reviewed in line with CCG/ System requirement / provision OOH Mon - Fri 30 Patients OOH Sat 140 Patients OOH Sun 140 Patients COVID testing car Mon - Sun 7 Hours per Day

In Hours Mon - Fri 60 Patients Commissioned additional In hours provision currently +10 visits per day M-F Provision to be further reviewed in line with CCG/ System requirement / provision OOH Mon - Fri 30 Patients OOH Sat 140 Patients OOH Sun 140 Patients COVID testing car Mon - Sun 7 Hours per Day

• Additional In Hours HVS • COVID Testing Capacity • Currently contracted to support ILI's. • Capacity can be modelled to anticipate growth and resourcing requirement put in place to meet demand in line with system data trends. • There is the capacity to flex for wider surges such as a flu outbreak

• Flexible movement of additional staffing from other areas if needed to help to support • Resources will be increased in specific areas of the operation at predetermined times in linewith predicted demand levels • Sickness is closely managed in line with DHU Policy to ensure maximum attendance of resource with plans for staff returns prior to peak periods.

• Additional crews and resource committed to match anticipated demand profile • We have already been approached to support a programme of flu vaccination, although the detail is yet to be finalised.

• Financial constraints • Any surge in demand that will require additional support may be limited by additional vehicle requirements and IT support. • Lead in times will be key particularly with the current 'downtime' in relation to clinical staffing. Therefore longer lead in times will support the sourcing and training of clinical staff. • The availability of sufficient vaccines • The availability of sufficiently trained vaccinators. We

Clinical Navigation/telephone advice and treatment

Mon - Fri 220 Patients Sat 700 Patients Sun 680 Patients

EMAS Cat 3&4 support 08:00 - Mid 7 days 62 APDS codes +8 codes relating to Pandemic triage (under 18s also included)

At this point there is no indication that this will change. Resource across all clinical areas will be flexed to enable capacity changes to meet demand Mon - Fri 220 Patients Sat 700 Patients Sun 680 Patients EMAS Cat 3&4 support 08:00 - Mid 7 days 62 APDS codes +8 codes relating to Pandemic triage (under 18s also included) further expanded scope and capacity via: Further expanded Code Set to broaden target flow Patients in public places and HCP referrals review

• PDSA running through September to test appointment validation pilot - In hours translation of potential benefit: :- triage pathway flow direct to clinic sites where capacity might sit :- reduction of risk to patients "bouncing" in hours NHS111 / primary care - and ending up self presenting to ED • EMAS 3s and 4s further dynamic review and monitoring of this pathway NHS111 First Support - further dynamic review and monitoring of this project to realise maximum potential benefit.

• Flexiblemovement of additional staffing from other areas if needed to help to support • Resources will be increased in specific areas of the operation at predetermined times in linewith predicted demand levels • Sickness is closely managed in line with DHU Policy to ensure maximum attendance of resource with plans for staff returns prior to peak periods. • An active list of Doctors who are willing to be contacted at short notice. A more formal process of on-call enhancement, rota fulfilment / remuneration is in place in order to robustly manage GPs rota fulfilment

• Further additional resources can be deployed in CNH from all areas of the operation based on demand and triage can be undertaken from our bases. • We are currently working with EMAS to broaden the code set to trigger the movement of patients into the CNH. This will result in higher referrals and provide positive impact for the LLR health economy.

• Financial constraints • Any surge in demand that will require additional support may be limited by additional space requirements and IT support. • Lead in times will be key particularly with the current 'downtime' in relation to clinical staffing. Therefore longer lead in times will support the sourcing and training of clinical staff.

TASL

Continuing the current arrangement, which has been in place since March; TASL will not ring-fence specific vehicles for discharges and will use all crews and vehicles for discharges and transfers, where capacity allows. The provides greater flexibility within the system to assist with flow. Discharge Coordionators will continue to work 0800 - 2000, seven days a week, out of the discharge lounge

Historical data used to identify peak demand and plan resourcing accordingly, paying particular attention to demand on days prior to Bank Holiday weekends.

Additional capacity would be created through overtime (pre- planned for anticptated surges and on-day for unanticipated excessive demand), bank staff shifts, additional taxi usage for C and C1 patients to create capacity on PTS ambulances and outsourcing to third party providers

Surge capacity will be staffed through a combination of standard rota hours, overtime and bank staff

TASL will ensure that there is management presence onsite for all weekdays where system OPEL level is 3 or above. Not in place in previous winters; Discharge Coordinators have received manual handling training to assess patient mobilities on wards. The benefits include reduced aborts and greater resource availability where the level of assistance and equipment required, is reduced.

The frequent risks/ issues remain high concentrations of discharge bookings made ready in the late afternoon periods, combined with tight cut-off times The new key risk/ issue is that social distancing on vehicles will continue to limit the numbers of patients who can travel together and single occupancy journeys are resource intensive

We have returned to elibility for elective journeys in order to protect capacity for discharge as we restore normal elective activity

Independent Sector

30 Nuffield beds

GP practices

City

All practices are working to restore to 'usual' levels of activity where clinically appropriate. This is being prioritised on on the GARs

prioritisation of services ( see appendix 1.) In doing so practices are balancing increasing demand for general practice, addressing the

covid-19 related backlog for all primary medical care services including immunisations and screening and increasing workforce

challenges. All practices have completed BAME risk assessments and have developed practice and PCN level Business Continuity plans to

support delivery now and over the winter period. The extended lockdown in Leicester City and parts of the county and the impact of

COVID-19 on BAME

Additional services are being commissioned to support the new model of primary care including place based hot hubs, flu vac for housebound patients, additional phlebotomy capacity etc. Work is also underway to accurately map the backlog facing general practice which will inform planning to ensure the

sustainable and safe general practice services. PCN and members practices are also seeking to maximise the opportunities presented by the PCN DES including

recruitment of additional role which will support service delivery and implementation of the Enhanced Care in Care Home specification.

During a surge practices would use the GARs list to step down provision of Amber and Green services to free up capacity.

Work has taken place to align the GARs provision to system OPEL levels and Covid - 19 Sage reporting. The decision to step up or move to a reduction in general practice service is driven at a

practice level as is dependent on a wide range of practice specific issues including premises and workforce. During a surge

practices and PCNs would enact Business Continuity plans to ensure delivery of key services.

Practice level buinsess continuity plans would be enacted with support at PCN level.

Complete work to realistically map the backlog for primary care services to inform winter plans.

Continued close co-operation with health and social care partners to ensure best use of resources and flexible approach to services delivery as seen during covid. Identifying changes in pathways that inadvertedly increase in activity in general practice.

West

East

Pharmacy Social Services

City

2744 care home beds (577 vacant as of 20/08/20)

12 total Assessment beds in Thurncourt and Vishram Ghar; ICRS and Reablement Capacity

Ability to commission additional Covid+ capacity as per Grey Ferrers model previously

Holding Team domiciliary care hours to restart to support same day discharge

Potential use of additional monies from new Discharge to Assess funding to bolster our Home First and Holding Team provisions

Provider market being unable to manage demand due to second wave of Covid-19

2

County

HART (domiciliary reablement, not bed based) - circa 75 - 87 starts per week depending on current staffing resource. CRS / ECT - crisis and urgent bridging capacity (domicilary based, not bed based) - existing referrals circa 150 per week to support step down / step up activity.

HART - 7am - 10.30pm 7 days a week CRS - 24 hrs a day, 7

days a week

Additional hours for CRS through redeployment of some existing in- house staff.

Existing operating hours apply

Existing in-house staffing resource where this is available. Consideration of using agency staff if available.

Ongoing recruitment initiatives into HART and CRS. Maintenance of some Emergency Care Team capacity to support bridging activity to faciliate timely discharge.

Recruitment to direct care roles remains challenging, as it has been impacted by the Covid- 19 pandemic. The gradual opening of some in-house provider servcies (short breaks / day services) may reduce some Emergency Care Team (ECT) capacity, although this is being closely monitored and managed to ensure that some resources are maintained in this area.

Rutland

There are 359 residential/nursing beds in Rutland care homes. Approximately 60 of these are currently vacant. Staffing may need to be increased if all beds were to be required.

There are approximately 400 packages of care being proivded by dom care agencies in Rutland at this time. It is impossible to say wha the capacity is as this is dependent on the number of staff the agencies choose to employ, the hours those staff wish to work, etc. A key constraint to expansion is the availabiilty of skilled staff happy to work in a largely rural area.

None

None

Should we run out of available placements in Rutland, we are able to approach homes in neighbouring Local Authorities. We do not at the moment believe this is likely. Ongoing Covid anxieties may also continue to suppress care home take-up.

In case of urgent need, we would use available resources and capacity creatively, including in the in- house care service MICARE and backfill and redeploy other skilled in-house resource. However, we may also see Covid anxieties reduce the take-up of homecare generally, with some individuals choosing eg. to rely more on family instead at this time. Providers charge private clients a higher hourly rate than they charge Rutland County Council. If we increased the

Discharge team: would reprioritise work, streamline and redeploy staff if needed to keep discharges flowing (eg. managers to operational roles). For in-house care services, we call on agency staff if required or have the option to redeploy staff across parts of the service. Care providers would have similar strategies.

We continue to promote the value of careers in care generally to support workforce sufficiency. Encouraging staff from in-house and external care agencies and from care homes, and those who could backfill redeployed staff, to get timely flu vaccination. Regular conversations with providers around capacity. Capacity Tracker enables care homes to flag significant workforce challenges.

* Covid & winter flu rates across the winter. * Limited budget to purchase additional capacity (potential to use modest contingency funding but finite). * Vital that all care workers who are able to take up flu vaccination. * Vital that regular Covid testing continues across in-house and external care providers. * Ability to sustain care if there is a significant Covid outbreak across any provdier - will require mutual aid etc. *Important that employment conditions do not compel external care workers to work

if unwell potentially with Covid.

in the overarching narrative, the philosophy of further local refinement of service provision according to practice operational status, workforce etc but with encouragement for practices to contact us to advise they need to stand down services so that we can risk assess this and provide support too.

Each of the below levels will need to be supported by escalation and stand down cheat sheets (one side of A4) for both commissioners and primary care.

Leve

l 5 Primary Care reinstates COVID-19 crisis management - all non-essential services

suspended. Continuation of telephone triage and remote consultation. Continuation of imms and vacs. Use of Hot Hubs, HVS and Community nursing services. Referrals continue but held by the Acute. 2 week and urgent referrals continue. EoL Plans and Care Plans reviewed. Possible shielding re-enactment. Cohorting principles apply. Following of national and local guidance. BCP and Workforce plans enacted.

Le

vel 4

Leve

l 3 Level 3C - Recommencement of High Priority Primary Care Services

Level 3B - Recommencement of High Priority & Priority Primary Care Services Level 3A - Recommencement of all Primary Care Services

Leve

l 2 Recommencement of green high priority and priority services and where possible low

priority services. Advertising that PC is open.

Le

vel 1

Full service recommencement. Advertising that PC is open.

Overriding principles: Pt cohorting

Telephone triage Remote consultation

F2F appointments when and where clinically safe and appropriate to do so

To prevent the spread of other community infections, continuation of imms and vacs

Principles of Shielding BAME risk assessment continuation

Staff safety PT safety

Appendix 2 Gap closure impact Activity impact Scheme

Gap Closure Opportunity

Best (bed numbers or state other activity impact)

Likely (bed numbers or state other activity impact)

Worst (bed numbers or state other activity impact)

Key actions required to deliver, including which organisations impacted

Risks/Dependencies

1

Increase numbers of patients discharged same day as MFFD

27

23

21

LPT to expand home first pathway as per CSR model Increase weekend discharge resources including implementing criteria led discharges in UHL and increase LA brokerage County: increase DRT capacity, recruit to new crisis response capacity, increase and work with Dom care on PoC pick up speed City to increase holding capacity service Other actions include improving pre MFFD MDT work esp for pathway 2/3 patients

Dependent on capacity in out of hospital services, LPT and County recruitment, bridging capacity and weekend

3

Frailty/multi- morbidity -

5

3

0

Applying a targeted approach to unwarranted variation of secondary care activity at a PCN Applying a proactive approach to identification and case management of complex pts at a practice level involving care coordination and MDT's

Covid impact on partners ability to fully implement system frailty model.

4

Home First Step up

4

3

0

Continuation of community services redesign work, including expansion of community team capacity with support from PCNs and practices to deliver enhanced

LPT recruitment -local authority recruitment to crisis response workers (fundd via ageing well pot) -effective pathways via the discharge hub model to support use of medical model -links to think 111 to increase uptake of Home First

5

Pre-transfer Clinical assessment/care homes

17

14

4

Confirmation of funding. EMAS, UHL, and PTCDA Clinical team are principal groups affected. Recruitment needs to take place immediately in order to replace the current voluntary arrangements which cannot continue beyond the end of September .

Dependent on the numbers of EMAS referrals

Sub total NEL bed impact 53 43 25 6

ED inflow (university and Cat 3 and 4 ambulances)

248

229

216

RB to add

University - engagement of the universities to promote and direct to appropriate health services. Cat 3&4 - Continued support from EMAS and DHU to continue. Need to consider the contracting requirement moving forward. The need to expand the code set is reliant on EMAS providing the codes with Clinical agreement.

7

111 First ED diversion

977

673

455

Increased triage of patients from 111, increased direct booking into DHU sites, ED or GP practices, UHL to divert walk ins to DHU or alternative services. Develop interim interoperability booking. Local comms to support

Staffing in CNH, IT interoperability interim

8

Restoration of full DHU urgent care capacity as pre-COVID

563

427

256

Re-open all extended primary care hubs. Transfer clinic 4 activity to MV.

Staffing pressures when combined with incrase in CNH and possibly hot clinic

17

Impact of continuation of the MH Urgent Care Hub

213

TBC

TBC

Figures are for both EMAS and ED avoidance

Ability to continue to staff MHUCB with appropraite high level skill set without impact on C&MHT team.

Sub total ED attendance impact (monthly) 2001 1328 927

3

1

LLR Surge and Escalation plan

2

LLR OPEL SURGE & ESCALATION PLAN 2020/21

Introduction

To support system wide escalation status, declaration and reporting 2020/21, the LLR Urgent Care Team are required to report a system-wide overall status on a daily basis. This will be based upon individual provider updates so it is essential that all providers continue to provide a daily escalation status through existing reporting and escalation conference calls.

Process

The Urgent Care Team (or CCG Director on-call during out of hours periods) will refer to the guidance below to inform them of a system-wide status. For the purpose of an overall system-wide status declaration, the following key providers are required to submit twice daily written status updates:

UHL (Inc. UCC) LPT (Inc. Community and Mental Health) EMAS TASL Adult Social Care DHU/111 DHU/OOH

*Where any provider declares OPEL 3 status based on information situational reports the CCG Resilience team will contact to investigate the need for all system partners will be alerted to join a teleconference at 10:30AM.

UK Free phone: 0800 917 1950

Paricipant code: 11264558#

3

NHS England and Improvement Operational Pressures Escalation Levels (OPEL)

OPEL 1: The local health and social care system capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.

OPEL 2: The local health and social care system is starting to show signs of pressure. The local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced coordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHSE/I colleagues at sub regional level informed of any pressures, with detail and frequency to be agreed at local level. Any additional support required should also be agreed locally if required

OPEL 3: The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 3 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in the NHSE/I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. National teams will also be informed by DCO/Sub-regional teams through internal reporting mechanisms.

OPEL 4: Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is an increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.

4

Defining LLR System OPEL Level LLR Application

GREEN OPEL 1: patient flow management - The Local Health and Social Care System capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of service will be decided locally.

No more than one key provider reporting AMBER (all other providers reporting GREEN)

EMAS not to be included as they report for the region not specifically LLR

AMBER OPEL 2: mitigation of escalation – The Local Health and Social Care System starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced co-ordination will alert the whole system to take action to return to green status as quickly as possible.

Two or more key providers reporting AMBER OR

One key provider reporting RED

RED OPEL 3: whole system compromised – Actions taken in Level 2 have failed to return the system to Level 1 and pressure is worsening. The Local Health and Social Care System is experiencing major pressures compromising patient flow. Further urgent actions are required across the system by all partners.

Two or more key providers reporting RED OR

One key provider reporting BLACK

BLACK OPEL 4: severe pressure and failure of actions – All actions have failed to contain service pressures and the Local Health and Social Care system is unable to deliver comprehensive emergency care. There is potential for patient care to be compromised and a serious incident is reported by the system. Decisive action must be taken to recover capacity.

Two or more key providers reporting BLACK OR

A major incident / business continuity event that causes system wide failure

5

Measure OPEL 1

(within expected levels of pressure / signs of early pressure)

OPEL2 (moderate pressure / number of providers

reporting issues)

OPEL 3 (severe or prolonged pressure across providers,

prolonged recovery)

OPEL 4 (multiple/confirmed pressure,

unsustainable increase in demand)

Indicators

Indicators

Indicators

Indicators

Em

erge

ncy

Depa

rtm

ent

How long is the wait to be seen?

Less than 1 hour 1 – 2 hours 2 – 3 hours 4 hours or more

How long is the EMAS waiting time to handover?

Less than 15 minutes 15 – 30 minutes 30 – 60 minutes 1 hour or more

How many patients on ambulances (POAs) are there?

0 1 – 5 6 – 10 11 or more

How many patients are in the Emergency Department?

0 – 29 30 – 59 60 – 99 100 or more

How many patients in the Emergency Department are waiting for a bed?

0 – 10 11 – 20 21 – 30 31 or more

How many patients are at risk of waiting 8 hours on a trolley in the next 2 hours?

0 1 – 5 6 – 10 11 or more

How many resus beds are available in the Emergency Department?

6 or more 3 – 5 1 – 2 0

What is the ED 4hr performance (Version 2)?

95% or more 85 – 94% 75 – 84% Less than 75%

Fl

ow

How many CMGs are expecting to end the day with negative capacity?

0 1 – 2 3 – 4 5 or more

How many elective cases have been cancelled as a direct result of operational pressures?

None 1 - 10 individual cases cancelled 1 full list cancelled

All elective work cancelled

How many medical outliers are there?

0 1 – 20 21 – 40 41 or more

How many funded adult critical care beds are empty?

20 beds or more 15 – 19 beds 10 – 14 beds 9 beds or less

What is the capacity of paediatric critical care, Trust-wide?

Elective activity to proceed at both GGH & LRI Elective activity unable to proceed at both GGH & LRI

1 stabilisation bed available at either GGH or LRI No stabilisation bed available at either GGH or LRI

How many elective cases have been cancelled as a direct result of operational pressures?

None 1 – 10 individual cases cancelled 1 full list cancelled All elective work cancelled

6

What impact are infection prevention measures having on the ability to admit patients?

None / Minor Moderate Significant & Maintainable Significant with Breaches

How is the nurse staffing level affecting quality & safety?

No Impact Minor Impact Moderate Impact Major Impact

How is the medical staffing level affecting quality & safety?

No Impact Minor Impact Moderate Impact Major Impact

Di

scha

rge

How many patients are medically fit for discharge?

0 – 69 70 – 89 90 – 119 120 or more

O

ut o

f hos

pita

l

Reablement capacity (at home)

• Able to accept referrals and provide on-going care

• Unable to guarantee non-urgent planned or unscheduled service response times in one locality

• Unable to guarantee non-urgent planned or unscheduled service response times in more than one locality

• Unable to guarantee urgent and non urgent unscheduled and planned service response times across the service line.

Domiciliary care capacity

• Normal rate and volume of work including normal rate of referrals from Acute and Community Hospitals

• 20% Increase in volume of referrals from Acute and Community Hospitals

• Persistent increased demand (>50%) in volume of referrals from Acute and Community Hospitals

• Continued and significant volume of referrals from Acute and Community Hospitals > 75%

DH

U

CNH Performance HVS Performance LUCC Performance Hubs Performance LRI Front Door Performance

• Service operating to plan – with no issues. Normal level of referrals.

• Planned staffing good no current concerns staffing levels meet referral levels

• Service experiencing high demand – referral levels above expected level but with no issues

• A number of staffing gaps, but able to work to referral levels with no current concerns

• Service experiencing high demand with some impact on operation

• A number of staffing gaps which are having some impact on operation in relation to referral levels

• Delays in patient care affecting performance • CNH Average number of calls waiting per

clinician is between 11 and 15 • HVS Where the number of home visits per crew

cannot be scheduled within the required time is between 11 and 19

• Urgent Care Where there are no appoints within the required time is affecting between 6 to 10 patients

• Walk in services – where the number of patients waiting over 3 hours is 6 to 10

• LUCC – Where the number of patients in the department waiting to be seen per clinician is between 7 and 9

• Continued high demand having a large impact on operation

• Significant staffing gaps large impact on operation in relation to referral levels

• Service levels and patient care significantly affected.

• CNH Average number of calls waiting per clinician is 16 or over

• HVS Where the number of home visits per crew cannot be scheduled within the required time is 20 or more

• Urgent Care Where there are no appoints within the required time is affecting between 11 patients or more

• Walk in services – where the number of patients waiting over 3 hours is 11 or over

• LUCC – Where the number of patients in the department waiting to be seen per clinician is 10 or over

7

Action Card Pages:

• Pages 4-13

• Pages 15-17

• Pages 17-19

• Pages 20-24

• Pages 24-26

• Pages 26 - 29

UHL

LPT

TASL

DHU

EMAS

Social Care

Primary Care Cell Triggers Primary Care Cell Actions COVID-19 Alert Level 5 Risk of healthcare services being overwhelmed

•l'lLLR COVID-19 alert system at level 5 •l'lUK Coronavirus alert level at level 4 or level 5 • Community transmission above x per 100,000 population • Local Care Home outbreaks remain at 10 and above • Primary Care OPEL Levels are 3 or above for the following individual areas; primary care capacity, workforce and appointments • 111 direct booking into primary care exceeds the 1 in 500 capacity • Hot Hub demand outstrips capacity • Cold Hub demand outstrips capacity • Extended Hours demand outstrips capacity • Home visiting demand outstrips capacity

All non-essential services suspended. Continuation of telephone triage and remote consultation. Continuation of imms and vacs. Use of Hot Hubs, HVS and Community nursing services. Referrals continue but held by the Acute. 2 week and urgent referrals continue. EoL Plans and Care Plans reviewed. Possible shielding re-enactment. Cohorting principles apply. Following of national and local guidance. BCP and Workforce plans enacted. Advertising pc is open but with changes.

COVID-19 Alert Level 4 Transmission is high or rising exponentially

• LLR COVID-19 alert system at level 5 • UK Coronavirus alert level at level 4 or level 5 • Community transmission above x per 100,000 population • Local Care Home outbreaks remain at 10 and above • Primary Care OPEL Levels are 3 or above for the following individual areas; primary care capacity, workforce and appointments • 111 direct booking into primary care exceeds the 1 in 500 capacity • Hot Hub demand outstrips capacity • Cold Hub demand outstrips capacity • Extended Hours demand outstrips capacity • Home visiting demand outstrips capacity

All non-essential services suspended. Continuation of telephone triage and remote consultation. Continuation of imms and vacs. Use of Hot Hubs, HVS and Community nursing services. Referrals continue but held by the Acute. 2 week and urgent referrals continue. EoL Plans and Care Plans reviewed. Possible shielding re-enactment. Cohorting principles apply. Following of national and local guidance. BCP and Workforce plans enacted. Advertising pc is open but with changes

COVID-19 Alert Level 3 Virus in general circulation

•l'lCommunity transmission above x per 100,000 population •l'lLocal Care Home outbreaks remain at 10 and above •l'lLocalised Lockdown restrictions remain in place •l'lIncreased activity in Hot Hubs •l'lLLR COVID-19 alert system at level 3a, level 3b or level 3c •l'lUK Coronavirus alert level at level 2 or level 3 • Primary Care OPEL Levels are 3 or below for the following individual areas; primary care capacity, workforce and appointments • 111 direct booking into primary care exceeds the 1 in 500 capacity • Hot Hub demand nearing or at maximum capacity • Cold Hub demand nearing or at maximum capacity • Extended Hours nearing or at maximum capacity • Home visiting nearing or at maximum capacity

Level 3C - Recommencement of High Priority Primary Care Services (green) Level 3B - Recommencement of High Priority (green) & Priority Primary Care Services (amber) Level 3A - Recommencement of all Primary Care Services (green, amber) Advertising that PC is open.

COVID-19 Alert Level 2 Number of cases and transmission is low

• Primary Care OPEL Levels are 2 or below for the following individual areas; primary care capacity, workforce and appointments •Hot Hub demand is less than or meets capacity •111 direct booking is operating within the capacity of 1 of 500 • Hot Hub demand meeting capacity • Cold Hub demand meeting capacity • Extended Hours demand meeting capacity • Home visiting demand meeting capacity •l'lDecreasing community transmission to below x per 100,000 population •l'lLow admissions to secondary Care •l'lLocal care home outbreaks below 10 •l'lAll PCNs have robust flu plans in place and operational •l'lAligned PC and System Winter Plans •l'lCommunity Services can operate as normal •l'lLLR COVID-19 alert system at level 2 or level 3a •l'lUK Coronavirus alert level at level 2

Recommencement of high priority (green) and priority services (amber) and where clinically appropriate and safe to do so low priority services (red) . Advertising that PC is open.

COVID-19 Alert Level 1 COVID-19 no longer present in LLR

•l'lPC catch up programmes, e.g. immunisations and vaccinations, screening, etc. operational achieving 70% •l'lAll lockdown restrictions lifted, with no increase in community cases for a minimum of 2 weeks •l'lAll green services fully operational across LLR •l'lSufficient PPE •l'lPractice and PCN business continuity plans stress tested, are resilient and all gaps filled •l'lPrinciples of cohorting can be successfully maintained by practices and PCNs •l'lLLR COVID-19 alert system at level 1 •l'lUK Coronavirus alert level at level 1 or level 2 • Primary Care OPEL Levels are 2 or below for the

following individual areas; primary care capacity, workforce and appointments •Hot Hub demand is less than or meets capacity •111 direct booking is operating within the capacity of 1 of 500

Full service recommencement. Advertising that PC is open.

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions UHL • Wait to be seen: 1 – 2 hours

• EMAS waiting time to handover: 15 – 29 minutes • Patients on Ambulances (POAs): 1 – 5 • Patients in the Emergency Department: 30 – 59 • Patients in the Emergency Department waiting for a

bed: 11 – 20 • Patients at risk of waiting 8hrs on a trolley in the next

2hrs: 1 – 5 • Available resus beds in the Emergency Department: 3

– 5 • ED 4 hour performance percentage (V2): 85 – 94% • CMGs expecting to end the day with negative

capacity: 1 – 2 • Elective work: 1 – 10 individual cases cancelled • Medical outliers: 1 – 20 • Funded adult critical care beds: 15 – 19 beds empty • Capacity of paediatric critical care: elective activity

unable to proceed at both GGH and LRI • Infection prevention measures: Moderate impact on

the ability to admit patients • Nurse staffing levels: Minor impact on quality & safety • Medical staffing levels: Minor impact on quality &

safety • Patients medically fit for discharge: 70 – 89

In addition to actions at OPEL 1:

Emergency Floor • Specialties to in reach into the Emergency

Department to ensure prompt movement of patients out of the department

• Maximise the use of GPAU

Discharges • Review ‘failed discharges’ from the day before • Review ‘Homefirst’ forms, MFFD, LLOS patient plans • Attendance on wards that are in greatest need of

support • Matron to review LLOS patients with Complex

Discharge Team • Escalate internal delays (e.g. diagnostics/therapies)

and action additional support to accelerate discharge e.g. consider out-patient diagnostics

• Support CMGs with Red to Green (R2G) • Wards to ensure TTOs are written and processed in a

timely manner • Early flow of patients to Discharge Lounge • Matron to escalate promptly delays in wards

releasing patients to the Discharge Lounge to CMG teams

• Matron to confirm and challenge with Discharge Lead regarding delays with patients medically fit for discharge

• Matron to review potential discharges for the


LPT • Review and manage bed availability by

patient need and gender to optimise bed availability

DHU • GP support for admission avoidance

TASL • Prioritise prompt booking of transport to

ensure cut off times and packages of care are met

following day and those that could be brought

forward or discharge before • Identification of patients that are next day

discharges before mid-day

Tactical Command • Tactical command bed meetings to update on

complex discharges • Matron to lead daily MDT with partners at 11am • Work with PTS providers to provide additional

resource to accelerate discharge/transfer times • Review all out of area transfers and utilize

community capacity (city/county)

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions UHL • Wait to be seen: 2 – 3 hours

• EMAS waiting time to handover: 30 – 59 minutes • Patients on Ambulances (POAs): 6 – 10 • Patients in the Emergency Department: 60 – 99 • Patients in the Emergency Department waiting for a

bed: 21 – 30 • Patients at risk of waiting 8hrs on a trolley in the next

2hrs: 6 – 10 • Available resus beds in the Emergency Department: 1

– 2 • ED 4 hour performance percentage (V2): 75 – 84% • CMGs expecting to end the day with negative

capacity: 3 – 4 • Elective work: 1 full list cancelled • Medical outliers: 21 – 40 • Funded adult critical care beds: 10 – 14 beds empty • Capacity of paediatric critical care: 1 stabilisation bed

available at either GGH or LRI • Infection prevention measures: Significant &

maintainable impact on the ability to admit patients • Nurse staffing levels: Moderate impact on quality &

safety • Medical staffing levels: Moderate impact on quality &

safety • Patients medically fit for discharge: 90 – 119


Emergency Floor • Additional nursing resource for ED, after discussion

with the Silver Nurse or CMG Leads

Patient Flow • Creation of additional capacity internally by opening

ambulatory areas as escalation areas • Ensure flow is maximized out of ED to avoid

overcrowding • Review all outlying patients and identify appropriate

outliers for additional capacity • Review all cardio respiratory patients at the LRI for

transfer to Glenfield Hospital, where appropriate • Ensure additional portering staff identified to

support patient movement • Consider additional sessions for diagnostics if

causing delay • Consider extra sessions of cath lab if causing delay • Radiology to provide additional support to prevent

delays in X-ray • Fast track radiology for patients who could go home

following investigation • Escalation of internal delays to CMG triumvirate

Discharges • Review all complex patients who are medically fit for

discharge and ensure clear plans are in place with partners

• Ensure all community capacity is full, alert EMAS and


LPT • Senior representation at the 11am complex

discharge meeting • Additional Board Rounds on each community

ward to identify patients suitable for transfer or discharge

• Discharge Coordinators and Senior Nurses to attend specific identified wards to support identification of patients for discharge

DHU • Increase in resources on a temporary basis to

support admission avoidance • Ensure full delivery and utilisation of home

visiting service • Ensure all appointments are available for

booking to support admission avoidance • Support the movement of EMAS patients into

Loughborough Urgent Care Centre

NHS 111 • Redeploy staff according to demand

TASL • Prioritise nursing home cut off times and

packages of care • Explore increased taxi usage to create

capacity on ambulances • Explore crewing-up single crews to create

GPs via CCGs to ensure alternative pathways

explored • Request additional PTS vehicles to expedite

discharge • Discharge Lead to liaise with CMG discharge teams

to expedite discharges • Discharge Lead to request LPT onsite presence to

review / pull appropriate patients • Discharge Lead to lead twice daily MDT with

partners • Discharge Lead to review LLOS patients with

Complex Discharge Team / Matron • Discharge Lead to review patient delays and request

additional LPT beds and spot purchase beds • Discharge Lead to undertake confirm and challenge

with Heads of Nursing regarding delays with patients medically fit for discharge

Tactical Command • Senior representation from each CMG at Tactical

Command Bed Meetings • Consider staffing for escalation areas, including

overnight • Head of Capacity & Flow / Deputy Chief Operating

Officer to escalate to other system leads to liaise Social Services/other providers to obtain increased flexibility in use of their capacity to take medically fit patients to alternative settings

additional double-crew resilience

SOCIAL CARE COUNTY • Team to support in ED (County only) • Targeted review

EMAS • Review turnaround times at LRI • Deploy manager to LRI if prolonged hand

over times are being experienced

GPs • Ensure availability of GP appointments • Maximise utilisation of admission avoidance

schemes

CCGs • Coordination of teleconference

communications and media

TRIGGER AND ACTION CARDS – LEVEL 4 LLR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions UHL • Wait to be seen: 4 hours or more

• EMAS waiting time to handover: 1 hour or more • Patients on Ambulances (POAs): 11 or more • Patients in the Emergency Department: 100 or more • Patients in the Emergency Department waiting for a

bed: 31 or more • Patients at risk of waiting 8hrs on a trolley in the next

2hrs: 11 or more • Available resus beds in the Emergency Department: 0 • ED 4 hour performance percentage (V2): Less than

75% • CMGs expecting to end the day with negative

capacity: 0 • Elective work: All elective work cancelled • Medical outliers: 41 or more • Funded adult critical care beds: 9 beds or less • Capacity of paediatric critical care: No stabilisation

bed available at either GGH or LRI • Infection prevention measures: Significant impact on

the ability to admit patients, with breaches against restrictions

• Nurse staffing levels: Major impact on quality & safety • Medical staffing levels: Major impact on quality &

safety • Patients medically fit for discharge: 120 or more


Patient Flow • Frailty criteria reviewed and discussed for possible

frailty patients to be Glenfield Hospital • Simple medical patients to be reviewed for possible

transfer to Glenfield Hospital (i.e. refer to GGH SOP)

Discharges • Matron or Discharge Lead to attend Board Rounds • Heads of Nursing to attend Tactical Command Bed

Meetings to update on complex discharges • Discharge Lead / Heads of Nursing to consider

additional MDT meetings with partners • Discharge Lead / Heads of Nursing to consider

changes to traditional pathways – temporary placements etc.

• Arrange additional transport to support discharge • External review of all patients awaiting a confirmed

discharge destination

Tactical Command • Implement whole hospital response • Ensure additional senior decision makers are

providing additional ward rounds • Request onsite presence of partners if deemed to be

beneficial • Review next day electives and consider cancellation • All non-essential meetings cancelled


LPT • SPA to support navigation of referred

patients to appropriate community provision • Review the requirement to open flexible

beds. UHL to identify patients suitable to transfer, confirm patients ready to transfer, confirm patients require a community hospital bed. Up to eight beds can be opened in a 12 – 24 hour period. A further 7 beds could be consider over a 48 – 72 hour period.

• Therapist to attend UHL to undertake review with senior UHL member of staff additional patients suitable for transfer

DHU • Increase resources on a temporary basis to

support admission avoidance. Ensure clinicians are aware of current position and requirement to find alternatives to the Emergency Department at the LRI

• Ensure full delivery and utilisation of Home Visiting Service. Consider redeployment of staff if required to see patients in their own homes

• Consider redeployment and request for more staff to provide full utilisation of HUBS

• Support the movement of EMAS patients into LUCC. Look at increasing or redeploying staff to allow the movement of appropriate

patients from the Emergency Department to LUCC Increase staffing into LRI front door to support streaming and redirection of appropriate patients to other services

TASL

Provide early transport Potential to use emergency department crews Crew single crewed resource and implement taxi use Deploy coordinator roles

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions LPT Community Hospital Beds

• Bed capacity is less than 15 beds available. • Discharges are planned for same day • Availability outweighs demand and discharges

planned within 24 hours. • Service area experiencing staffing issues

Community Services

• Unable to guarantee non-urgent planned or

unscheduled service response times in one locality.

• Staff unable to participate in community hospital board rounds to proactively identify patients to discharge into the service.

• Service demand in a single locality outweighs the staff available.

Community Hospital Beds - As level 1 plus;

• Matron for beds respond to 8.30am bed state and daily census information to identify delays in discharge and escalate to relevant service manager as appropriate to support resolution

• Staffing issues managed within service line • Matron for beds escalate to social care areas of

pressure for packages of care or residential placements

• Matron for beds escalates to senior manager UHL admission outweighing discharges to identify if move to level 3 actions required.

Community Services • Prioritise caseloads to ensure management of

essential and critical patients, rescheduling planned non-essential activity to maximise capacity.

• Service managers to engage with colleagues in other teams and localities to work across boundaries to support activity.

• Escalate issues relating to equipment delays to commissioners to consider action that can be taken with equipment provider.

• Consider the need to utilise business continuity plans to respond to increase or persistent pressures

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions LPT Community Hospital Beds

• Bed capacity is less than 7 beds available. • Availability less then demand with discharges

planned in the next 24 hours • Service line experiencing staffing issues

Community Services

• Unable to guarantee non-urgent planned or

unscheduled service response times in more than one locality

• Staff unable to participate in community hospital board rounds to proactively identify patients to discharge into the service

• Service demand in more than one locality outweighs the staff available

Community Hospital Beds - As level 1 & 2 plus;

• Delay admissions until next day • Staffing issues managed within LPT through

staff relocation. Review of leave and training • Undertake afternoon board round to support

identification of suitable discharge along with community and social care

• Discuss bed capacity challenges with patient/family and re offer interim placements to support discharge

• Request additional senior clinical review to support appropriate discharge (geriatrician)

• Escalate to Head of Service to inform LPT on call director of deteriorating picture (out of hours – on call manager to call on call director)

Community Services • Increase capacity within teams through review of

use of annual leave and overtime for substantive staff.

• Review staff training and cancel where clinically safe to do so to support staffing levels.

• Primary care to be requested via the CCG’S to support early discharge from community services for identified patients.

• Community nursing team administration staff to request relatives to provide transport for housebound patients to access primary Care services once appointments has been obtained.

TRIGGER AND ACTION CARDS – LEVEL 4 LRR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions LPT Community Hospital Beds

• No beds available • No discharges planned in the next 24 hours • CHS experiencing staffing issues across all

service lines Community Services

• Unable to guarantee urgent and non-urgent

unscheduled and planned service response times across the service line.

• Cancelling routine clinic appointments to release staff.

CHS experiencing staffing issues across all service lines

Community Hospital Beds - As level 1, 2 and 3 plus;

• Director advises LLR partners level of escalation

and strategic (Gold) command activated • Contact external organisation (partners) to

request staffing support • Stop admission to community hospitals • Cohort patients to multi ward sites to

maximise staffing resources • Cancel all training and consider cancellation of

all annual leave. • Activate CHS plan to redeploy all clinical

staff from non-essential roles across LPT Community Services • Primary care to be advised of capacity and

only urgent essential referrals to be taken. • All visits cancelled except urgent essential care.

Primary Care and patients to be advised of each cancelled visit.

• Cancel all training and consider cancellation of all annual leave

• Activate CHS plan to redeploy all clinical staff from non-essential roles across LPT.

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions TASL Heightened risk to operations - Prioritise nursing home cut off times and

packages of care - In collaboration with the UHL Transport

Coordinator, TASL Discharge coordinators to contact wards, where planned journey times have passed, without being made ready

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions TASL Medium risk to operations • Prioritise nursing home cut off times and

packages of care • In collaboration with the UHL Transport

Coordinator, TASL Discharge coordinators to contact wards, where planned journey times have passed, without being made ready

• Explore increased taxi usage to create capacity on ambulances

• Explore crewing-up single crews to create additional double-crew capacity

• Discharge coordinators to assess patient mobilities on wards

• TASL manager onsite at LRI • Explore resource from other contract areas • Offer overtime to staff

TRIGGER AND ACTION CARDS – LEVEL 4 LRR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions TASL High risk to operations

• Prioritise nursing home cut off times and packages of care

• In collaboration with the UHL Transport Coordinator, TASL Discharge coordinators to contact wards, where planned journey times have passed, without being made ready

• Explore Increased taxi usage to create capacity on ambulances

• Explore crewing-up single crews to create additional double-crew capacity

• Discharge coordinators to assess patient mobilities on wards

• TASL manager onsite at LRI • Explore resources from other contract areas • Offer overtime to staff • All non-essential meetings postponed • All non-essential training postponed • TASL manager present onsite at LRI • Explore additional third-party provision • Where possible, Station Managers to assist

with discharges and transfers • Explore potential to use ED crews

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions DHU • CNH Average number of calls waiting per clinician is

between 6 and 10 • HVS Where the number of home visits per crew

cannot be scheduled within the required time is between 6 and 10




• Adastra & Systm One Instant Message to appropriate staff on duty – “AMBER ALERT (Title) ….” with brief details of reason for escalation and include instructions as appropriate from actions below

• Review workload over whole Division & identify key pressure points. Can clinicians be redeployed to work on other queues?

• Shift Lead to inform Silver On Call • Silver On Call to review AMBER Alert Status

and confirm as accurate for the situation • Ask clinicians to start early/finish late and

withdraw from breaks • Shift Lead to liaise with 111 Division and other

DHU Urgent Care Divisions notifying them that your Division is on Amber Alert & assess issues across Divisions/sites

• If issues affect other Divisions, Silver On Call to consider initiating a conference call between Silver On Calls for other Divisions, agree who will lead on issue, establish frequency of further conference calls

• Liaise with other DHU Divisions to free up any trained staff - admin, clinical, drivers

• Consider changing DOS to reflect current status • Contact Clinicians (including Home Triage

Clinicians) to attend main sites • Deploy managers, admin staff, non-clinical shift

staff (eg supervisors, co-ordinators, drivers) • Comfort Call as soon as timeframes are

exceeded • Request support from DHU 111 Division to

provide tel. advice to cases in the IUC Shared

• OPEL Reporting – Silver On Call to consider updating OPEL status

Advice queue

• Request support from other DHU Urgent Care Divisions clinicians to provide telephone advice to cases in the IUC Practitioner Cases queue

• Consider sending SMS text to appropriate staff groups for more staff “AMBER ALERT- all available staff please call (enter appropriate tel no) to confirm availability”

• Continual re-evaluation of processes, key pressure points, key performance indicators, keeping close contact with Silver On Call regarding decision to continue, escalate to RED ALERT or resume usual service delivery

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions DHU • CNH Average number of calls waiting per

clinician is between 11 and 15 • HVS Where the number of home visits per

crew cannot be scheduled within the required time is between 11 and 19




• Silver On Call to review Red Alert Status and confirmed as accurate for the situation – use judgement when assessing status & take into account all factors in addition to escalation triggers.

• Ensure all Amber actions are complete & re- considered in light of Red Alert & repeat actions if required

• Shift Lead to liaise with 111 Division and other DHU Urgent Care Divisions notifying them that your Division is on Red Alert & assess issues across Divisions/sites

• Shift Lead - Adastra Instant Message to appropriate staff on duty – “RED ALERT (Title) ….” with brief details of reason for escalation and include instructions as appropriate from actions below

• Clinician to review home visits prior to despatch – if necessary re-assess

• Ask clinicians who are willing to do so to carry out home visits in own vehicle (must have insurance business cover). Ensure disclaimer is signed

• Implement telephone advice from bases • Silver on Call to attend appropriate site if

applicable • Consider transport for staff – if appropriate • Consider use of taxis • Call in all Senior Managers if applicable • Send SMS text to Clinical staff “RED ALERT –

Assistance Required - Please attend (Site Name) Immediately”

• Re-assess staff welfare & consider refreshments

• Consider closing DOS for affected areas (capacity management)

• Notify EMAS/Acute Providers of effect of demand

• Review emergency appointments/home visits as a priority and call 999 if necessary

• Silver On Call to consider initiating a conference call with external organisations – if applicable

• OPEL Reporting – Silver On Call to consider updating Opel status

• Silver On Call to cancel all non-urgent training

and meetings to free up staff to cover the service

• Silver On Call to notify Gold On Call of situation • Silver on call to liaise with Gold On Call for

purchase of equipment required e.g. mobile phones and headsets (outgoing calls)

• Continual re-evaluation of processes, Key Pressure Points, key performance indicators, Red Alert to continue, escalate to BLACK ALERT, downgrade to AMBER ALERT or resume usual service delivery

TRIGGER AND ACTION CARDS – LEVEL 4 LRR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions DHU • CNH Average number of calls waiting per clinician is

16 or over • HVS Where the number of home visits per crew

cannot be scheduled within the required time is 20 or more

• Urgent Care Where there are no appoints within the required time is affecting between 11 patients or more

• Walk in services – where the number of patients waiting over 3 hours is 11 or over

• LUCC – Where the number of patients in the department waiting to be seen per clinician is 10 or

• Gold On Call to review Black Alert Status and confirmed as accurate for the situation

• Ensure all Amber and Red actions are complete & repeat as required.

• Send SMS text to for more clinical and non-clinical staff

• “BLACK ALERT – Attendance Required – Please Attend (Site Name) Immediately”

• Gold On Call to review pressures and capacity across all DHU Divisions to identify areas of support

• Gold On Call to alert DHU’s External Communications Consultant of potential need for support

• Gold On Call to notify CCG director on call for Division affected - refer to Contacts Directory

• Suspend local quality standards with agreement from Commissioners – force majeure

• OPEL Reporting – Silver On Call to consider updating Opel status

over • Gold On Call to cancel ALL training and

meetings to free up staff to cover the service

• Corporate management and staff to take on operational roles

• Refuse all requests for short notice annual leave and consider a request for staff to cancel pre booked annual leave for the coming week

• Gold On Call consider convening BCMT (Business Continuity Management Team)

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions EMAS • Abstractions within EMAS have increased by 5 - 10%

over normal seasonal levels. • Reap 2 • Abstractions within Control have increased by 15%

over normal seasonal levels. • Call abandoned rate at 10%. • 90% calls answered within 5 seconds. • Supply chain difficulties are short lived. • Events are having a limited local impact on activity. • Hospital delays are being experienced at a single site. • Critical infrastructure issues have been experienced

for a period of 6 hours and are not expected to reoccur.

• High Vehicle off Road numbers potentially effecting service delivery.

• Severe Weather Warning (LLR) • Up to two performance trajectories not meeting

contracted level by less than 10%. Hospital delays of greater than 15 minutes but less than 60 minutes are being experienced on a single site.

• OPEL Reporting – Silver On Call to consider updating OPEL status

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions EMAS

• All 4 performance trajectories are not achieving contracted level.

• Reap 3 • One or two trajectories are greater than 10% under

expected level. • Severe staffing pressures. 10 % to 15% above normal

abstraction numbers. • Higher than anticipated levels of demand. • Off loading delays at 1 hour or more at acute hospital

with no plans to resolve. • Severe Weather • Major incident declared in neighbouring Trust • Activations between 5%-10% above norm. • Abstractions within Control have increased by 15%

over normal seasonal levels. • Call abandoned rate >15%. • 80% calls answered within 5 seconds. • Hospital delays are being experienced at multiple sites

& severe delays 60 minutes plus. • Critical infrastructure issues have been experienced

for a period of 12 hours and are expected to continue for a specified time of no more than 6 hours.

• High Vehicle Off Road numbers effecting service delivery

TRIGGER AND ACTION CARDS – LEVEL 4 LRR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions EMAS • Failure to meet all four trajectories by greater than

10% • Reap 4 • Activations more than 10% above norm. • Abstractions within EMAS have increased by 15% over

normal seasonal levels. • Abstractions within Control have increased by 15%

over normal seasonal levels. • Call abandoned rate 20%. • 70% calls answered within 5 seconds. • Hospital delays are being experienced at multiple sites

no evidence of reduction or single site – severe delays + 90 minutes

• Major critical infrastructure issues have been experienced for a period of up to 24hours and are expected to continue for a specified time of no more than 24 hours.

TRIGGER AND ACTION CARDS – LEVEL 2 LLR LHE OPERATIONAL BUT EXPERIENCING SOME PRESSURE TELECONFERENCE TO BE CONSIDERED Provider Triggers Organisational Actions System Wide Actions Leicestershire County Council Adult Social Care

HART Staff availability reduces to below 85%

Capacity rejections between 10 – 20 in the last 7 days

> 50% pick up times at next day

Home Care >50% pick up times at 48 hours

Await care list for hospital cases rises to 25 cases

<10% of Providers reporting a critical position

Residential Care Between 26 - 50 beds available for Covid+ admissions

Start to use Crisis Response Team to bridge gaps in HART rotas and DRT also for bridging

Step down cases from HART as soon as possible to release capacity

Start to use interim beds Start work to identify where frequency and duration of existing calls could be reduced where alternatives are temporarily available (“green calls”)

Ensure that block booked beds (Cedar Court) are utilised fully Increase management controls to ensure available beds are prioritised for hospital discharge

Service manager joins daily calls in UHL at 11am and follow-up at 2pm, to ensure smooth and prompt flow in discharge process

Request made to CCG to consider

commissioning block beds for step down of Covid+ patients

TRIGGER AND ACTION CARDS – LEVEL 3 LLR LHE PROLONGED PRESSURE – ORGANISATIONS TRIGGERING LEVEL 3 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ONCALL DIRECTOR - LHE TELECONFERENCE NECESSARY Provider Triggers Organisational Actions System Wide Actions

Leicestershire County Council Adult Social Care

HART

Staff availability at 65% -84%

Capacity rejections rise to between 21- 30 in the last 7 days

> 50% pick up times at >48 hours

Home Care

>50% pick up times at 72 hours

Await care list for hospital cases rises to 30 cases

10% to 25% of Providers reporting a critical position

Residential Care

Between 10 and 25 beds available for Covid+ admissions

Interim bed average stay increases to 14 days+ as home care waits increase

General – e.g. major IT system outage

Care Act Easements considered (statutory process to request specific flexibilities, including moving to Human Rights Act Assessment and suspending other functions such as review and financial assessment) to allow for following actions:

Increase capacity of Crisis Response Team with temporarily re-purposed care pathway staffing to support HART

Start reducing frequency and duration of calls where alternatives are available to meet needs (HART and Home Care)

Maximise remaining capacity with providers by moving and sharing packages

Increase use of interim beds and implement options to temporarily extend bed base

Diversion of care pathway staff to critical services

Employment of agency support

Request support from LPT to increase use of Community Hospital beds and Community health services for people with highest level of needs

Covid+ patients to be retained in bedded environments

Escalate to Local Resilience Forum (LRF)

Mutual aid requested from Leicester City and Rutland Councils

Increase Trusted assessments

TRIGGER AND ACTION CARDS – LEVEL 4 LRR LHE UNDER EXTREME PRESSURE, UNABLE TO SUSTAIN BUSINESS CONTINUITY ORGANISATIONS TRIGGERING LEVEL 4 SHOULD NOTIFY THE URGENT CARE TEAM / CCG ON-CALL DIRECTOR IMMEDIATELY - LHE TELECONFERENCE ESSENTIAL Provider Triggers Organisational Actions System Wide Actions

Leicestershire County Council Adult Social Care

HART

Staff availability is below 64%

HART not able to pick up new cases as no onward provision for exiting cases

Capacity rejections are above 30 in the previous 7 days

Home Care

Await care list for hospitals >35 cases

Very little capacity to pick up any new cases

Residential Care

>10 Covid+ beds available

Significant level of provider failures occurring that isplacing increased strain on the remaining residential bed base. Include infection control failure?

No interim bed availability

Care Act Easements (see above) must be in place for the following actions:

Prioritise calls to people with the highest level of needs using Human Rights Act assessments.

Ensure flow through system by taking all hospital discharges, halting reablement, and continue to prioritise calls in line with vulnerability rating working with providers in line with Human Rights Act assessments

Crisis Response Team to be utilised where needed to support flow - training of other staff across LCC / volunteers to support direct care provision for the highest level of need only

Look to source placements out of LLR area Consider insourcing of services into LCC owned property (vacant Care Home)

Continued support requested from LPT for community hospital beds and community health services

Health and social care provide support on a agreed basis including identification of patients that can be cared for by either health or social care (not both)

Mutual aid request extended to all Councils in the East Midlands region

Further escalation to LRF and to NHSE

Actions Specific to discharge:

LLR SYSTEM WIDE DISCHARGE RESILIENCE AND ESCALATION PLAN

OPEL 1 OPEL 2 OPEL 3 OPEL 4

The local health and social care system has enough capacity to maintain patient flow and be able to meet anticipated demand within available resources.

The local health and social care system is starting to show signs of pressure.

The local health and social care system is experiencing major pressures compromising patient flow and continues to increase.

Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised.

LLR System Response OPEL 1 OPEL 2 OPEL 3 OPEL 4

UHL In addition to actions at OPEL 1: • Review ‘failed discharges’

from the day before • Review ‘Homefirst’ forms,

MFFD, LLOS patient plans • Matron to review LLOS

patients with Complex Discharge Team

• Escalate internal delays (e.g. diagnostics/therapies) and action additional support to accelerate discharge e.g. consider out-patient diagnostics

• Support CMGs with Red to Green (R2G)

• Wards to ensure TTOs are written and processed in a

In addition to actions at OPEL 2: • Review all complex patients

who are medically fit for discharge and ensure clear plans are in place with partners

• Ensure all community capacity is full, alert EMAS and GPs via CCGs to ensure alternative pathways explored

• Request additional PTS vehicles to expedite discharge

• Discharge Lead to liaise with CMG discharge teams to expedite discharges

• Discharge Lead to request

In addition to actions at OPEL 3: • Discharge Lead / Heads of

Nursing to convene additional senior MDT meetings with partners

• Matron or Discharge Lead to attend Board Rounds

• Heads of Nursing to attend Tactical Command Bed Meetings to update on complex discharges

• Discharge Lead / Heads of Nursing to consider changes to traditional pathways – temporary placements etc.

• Arrange additional transport to support discharge

• External review of all

timely manner

• Early flow of patients to Discharge Lounge

• Matron to escalate promptly delays in wards releasing patients to the Discharge Lounge to CMG teams

• Matron to confirm and challenge with Discharge Lead regarding delays with patients medically fit for discharge

• Matron to review potential discharges for the following day and those that could be brought forward or discharge before

• Identification of patients that are next day discharges before mid-day

• Tactical command bed meetings to update on complex discharges

• Matron to lead daily MDT with partners at 11am

• Work with PTS providers to provide additional resource to accelerate discharge/transfer times

• Review all out of area transfers and utilize community capacity (city/county)

LPT onsite presence to review / pull appropriate patients

• Discharge Lead to lead twice daily MDT with partners

• Discharge Lead to review LLOS patients with Complex Discharge Team / Matron

• Discharge Lead to review patient delays and request additional LPT beds and spot purchase beds

• Discharge Lead to undertake confirm and challenge with Heads of Nursing regarding delays with patients medically fit for discharge

• Head of Capacity & Flow / Deputy Chief Operating Officer to escalate to other system leads to liaise Social Services/other providers to obtain increased flexibility in use of their capacity to take medically fit patients to alternative settings

• Ensure additional portering staff identified to support patient movement to discharge lounge

• Ensure pharmacy prioritizing discharge TTOs

patients awaiting a confirmed discharge destination

• Implement whole hospital response

• Ensure additional senior decision makers are providing additional ward rounds

• Request onsite presence of partners if deemed to be beneficial

LPT In addition to actions at

OPEL 1: LPT • Review ‘failed discharges’ from the day before • Ensure action and referral

taken for all MFFD • Address internal delays • Identification of next day

discharges and ensure actions in place for discharge

Partner support • TASL- to support early

discharge of patients identified as MFFD on previous day

• UHL/acute to ensure early transfer of patients to community hospital

• ASC to communicate potential delays for transfer and support bridging

In addition to actions at OPEL 2: LPT • Additional Board Rounds

on each community ward to identify patients suitable for transfer or discharge.

Partner support • TASL to prioritise morning

transfer of MFFD patients • UHL to ensure same day

transfer of identified patients

• ASC to identify interim arrangements for patients awaiting care packages

In addition to actions at OPEL 3: LPT • Matron to attend Board Rounds • Service Leads/ Heads of

Nursing to consider additional MDT meetings with partners

• Service Leads/ Heads of Nursing to consider changes to traditional pathways – temporary placements etc.

• Review Covid positive and negative capacity to optimise bed usage

Partner support • Request onsite presence

of partners if deemed to be beneficial

Adult Social Care Domiciliary Support: Continue to monitor for change

Domiciliary Support: Utilisation of volunteer workforce to shadow staff in case they are needed into the future. Providers reminded to keep RAG ratings up to date in case action needed.

Domiciliary Support: Reduce all calls where alternative provision is available. Move red calls between providers to maximise remaining capacity Make full use of bed based placements as an

Domiciliary Support: Prioritise calls to people with the highest level of needs. Use alternative workforce to full capacity and all bed based provision to full capacity. Seek mutual aid from

Look at distributing calls

between providers if some are stretched.

alternative to home care neighbouring Councils

Domiciliary Support: Move packages between providers, redistributing workload. If still needed, use RAG rating to reduce frequency and duration of calls where alternatives are available to meet needs. Full use of volunteer workforce. Start to consider the use of bed based placements in the short term

Residential/ Nursing Care: Continue to monitor for change

Residential/ Nursing Care: Support with volunteer workforce in homes falling close to critical staffing levels Increase management controls to limit new care home placements. Consider alternative provision e.g. hotel based and fully scope.

Residential/ Nursing Care: Contact neighbouring Councils for mutual aid. Escalate to NHE and LRF Escalate and seek support from LPT to divert patient to community hospitals.

Residential/ Nursing Care: Escalate through LRF for mutual aid. Consider insourcing and commissioning out of area.

Covid +ve discharge beds:

Continue to monitor for change

Covid +ve discharge beds: Ensure people are moved on as soon as isolation period ended, ensure system flow is achieved

Covid +ve discharge beds: Hold discussions with system re any alternative provision e.g. community beds. Ensure no other options for expansion of bed capacity e.g. another scheme, hotel based provision etc. Ensure all partners are briefed on difficulties and solutions sought across system

Covid +ve discharge beds: Make full use of wider system, consider out of area placements/support from other LA's

Covid +ve discharge beds: Consider increasing capacity for short or long term (provision in contract to add an additional 5 beds) either at this scheme. Consider other block purchases through another route/scheme (i.e. community hospitals or other homes accepting C+ve)

Supported Living: Continue to monitor for change

Supported Living: Support with alternative workforce in homes falling below/close to critical staffing levels

Supported Living: Ensure use of RAG ratings to prioritise essential care. Ensure full use of alternative staff and agency, HRDC etc. Consider whether dom support or other providers can add to workforce. Consider outreach provision from less stretched providers

Supported Living: Use all options above. Consider residential support for those people that cannot continue to live independently without critical staff.

Supported Living: Support

with alternative workforce, ensure full use of agency staff and other available service provision. Ensure providers make use of RAG ratings to prioritise essential care. Utilise HRDC for additional support.

ICELS: Monitored weekly ICELS: None but continue to monitor if demand rises above 20% and any impact on staffing levels

ICELS: Invest further in equipment provider staffing resource or support with alternative workforce. Potential to prioritise some activities above others

ICELS further investment in staffing resource for equipment provider, supported with alternative workforce, prioritising activity

ICELS: Invest further in equipment provider staffing resource or support with alternative workforce

SOCIAL CARE CITY · Targeted review · Targeted review SOCIAL CARE COUNTY · Team to support in ED · Team at front door

· Targeted review · Targeted review TASL · Prioritise nursing home

cut off times and packages of care

Prioritise nursing home cut off times and packages of care

· Provide early transport

Explore increased taxi usage to create capacity on ambulances

· Potential to use emergency department crews

Explore crewing-up single crews to create additional double-crew resilience

· Crew single crewed resource and implement taxi use

Discharge coordinators to

scrutinise mobilities · Deploy co-ordinator roles Senior mgt presence on site to support liaison with hospital staff

CCG’S · Co-ordination of Teleconference comms and media · System wide 10:30 Escalation call · 12:30 Discharge sitrep to take place Enhanced liaison with partners to ensure actions followed up Escalate any OOA delays

· Co-ordination of Teleconference comms and media · System wide 10:30 Escalation call · 12:30 Discharge sitrep to take place Enhanced liaison with partners to ensure actions followed up Escalate any OOA delays

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Leicester, Leicestershire and Rutland

Seasonal Flu Plan 2020/21

Final: Flu Board, 15th September 2020

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Contents 1. Introduction ................................................................................................................................. 3

2. Governance and planning arrangements within STP ....................................................... 3

3. Assurance processes and findings around: ....................................................................... 4

3.1 Sufficient and correct flu vaccines ordered ........................................................................ 4

3.2 Clarity on which GP Practices are operating as hot/cold ............................................... 5

3.3 Clarity of PPE requirements and provision....................................................................... 6

3.4 Monitoring how long it takes to administer a flu vaccine due to Covid requirements ..................................................................................................................................... 6

3.5 Additional staffing requirements ......................................................................................... 6

3.6 Additional venue requirements ........................................................................................... 7

3.7 Domiciliary service for shielded patients ........................................................................... 7

3.8 Cold chain storage requirements ....................................................................................... 7

3.9 Enhanced call/recall requirements..................................................................................... 7

4. Practice support ......................................................................................................................... 8

4.1 Plan for low performers from last year ................................................................................ 8

4.2 Monitoring vaccine orders and transfers........................................................................... 8

4.3 Immunisation training provision and assurance ................................................................ 8

4.4 Managing performance through the season ...................................................................... 9

5. Review of local priorities ....................................................................................................... 10

Demographic description and identification of vulnerable groups .......................................... 10

5.2 Review of last year’s uptake ............................................................................................. 11

5.3 Approach to health inequalities ........................................................................................ 13

6. Local arrangements ................................................................................................................. 14

6.1 Residential, nursing and hospice, Supported Living, Domiciliary care ...................... 14

Direct Payment and Personal Health Budget Personal Assistants self-employed, employed by DP/PHB holder and via agency .................................................................................................. 14

6.2 Maternity .............................................................................................................................. 14

6.3 Inpatient/Outpatient ............................................................................................................ 14

6.4 School Age Immunisation Service (SAIS) ...................................................................... 15

6.5 Workforce ............................................................................................................................ 16

7. Outbreak management – Linking in with local EPRR arrangements ......................... 16

7.2 Swabbing ............................................................................................................................. 16

7.3 Treatment – use of antivirals ............................................................................................ 16

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8. Requests to NHSE for local commissioning ..................................................................... 16

9. Communications and engagement ..................................................................................... 17

10. Action Plan ............................................................................................................................. 19

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1. Introduction

This STP/ICS Flu Plan supplements the NHSE/I Regional Flu Plan which outlines the scope and ambitions of the National Flu Programme for 2020/21. The primary purpose of this plan is to set out the STP/ICS led approach to achieving the National Flu Programme for 2020/21 and the general NHS response to flu outbreaks.

LLR STP

Now more than ever before it is important to maintain high vaccination coverage. The flu vaccine remains one of the best defences available against flu however the delivery of this year’s programme is going to be more challenging because of the impact of COVID-19.

There is no one wonderful way of maximising flu vaccinations it will take effort from everyone. For example for general practice planning is dependent on the size of their eligible population, their practice estate and infrastructure, collaborative working with PCN and working within COVID-19 guidelines. Some main principals are:

• Right risk assessments undertaken • Right IPC in place • Right IG in place • Competent staff • Working collaboratively • Blended approach

Within Leicester, Leicestershire and Rutland STP there are 3 Clinical Commissioning Groups, with 25 Primary Care Networks and 133 general practices. The number of care homes across LLR is highlighted in the table below.

Leicester City Leicestershire County

Rutland County

Number of care home 95 182 11

2. Governance and planning arrangements within STP

Area Name Email STP Flu Lead Caroline Trevithick

Executive Director of Nursing, Quality and Performance

Caroline.Trevithick@westleicestershireccg .nhs.uk

CCG Flu Lead Wendy Hope Head of Quality & Safety

[email protected]

Leicester City Local Authority Flu Lead

Julie O’Boyle Consultant in Public Health

[email protected]

mailto:[email protected]




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Leicestershire County Local Authority flu Lead

Fiona Grant Consultant in Public Health

[email protected]

Rutland Local Authority

Fiona Grant Consultant in Public Health

[email protected]

PCN Flu Leads

Flu leads have been identified across PCNs and many general practices have flu champions.

LLR STP Flu Board

LLR has established a LLR STP Flu Board which takes its membership from the following partners.

• NHS Leicester City, West Leicestershire and East Leicestershire and Rutland Clinical Commissioning Groups

• Leicester City Council • Leicestershire County Council • Rutland County Council • Public Health England • University Hospitals of Leicester NHS Trust • Leicestershire Partnership NHS Trust • DHU Health Care • Primary Care Networks • Leicestershire Local Medical Committee • Local Pharmaceutical Committee

Other members will be include as identified. The Flu Board has established terms of reference and has agreed to meet fortnightly during the flu season. There is a clear governance process from monitoring the plan and escalation routes have been identified to ensure we are able to meet the challenge and ‘unblock’ any issues at the earliest opportunity.

A number of areas of focus have been identified and named leads have been allocated to specific areas. The named leads will report progress, challenges and risks at each bord meeting.

The leads have all contributed sections of this plan to ensure it is owned by all partners.

3. Assurance processes and findings around:

3.1 Sufficient and correct flu vaccines ordered LLR CCGs collected data in May about the numbers of vaccines that had been ordered by all practices and this was submitted to NHS England. This was a large and thorough exercise and identified most practices had ordered based on 2019 uptake. Due to expansions in the programme, the ordering is likely to not correlate with the amount required.



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Utilising our existing tri weekly COVID-19 situation report all LLR general practices were asked to completed a “planning for flu” survey). This survey included a specific question asking practices to assess if they have ordered enough vaccines.

Public Health data indicates that across LLR general practices there are 418K people over the age of 50 years old. Due to the expansion of the flu programme for 2020, concern has been expressed by some general practices about the numbers of vaccines ordered as these were based on the 2019 activity and not expanded cohorts. This issue will be explored within the our medicine optimisations subgroup in collaboration with Public Health England.

Vaccines are being delivered to practices during September and October 2020.

On 5 August, the Department of Health and PHE published an update to the national flu immunisation programme 2020 to 2021 that included a request to all Hospital Trusts to offer flu vaccination to clinically at risk eligible in-patients and out-patients. This is a new and welcome approach; secondary care should be working in partnership with primary care in a coordinated way to maximise immunisation coverage. However, because this is a late request, Hospital Trusts will not have ordered any flu vaccine for patients and this is a risk for delivery.

3.2 Clarity on which GP Practices are operating as hot/cold There is a mixed landscape across Leicester, Leicestershire and Rutland presently about how practices are managing this. The LLR CCGs produced a Standing Operating Procedure for the establishment of hot / cold sites or zones and allowed practices to deliver this as they felt appropriate.

A collaborative Business Continuity Planning (BCP) review and development exercise has been undertaken with all LLR practices at practice, PCN and place level. In this, all practices and PCNs described their individual arrangements and processes for hot and cold patient management. This was a proactive exercise and included preparation for winter including flu.

All practices are adhering to cohorting principles but the approach varies depending on the constraints of buildings and working arrangements. Some practices are using branch sites as hot / cold sites, others have zoned their single building and managed the flow of patients and other groups have been delivering or will scale up services at a federation or PCN level.

Since the start of the Covid-19 pandemic all LLR practices have been returning an individual practice level “SitRep” in which they are able to highlight operational and IPC/PPE issues to trigger support from the CCGs and or PCN/Federation. (Currently this is tri-weekly, but practices know they can escalate issues direct to the CCG on a daily basis). The combination of the BCP development and the SitRep reporting provides assurance that individual practice/PCN cohorting and hot/cold management processes are working and there are robust “scale up” plans in place should this be required.

Individual practice and PCN cohorting capacity, and therefore ability to deliver the Flu vaccination programme, is also supported by LLR commissioned “Hot Hubs” and “Enhanced Home Visiting Service” to which practices can refer confirmed or suspect Covid-19 patients. Both these services are continually reviewed as it is recognised that the required clinical

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model and service capacity is changing and will continue to change with increasing winter presentations and complexity.

General practices are delivering the programme in a variety of ways ensuring patient safety at each step. Information has been provided to providers on their responsibilities in relation to a variety of implementation methods whether this be an inside or outside clinic. National information such as the RCGP information has been shared.

3.3 Clarity of PPE requirements and provision Across LLR, all practices have developed, implemented and maintained robust processes for the ordering of PPE and IPC supplies. Again these processes vary, but include individual practice orders, PCN level ordering and Federation/Locality level ordering.

As before, practices can highlight any issues they have with either PPE stock levels or ordering through their SitRep return. This “RAG” rated alert triggers practical support from the CCG, PCN or Federation. In extreme “Red” situations an emergency supply process can be activated, though as all practices have robust processes in place, this is very infrequent.

Robust processes are in place for the ordering of PPE and practices/PCNs/Federations have, based on guidance and clarification provided by the LLR Flu Board and IPC Leads, started to factor in to their ordering the requirements for PPE associated with this year’s Covid-19 impacted Flu programme. However there is concern around the availability of PPE and national stocks should demand increase in an unforeseen/unplanned way.

3.4 Monitoring how long it takes to administer a flu vaccine due to Covid requirements

It is recognised that the time allocated per flu vaccination appointment during the 2020 flu season will need to be significantly greater than has been historically given. This is due to the requirements for the member of staff giving the vaccine to adhere to strict hygiene measures, distancing requirements for each patient seen. Discussions with clinicians have indicated that this will likely be approximately an additional 6 -8 minutes if undertaking in a traditional clinic setting. This does depend on the experience of the vaccinator so can only be taken as an indicative guide. This aspect has been built into planning assumptions.

3.5 Additional staffing requirements

PCNs, general practice and Federations are developing their flu plans and how this can be managed under the challenges that Covid-19 places on a delivery model. There is recognition that due to maintaining IPC procedures and social distancing requirements a general practice clinic session will take longer than usual or not as many people will be seen in the time available. Therefore additional staffing hours will be required.

Across LLR it has been agreed that PCN DES Extended Hours can be utilised for Flu Clinics which will enable some additional time required for flu and may provide a further opportunity for cohorting and to “scale up” vaccination provision. In addition we have discussed the option of giving practices flexibility in using their appointments in the first few weeks of October to accommodate flu vacs

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We are looking at providing additional workforce through other avenues and are currently exploring opportunities with foundation dentists to support PCN's in delivering flu vaccinations and have arranged bespoke training for our general practice pharmacists.

3.6 Additional venue requirements

Through the BCP exercise, the majority of LLR GP practices have indicated an intention to provide a practice based Flu service, either purely in-house or within their PCN. However we anticipate that additional venues or further flexibility in usage of current premises may be required to deliver an effective flu programme and are currently quantifying how this will work most effectively in conjunction with provider partners.

3.7 Domiciliary service for shielded patients As per national guidance regarding the relaxing of enhanced shielding arrangements, responsibility for domiciliary care, including flu vaccination for housebound individuals, has reverted back to either the patient’s general practice, for practice initiated care, or to Community Health Services if individuals were previously on their caseload.

The CCG is also considering a centrally delivered service funding dependent.

3.8 Cold chain storage requirements

It is imperative that the cold chain is maintained at all time, regardless of clinic setting. Pressures on supply mean that tight controls are necessary to minimise waste. In addition assessing and managing potential cold chain breaches uses considerable staff and time resource, as well as adding anxiety for staff and patients.

General practices have been issued with guidance information around cold chain and transporting vaccines and are aware of the requirements. MHRH guidance received will be reviewed and circulated in regards vaccine transportation.

Additional appropriate and validated refrigeration and cool boxes will be required across the partner organisations due to COVID-19, expansion of flu programme and the need to consider a blended approach to delivery.

3.9 Enhanced call/recall requirements The “Planning for Flu” survey included a specific question asking practices to describe/confirm their call/recall arrangements. General practices have outlined how they plan to use a variety of mechanisms to effectively call and recall patients. There will be phased and targeted systems prioritising those with most clinical needed utilising SMS, letters and telephone calls.as well as maximising making every contact count ethos.

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4. Practice support

4.1 Plan for low performers from last year

Flu data has been examined at CCG and practice level for each “at risk” cohort category and outliers have been identified with lower than expected % uptake. Low performers have been reviewed and prioritised for additional support and work during the 2020 flu season. This will be managed at a local level by Primary Care Teams who have existing and established relationships with practices. Practices will be contacted proactively to discuss their flu plans and approach and how uptake can be maximised.

As part of this process, comparator practices with high uptake figures have also been highlighted and will be contacted to understand what their approach has been and how they have achieved this. Where appropriate, good practice will be shared and discussions encouraged between low and high performers to see what learning can be shared.

4.2 Monitoring vaccine orders and transfers As per 3.1, all LLR practices have been asked to assess their orders and targeted support will be provided to those who have indicated any potential issues. It is anticipated that any need for transfers will be identified through practice SitRep reporting and will be proactively managed by CCG Primary Care, PCN and Federation managers.

As well as using SitRep reporting and response to identify and manage specific issues, there will be a “focus on Flu” through and at all practice/PCN/Federation engagement events/meetings encouraging and allowing practices to raise concerns, seek support and share learning and good practice.

4.3 Immunisation training provision and assurance

There is national guidance to support identification of potential immunisers and their training and development needs and this is the approach we have adopted, https://www.gov.uk/government/publications/flu-immunisation-training-recommendations This should be read in conjunction with the National Minimum Standards documents to which it refers.

New immunisers should have a period of supervised practice and support with a registered healthcare practitioner who is experienced, up to date and competent in immunisation. See Public Health England. National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners and immunisation training for healthcare support workers in the links below.

https://www.gov.uk/government/publications/national-minimum-standards-and-core- curriculum-for-immunisation-training-for-registered-healthcare-practitioners

https://www.gov.uk/government/publications/immunisation-training-of-healthcare-support- workers-national-minimum-standards-and-core-curriculum

https://www.gov.uk/government/publications/flu-immunisation-training-recommendations

https://www.gov.uk/government/publications/flu-immunisation-training-recommendations

https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners

https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners

https://www.gov.uk/government/publications/immunisation-training-of-healthcare-support-workers-national-minimum-standards-and-core-curriculum

https://www.gov.uk/government/publications/immunisation-training-of-healthcare-support-workers-national-minimum-standards-and-core-curriculum

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National guidance has also been produced around COVID-19: https://www.gov.uk/government/publications/immunisation-training-guidance-during-the- covid-19-pandemic

Information on training requirements has been made available to all areas and training provision will be provided in a number of ways. The two main mechanisms being eLearning and face to face training.

Flu immunisation e-learning programme

This free interactive flu immunisation e-learning programme, written by Public Health England and produced by Health Education England’s e-Learning for Healthcare, is available for anyone involved in delivering the flu immunisation programme. It is particularly useful for those experienced professionals who require an update and we have encouraged this method of learning for appropriate staff.

Flu Immunisation face to face training

For general practice the CCG training department has arranged a series of face to face immunisation training dates. Targeted at new and less experience vaccinators this programme will enable registered clinicians and healthcare assistants to provide safe and effective Influenza, Pneumococcal and Shingles Immunisation programmes for those eligible patients in line with national policy, Green Book and best practice guidance. All face to face training venues have undergone risk assessments to ensure compliance with COVID-19 guidelines.

Whilst the example of primary care has been used other areas training needs will follow the same principles to ensure the whole of the flu programme can be delivered safely.

4.4 Managing performance through the season Information and reports will be reviewed by the various flu operational groups to allow any concerns to be managed quickly and escalated through appropriate governance channels up the STP Flu Planning Board if required.

Information will be shared with all appropriate partners and providers to ensure open and transparent conversations can take place to understand barriers and challenges to performance or to share learning from practices performing well.

The CCG has access to IMMFORM.

Community pharmacies are part of the flu board and relevant sub groups and the “Pharmaoutcomes” systems has been reviewed and tested with encouragement for timely submission to support accurate monitoring.

https://www.gov.uk/government/publications/immunisation-training-guidance-during-the-covid-19-pandemic



http://www.e-lfh.org.uk/programmes/flu-immunisation/

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5. Review of local priorities

Demographic description and identification of vulnerable groups The Department of Health and Social Care and Public Health England have defined the people who are eligible for the vaccine. These include everyone in a clinical risk group aged between 6 months and 65 years, everyone aged over 65 years and all children aged between 2 and 11 years on 31 August 2020.

There are additional at vulnerable groups which may be targeted as part of the flu vaccination campaign 2020-21. These include

• Household contacts of those on the NHS Shielded Patient List, specifically individuals who expect to share living accommodation with a shielded person on most days over the winter and therefore for whom continuing close contact is unavoidable;

• Health and social care workers employed through Direct Payment (personal budgets) and/or Personal Health Budgets, such as Personal Assistants, to deliver domiciliary care to patients and service users;

• Planned extension of the vaccine programme in November and December 2020 to include those aged 50-64 years subject to vaccine supply.

There is further guidance explaining the ambition to increase flu vaccination levels for those people living in the most deprived areas and from BAME communities. The BAME groups are particularly important to capture for flu vaccination given our population. This emphasises the need to ensure equitable uptake, to protect those who are more at risk of COVID-19 and flu. These aims will require culturally competent engagement with local communities, employers and faith groups.

The national flu immunisations programme later of 5th august 2020 indicates that frontline health and social care workers should receive a vaccination this season. We will ensure there is a 100% offer to health and social care workers for them to receive a vaccination. Important to this will be ensuring staff are aware of where they are able to access a vaccine. Through our flu sub group structure we will promote this through are usual mechanisms for staff to be vaccinated. Additionally should funding become available other avenues can be explored such as pop ups.

This should be provided by their employer, as part of their responsibility to protect staff and patients and ensure safe running of services. Employers should commission a service which makes access easy to the vaccine for all frontline staff, encourage staff to get vaccinated, and monitor the delivery of their programmes.

Table: Number registered with a LLR GP eligible for a free vaccine.

Eligible group Leicester Leicestershire Rutland TOTAL Core eligibility

All children aged 2 to 11 years on 31 August 2020

53,868 77793 3831 135,492

People aged 6 54,338 82,868 4340 141,546

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months to 65 years in a clinical risk group*

People aged 65 years and over

47,541 143,277 10,127 200,945

Broader ambition Health and social care workers employed through direct payments

Household contacts of people on shielded list

Everyone aged 50-64 years

64,617 143,138 8657 216,412

* People aged 6 months to 65 years in a clinical risk group according to flu immunisation data as at February 2020 Chronic (long-term) respiratory disease, such as severe asthma, chronic obstructive pulmonary disease (COPD) or bronchitis; Chronic heart disease, such as heart failure; Chronic kidney disease at stage three, four or five; Chronic liver disease; Chronic neurological disease, such as Parkinson’s disease or motor neurone disease; Learning disability; Diabetes; Splenic dysfunction or asplenia; A weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment); Morbidly obese (defined as BMI of 40 and above).

5.2 Review of last year’s uptake

Overall uptake up to February 2020 is highlighted in the table below. Flu data has been examined at CCG and practice level for each “at risk” cohort category and outliers have been identified with lower than expected % uptake. The table clearly highlights the scale of the challenge to achieve 75% uptake in all eligible groups. This is especially clear within the under 65 (at risk only) group, where two of the three CCG’s areas are lower than the England average.

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GP Practice Flu Immunisation uptake up to the end of February 2020

Table: GP Practice Flu Immunisation uptake up to the end of Feb 2020

Summary of Flu Vaccine Uptake % Former DCO

CCG Code

Org Name

65 and over

Under 65 (at-risk only)

All Pregnant Women

All Aged 2

All Aged 3

Central Midlands

ENGLAND 72.4% 44.9% 43.7% 43.4% 44.2% Q78 Central Midlands DCO 72.5% 42.8% 42.4% 48.1% 48.0% 03T NHS LINCOLNSHIRE EAST CCG 67.4% 41.3% 44.5% 44.7% 47.1% 03V NHS CORBY CCG 67.5% 39.7% 37.1% 30.0% 31.1% 03W NHS EAST LEICESTERSHIRE AND RUTLAND CCG 74.2% 39.3% 44.7% 56.8% 53.3% 04C NHS LEICESTER CITY CCG 69.0% 39.3% 37.7% 38.9% 37.9% 04D NHS LINCOLNSHIRE WEST CCG 74.8% 44.7% 46.5% 55.8% 55.0% 04G NHS NENE CCG 71.9% 44.8% 37.1% 44.5% 45.3% 04Q NHS SOUTH WEST LINCOLNSHIRE CCG 76.9% 51.4% 50.9% 55.7% 54.7% 04V NHS WEST LEICESTERSHIRE CCG 73.9% 40.5% 50.7% 55.5% 57.1% 99D NHS SOUTH LINCOLNSHIRE CCG 76.3% 51.3% 50.4% 56.1% 54.0%

Central Midlands DCO 72.5% 42.8% 42.4% 48.1% 48.0%

Practice level data indicate varied flu vaccination rates across the STP, in the 2019/20 season. For example, the graph below, shows that, for those at risk aged under 65 years, vaccination take up ranged from 65.4% of eligible population down to 20.9%. This indicates the scale of the challenge to vaccinate 75% of people in eligible groups and may help to target extra support.

Table: Proportion of at-risk people aged 6 months to under 65’s having flu vaccinations in season 2019/20 by LLR GP practice

There were higher proportions of people vaccinated in those aged over 65 years. The highest uptake at 85.2% to the lowest at 37.7% (last bar on the table excluded).

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Table: Proportion of people aged over 65 years having flu vaccinations in season 2019/20 by LLR GP practice

5.3 Approach to health inequalities The impact of the COVID-19 lockdown has been to emphasise the bearing of societal inequalities on health and wellbeing. Important factors are likely to include:

• People living in areas of high socioeconomic deprivation; • Ethnic inequalities in COVID-19: People from Black British and Asian British ethnic

backgrounds may be at high risk of illness; • Interaction of ethnic and socioeconomic inequalities, demonstrating the

intersectionality of multiple aspects of disadvantage; • Other marginalised groups (such as homeless people, asylum seekers, prisoners

and street-based sex workers).

People in groups where the impact of health equalities is greatest, are also more likely to be in a clinically at-risk group, eligible for the vaccine. For example, rates of hypertension, diabetes, asthma, chronic obstructive pulmonary disease, heart disease, liver disease, renal disease, cancer, cardiovascular disease, obesity and smoking, are likely to be higher among people in the most marginalised or deprived groups.

The STP area covers local authority areas with diverse populations. Approaches to increase uptake will be tailored based on the target population, practice data and uptake records. Existing systems which work with vulnerable people and provide support will also be utilised to increase uptake. We will work with local groups and influencers to support vaccination uptake.

There will be a communications campaign to ensure equitable take up for people from black and minority ethnic backgrounds and to advertise local clinics in rural areas where access to clinics may be difficult.

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There will be ongoing reviews of the relationship between these health inequalities and flu vaccine uptake. Responses are likely to involve different engagement techniques depending on the target group. These are highlighted in Section 9, communications and engagement.

6. Local arrangements

6.1 Residential, nursing and hospice, Supported Living, Domiciliary care Direct Payment and Personal Health Budget Personal Assistants self-employed, employed by DP/PHB holder and via agency.

Care homes have historically been supported by general practice for flu vaccination with support from community nurses where appropriate. Care home are a high priority for LLR. GP practices are able to vaccinate residents and staff who are registered with their practice; they cannot vaccinate care home staff unless the staff member is a registered patient with the practice. The preferred delivery model for care homes will be for general practice to continue to undertake this service for residents.

The local authority is taking a lead on this aspect as one of the key areas of focus and a sub group of the board has been established. The principles are to build on and develop current systems, contracts, relationships and communication channels to maximise take-up across the sector (particularly those hard to reach staff groups) through a co-ordinated multi-agency approach; to minimise the number of parties entering establishments to administer vaccinations (to reduce risk to vulnerable residents) where applicable, and to offer immunisation early in the season.

6.2 Maternity Our local maternity department has, for the last few years, adopted the approach of universal influenza immunisation at 12 weeks gestation (assuming the mother presents in time). UHL will continue to offer influenza immunisation to all pregnant women at around 12 weeks gestation” and then opportunistically during their maternity care

6.3 Inpatient/Outpatient UHL will explore a programme that identifies in and out-patients (including ED attendees) who are eligible for influenza vaccination (as set out in Appendix A of the 2020-21 national immunisation programme). The primary care summary care record will then be used to ensure that patients who have not yet received influenza immunisation in the current flu season will be offered immunisation while attending UHL. All immunisations provided to UHL patients will be notified to their general practitioner to allow their health records to be updated.

Whilst our aim is to be in a position to delver this this, as stated earlier, and as indicated on the risk log, there is a risk to delivery as Hospital Trusts will not have ordered any flu vaccine

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for patients due to the late request to deliver this aspect and are unaware if any funding will be available to support delivery.

6.4 School Age Immunisation Service (SAIS) The school aged immunisation programme is commissioned by NHS EI and delivered in LLR by LPT. The programme has been running for many years now and LPT participated in the initial pilot of the programme in 2012/13.

This year the programme will be offered to all those in reception through to year 6 in primary schools and in year 7 in secondary schools. The inclusion of year 7 adds a disproportionate volume of additional work as it means the service has to visit every secondary school in the area as well as every primary school. The service has offered the vaccine to secondary school aged children once previously when year 7 was part of the pilot programme for one year.

The service will offer the vaccine to those in all schools (state, private, boarding etc) as well as to those children who are not in school such as those who are home educated. The service is also commissioned to offer the vaccine to all children (4-18 years) and staff in special schools that cater for those who have more profound mental and/or physical disabilities.

All vaccine for the programme is procured nationally by PHE and is made available to the services via Immform. The service will offer the nasal flu vaccine (Fluenz Tetra) as the first choice of vaccine. Those children who are at risk and are contraindicated to or will not accept the nasal vaccine will be offered an inactivated injectable vaccine. This year for the first time, due to the current Covid-19 situation, children whose parents do not want them to have the nasal vaccine may be offered an injectable inactivated vaccine but this is on the understanding that such a vaccine is not as effective, will not be available until at least November and is dependant on the vaccine being available. It is unlikely that the vaccine will be able to be given in schools and a community clinic model is likely to be offered depending on affordability and funding.

Consent for the vaccine is sought from the parent/guardian of every child. This is principally via an e-consent process, the details of which are distributed through the schools. For those who are home educated information is sent to the families through the local authorities. Vaccine is due to be available from the end of September 2020 and the service will start visiting schools shortly afterwards.

The assumption is that schools will be operating normally and children will be at school 5 days per week. If this proves not to be the case, either nationally or locally, then the service will be provided in community venues, which might include school estate if they are otherwise empty.

Services have to provide a second offer of the nasal vaccine for those who missed the opportunity to receive the vaccine at school. LPT provide this via a subcontract arrangement with a number of community pharmacists across the area. This is managed on a named patient basis such that parents have to contact LPT in the first instance and they are

16

informed as to which pharmacists are providing the service in their area. LPT pay the pharmacists directly for each vaccine given. The service is planning to complete the programme by the end of the Autumn term. However the risks posed by Covid-19, the additional year 7 cohort and the addition of the option for parents to choose an inactivated injectable vaccine all make the programme more complicated and with a higher degree of risk.

6.5 Workforce

There is greater emphasis this year to increase the number of staff who will receive the flu vaccination and therefore this is a priority cohort for the STP. It is one of our specific areas of focus and work links in with the workforce cell.

A blended approach will be taken across the organisations as needs and logistics differ with progress being reported into the flu board.

7. Outbreak management – Linking in with local EPRR arrangements

The attached provides information on a page of the LLR Response of an outbreak of influenza like illness during an in season and an out of season period within a localised community setting.

In of Season Flu

Outbreak Arrangeme out of Season Flu

Outbreak Arrangeme

7.2 Swabbing The swabbing for a single incident will be carried out as per advice from Public Health England. In the event of an outbreak this will be delivered as per the LLR Outbreak Plan.

7.3 Treatment – use of antivirals

This will be as per national guidance.

8. Requests to NHSE for local commissioning

8.1 Funding would be required if the following areas were to go ahead • Vaccinator teams to work across Residential, nursing and hospice, Supported Living,

Domiciliary care Direct Payment and Personal Health Budget Personal Assistants self-employed, employed by DP/PHB holder and via agency.

• Central housebound patient service

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• Strong communication message particularly with Faith Councils and key community

influencers. • Increased support to PCNs with workforce and training and estate work • Additional refrigeration and cool boxes to meet the extra uptake by providers • Development of flu champions - whilst the role would be voluntary there may be

training needs, provision of information and maybe some small expenses.

9. Communications and engagement Overall aim Our communications and engagement plan and activities will support the aim of maximising the uptake of flu immunisation in LLR across all target groups entitled to be vaccinated.

We will do this by: 1. Maximising awareness of entitlement to flu vaccination 2. Actively encouraging the uptake of vaccination 3. Ensuring those entitled, know how to access vaccination 4. Emphasising the benefits and safety of vaccinations including precautions against

COVID To support our communications we will undertake some rapid insight gathering through our citizen panel. This will help us to sharpen and target our message and help us to identify:

• Current attitude/intentions regarding flu vaccination • Understand why some people in the target groups may not want to be vaccinated

e.g. low uptake groups • Any concerns people may have about vaccinations in particular links with concerns

over COVID • Questions people may have regarding the vaccination: this will be helpful given the

inclusion of all over 50s as there will be people new to the list of target groups We are currently developing the detail of our delivery plan but in broad terms it will include:

Primary messages (all those eligible for vaccination):

• Vaccination offers the best protection against the potentially serious risks of flu • This year vaccination is particularly important with the threat of COVID still present • Having the vaccine is safe and easy to access • You are protecting yourself, others and the NHS by having the flu jab

Secondary messaging will be developed from the insights work

Channels

• Media • Community Radio • Social media

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• Videos: GPs and patient advocates – these will be ‘shareable’ on social media and

WhattsApp • Toolkits for voluntary and community sector (VCS) • Syndicated copy for partner bulletins e.g. Local authority newsletters and websites • Outreach to target groups e.g. through the Council of Faiths to reach specific

communities • Capitalise on staff members working in local communities e.g local area coordinators • Direct comms e.g. letters to patients, text messaging • Extending our reach through established networks e.g. PPGs

Underpinning the above will be the provision of information of in languages other than English

We will amplify national messages and in the main use PHE campaign material. Consideration will be given to the development of more targeted local material

Schedule

A schedule of planned activities will be produced. Activities will be linked with specific actions/milestones in the overall flu plan and will need to flex in response to actions taken by to e.g. boost uptake within particular groups

Staff communications

Action will be co-ordinated across the LLR NHS working through our established communications cell. More detail on this to follow but each NHS organisation will develop an internal communications plan to support uptake of vaccination. Through the comms cell we will facilitate an exchange of good practice and where appropriate undertake joint activities including development of joint collateral/material.

Risks/constraints

• Availability of vaccine: demand for vaccination could be very high • Patient concerns over vaccinations • Prevalence of COVID causing concern about attending practices etc. to have the

vaccination • Logistical difficulties around the access to vaccination during a potential lockdown

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10. Action Plan

This is a high level action plan

Reference Action Lead Due date 1 Sign of Flu plan at STP Flu Board CCG September 2020

3 Receive updates and review exception reports from identified areas of focus at fortnightly LLR Flu Board

Flu Leads Flu Board Meeting dates

4 Continue to review GP and PCN flu plans and support practices to achieve the maximum uptake

Primary care Lead Ongoing

5 Continue to strengthen the flu plan reacting to changes in guidance, reports from across the STP, learning and new idea and thoughts as they materialise

Flu Board Ongoing

6 Finalise the housebound service provision

Flu Board September 2020

7 Review data to support ambitioning achievement and to react to areas of poor performance, managing risk to delivery.

Flu Board On going

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9 Explore option for the delivery of the

vaccine programme to household members of people on the D/N caseload and to shielding patients

Flu Leads October 2020

LLR Flu vaccination programme 2020/21

Risk Log – 15th September 2020

Risk ID

Area

Date

Risk Sub Group

Owner Opening Score Mitigating Actions Current Score

L I RAG L I RAG

01/F

Vaccine availability

Sept 2020

There is a risk of shortfall in vaccine availability.

There is an expansion in the eligibility criteria for vaccinations which has increased the demand for flu vaccine this year.

General practice would not be aware of health and social care staff numbers unless they already fell in eligible at risk group.

This affects: • primary care - general practice ordered some

months ago based on previous year update and before the COVID-19 pandemic impacted

• Hospital Trusts - New national request for hospital trusts to offer flu vaccination to appropriate groups in in and out patient areas. Due to late request no vaccines order by Trust for this cohort of people. Ability to meet this is requirement is subject to vaccine availability and funding.

• Care providers - additional cohorts of staff to be vaccination which would not have been accounted for when ordering vaccines.

Primary Care Pharmacy

Care Providers Hospital Trust

4

4

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• Modelling at the various eligibility points and delivery being scoped as to what a maximum capacity would look like in primary care.

• 50-64 age range will be vaccinated later in the season following guidance from NHSEI.

• UHL have raised issues with Prof Chris Whitty and Prof Jonathan Van Tam

•

4

4

16

02/F

Vaccine availability

Sept 2020

General public can pay for flu vaccines at Pharmacies regardless of being in the current at risk group or not. This may have an impact on the supply of vaccines for at risk groups if uptake is high.

Primary care Local

Pharmaceutical Committee

4

4

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• Encourage collaborative working between practices and pharmacies to prioritise at risk group.

• Ensure LPC representation on appropriate groups

• Escalate through regional PH leads to ensure risk is on national risk register in the event of a demand outstripping supply

3

4

12

03/F

Productivity

Sept 2020

In primary care there is a risk that productively and throughput will be lower due to the restrictions of social distancing, estate and operational factors

Primary Care

4

4

16

• PC sub group in place • PC team supporting general

practices with plans • COVID PID process • Flexibility with appointments

such as use of Extended hrs DES for flu, PLT

• Additional workforce eg Foundation dentists support

• Additional funding for general practice to support productivity being explored

3

4

12

04/F

PPE

Sept 2020

Potential for limited supply of PPE to be able to deliver against delivery model

PPE & Outbreak Management

3

4

12

• Following recent update to PPE guidance the level of PPE required is now reduced.

• Monitoring General Practice via Sit Rep exception reporting

• Emergency supply through e- portal

2

4

8

05/F

Vaccine availability in

right place

Sept 2020

Risk that vaccines we do have are not in the most appropriate place leading to underutilisation or waste. .

It will be very difficult to move vaccine around the system once it has reached its destination from wholesaler / manufacturer. It is not permissible to sell or supply vaccines without a wholesaler dealers’ licence that gives assurance about the storage conditions.

Risk has a link with vaccine availability

Pharmacy

4

4

16

• Currently no confirmation on whether we can move vaccine around. Aware MHRA looking at this issue.

4

4

16

06/F &C

COVID Vaccine

Sept 2020

Possible COVID vaccine where this will be delivered through a 2-stage vaccine, where patients will need to wait 28 days to be able to take a flu vaccination in between the 2 stage COVID vaccination. There is a safety risk which could have an impact on the delivery of the flu vaccination programme

Flu and COVID- 19 Board

4

4

16

• Currently awaiting further information from national team.

• STP COVID board being established

4

4

16

07/F

Cold chain

Sept 2020

Cold chain storage issues - Providing we receive all vaccine supply there is a risk that there will not be adequate cold storage available to store vaccines.

Links in with vaccine movement and staff vaccination and risk with optimisation of MECC

Pharmacy

4

4

16

• Review of guidance re 50% vaccine fridge capacity

• Provision of information to partners on latest guidance (PC Webinar 10 September 2020)

• Guidance issued re validated cool boxes

3

4

12

08/F

Public

Expectations

Sept 2020

Risk of increasing pubic expectations by the national and local message for eligible groups to receive a flu vaccination and the ability to deliver due to non- availability of vaccines.

This could also lead to increased complaints across all organisations

Communications

4

4

16

• Deploy a range of tactics to try and manage expectations

• Links to actions in 01/F and 02F

4

4

16

09/F

Care provers – staff

Sept 2020

Staff within care provider sector such as domiciliary care, supporting living and care homes may have difficulty accessing flu vaccination • Approx. 30,000 staff • Links to availably of vaccines • Links to lack of funding to support innovation

Care provider

group

4

4

16

• Specific care provider group established

• Continue to promote usual mechanisms for these staff to be vaccinated in other areas and ensure staff know where to access

4

4

16

F

Blank Page


Rutland CCG


interest: No specific conflicts identified as this is a report providing assurance.


This report provides assurance of mitigations in place to support risks relating to EPRR and business continuity and risks are escalated accordingly in line with the risk management processes.


No specific resource implications identified as this is a report providing assurance.


No specific quality and patient safety implications identified as this is a report providing assurance.


Not required in relation to this report.


Not specifically required in relation to the production of this report.



Paper: F Public Confidential

Report title:

CCG EPRR and Core Standards Update

Presented by: Dan Webster, Head of Emergency Care and Resilience

Report author: Amita Chudasama, Operational Resilience & Emergency Planning Officer

Executive lead: Rachna Vyas, Executive Director, Integration and Transformation



Executive summary: 1. An update on the EPRR programme for the LLR CCGs 2. Update on the Core Standards process and submission for the LLR CCGs

Appendices: • N/A

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE this update report for their information.


•

2

LLR CCGS EPRR AND CORE STANDARDS UPDATE EPRR Update 1. In March 2020 and in line with NHSEI requirements the CCG put in place a

robust Command and Control Plan. In line with EPRR standards this plan has been continuously assessed and updated to ensure it meets the needs of the LLR system and that plans reflected the ever changing COVID-19 incident. Specific EPRR plans and governance documents were created which included the setting up of the Health Tactical and Strategic Groups and cells, situation report templates and a reporting process to ensure issues could be escalated and resolved within a short timeframe. These plans and the structure continue to be reviewed regularly.

2. Risks and issues are recorded on the weekly cell sitreps which are then used to

inform the agenda of the Health Economy Tactical Coordinating Group (HETCG). The risks and issues are discussed in depth at the weekly Health Economy Tactical and resolutions sought. If issues need escalating they are reported to the Health Economy Strategic Coordinating Group (HESCG).

3. All NHS organisations were required to participate in a NHSEI designed exercise

in March 2020. Exercise Novus Coronet was designed primarily for health organisations to explore the response to the Coronavirus outbreak. The scenarios, injects and questions were designed to demonstrate, test and explore the reasonable worst-case scenario that may arise from an outbreak. This exercise was held over 5 days with organisations required to complete a workbook and submit daily. The CCGs worked with LLR partners to complete and submit these exercises and to implement any learning. The LLR system EPRR Leads have designed a new exercise to the test the LLR Surge Plans for a second wave and this exercise will take place on November 4th 2020.

4. Following a rise in the numbers of cases and the SAGE rating the HETCG will

recommence twice weekly meetings from 9th November 2020.

5. The CCGs other EPRR responsibilities continue including updating of plans and policies not related to COVID-19, an update of the CCG on call rota and on call pack.

EPRR Core Standards Process 2020 6. The EPRR Process for 2020 was changed as the previous detailed and granular

process was deemed to excessive when NHS organisations were in the midst of

3

a pandemic and planning for a second wave. Therefore NHSEI focussed on 3 keys areas without the need for organisations to complete the self-assessment.

• progress made by organisations that were reported as partially or non-compliant in the 2019/20 process

• the process of capturing and embedding the learning from the first wave of the COVID-19 pandemic

• inclusion of progress and learning in winter planning preparations. In addition to this the CCGs were asked to provide assurance on our providers position.

Assurance Position

The CCGs remain fully compliant as per the 2019/20 Core Standards Submission. The recommendations within the NHSEI confirmation letter have been addressed as follows:

The CCGs were partially compliant against the deep dive items of last year’s core standards and an update to these is provided below:

• Business Continuity is now a standard item on Board Agenda’s and there has been a renewed focus on this given the current COVID situation.

• Climate Change – Climate change as a specific risk does not appear on the

corporate risk register. What appears at operational level are the various components that support the sustainability agenda and reduction in carbon footprint. For instance, travel plans and reduction in transport and travel emissions; estates and how they are used for corporate purposes and across primary care; reduction in waste and ensuring recycling facilities are available in offices; consideration of population health management, including health inequalities; enhancing and embracing use of technology etc. Furthermore, the CCG will need to consider the recently published “Delivering a ‘Net Zero’ National Health Service” at our next regular EPRR meeting.

• Estate modifications - All 3 buildings the CCG occupy are not owned by us and

therefore the CCG has no control over any estates and modifications the landlords may wish to make, however we have liaised with our landlords with regards to their long term plans and they currently have no plans for any adaptions especially given the current situation of most employees working from home with limited office attendance.

4

Provider Assurance A statement of assurance for the LLR CCGs providers was provided as below:

UHL have made significant progress against core standards compliance and work continues to further progress and achieve full compliance. The table below details UHL’s compliance against the standards.

LPT remain on full compliance against the core standards.

EMAS – this will be submitted by the regions Lead Commissioners at Derby CCG.

TASL - have carried out a comprehensive review of their Core Standards and provided the CCG with evidence to support this along with action plans.

COVID-19 Pandemic Response

The CCG have robust command and control processes in place and Chair the Health TCG and SCG as well as the wider LRF TCG and SCG. The COVID escalation is monitored by the LLR SAGE Group which meets twice weekly to review community infection rates and COVID admissions. The SAGE alert level acts as a trigger point and each level has an associated set of actions that will be implemented by our providers/HETCG Cells.

The LLR CCGs have undertaken an in-depth gap analysis following the findings from the regional Lessons Learnt Review (system experiences from managing the COVID-19 pandemic). A tracker has been devised and actions to address any gaps are in place and reviewed regularly.

The Dame Mary Ney review was a rapid stocktake undertaken between 5 and 21 August 2020 and has sought to identify the good practice and key learning in dealing with a local Covid-19 outbreak, with a focus on the experience in Leicester City and Leicestershire. A number of key learning points and areas of good practice were

Year Applicable Standards

Fully Compliant Partially

Compliant Non-

Compliant Self-Assessment Rating

2018/19 64 49 6 9 Partially Compliant

2019/20 64 57 6 1 Substantially Compliant

2020/21 64 59 5 0 Substantially Compliant

5

identified and these have been discussed at the LLR SCG and the LLR SCRG to ensure any learning is embedded within the system.

Winter Preparedness

The LLR winter plan is embedded this year with the CCG phase 3 return to NHSE/I. The system has also undertaken a readiness meeting with NHSE/I focussed on the winter preparedness element.

A full and comprehensive overview of preparations are included in the phase 3 return however the CCG have also taken additional steps and produced the following documents/plans to further support winter preparedness:

Revised surge and escalation plan for LLR Creation of GP OPEL reporting Flu plan

Recommendations The LLR CCGs’ Governing Bodies are asked to:

• Receive this report for information.

G

Blank Page

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group




Paper: G Public Confidential

Report title:

Finance Report Month 6

Presented by: Nicci Briggs, Director of Finance, Contracting and Corporate Governance.

Report author: Sarah Ferrin, Head of Operational Finance

Executive lead: Nicci Briggs, Director of Finance, Contracting and Corporate Governance.


Executive summary: Context: The original 20/21 financial plan has been set aside during the pandemic. The first 6 months of 20/21 are being monitored against a subset of the financial plan, based on historic cost minimal growth uplift and NHSE/I advised payments. The CCG finance regime for the first 6 months of the year has been predicated on the operation of block mandate payments with NHS providers and a reimbursement process for necessarily incurred expenditure. An LLR system financial plan for months 7 to 12 has been produced and submitted to NHSE/I. Organisational plans will be derived from the system plan and form the basis of the budgets against which expenditure will be monitored for the reminder of the financial year. Questions: 1 What is the financial performance for the period ending 30th

September 2020 (Month 6)?

LLR CCGs are reporting a year to date adverse expenditure variance of £11.275m against the NHSE/I break even plan. This is built up of a £3.822m adverse variance against the CCG plan and £7.453m specific Covid spend, (see Appendix 1). During the month the CCGs received additional allocations to fund Covid expenditure incurred up to month 5 and to offset reported over/under spends in relation to the NHSE/I budget alignment exercise and any operational variances. These allocations effectively brought the CCGs back into balance as at month 5. The reimbursement for Covid expenditure incurred to date was allocated to the individual budgets affected, as was the additional funding received to offset the remaining over/under spends at month 5. The main areas contributing to the £3.822m adverse variance against the CCG plan in month 6 are Corporate, Primary Care Co Commissioning and

2

Reserves as outlined below:

• Corporate - £1.457m over spend: A £1.400m provision has been created in relation to anticipated redundancies due to the current management of change process.

• Primary Care Co Commissioning - £1.346m over spend: The over spend is attributable to PCN funding (£0.565m), NHSE/I budget shortfalls (£0.554m) and other GP services (£0.151m). The PCN position is showing a significant overspend as it has been recognised that there is a commitment to spend the full PCN ‘Additional Roles’ allocation before the end of March 2021.

• Reserves - £1.051m over spend: This relates to the impact of prior year commitments which have materialised this month, mostly relating to changes in the ‘who pays’ guidance (c£650k).

A draft additional allocation has been assumed within the returns to NHSE to cover the reported £11.275m overspend, allowing a breakeven forecast to be declared at this point. NHSE/I will be undertaking a robust review of the CCGs’ expenditure prior to confirming the additional allocation top-up for month 6. 2 What is the level of expenditure relating to Covid? Between April and September the CCGs have spent £30.570m on Covid which has been retrospectively funded up to month 5 (£23.117m). As stated above, a robust review will be undertaken by NHSE/I prior to confirmation of reimbursement of month 6 Covid expenditure (£7.453m) Appendix 2 analyses the £30.570m of expenditure from 1 April 2020 to 30 September 2020 as contained within relevant reports to NHSE/I. This is split into high level categories of expenditure to aid understanding:

Within the first 4 columns of data, Appendix 2 splits the total expenditure against the CCG that directly incurred it. This includes a number of items (such as DHU urgent care support, purchase of PPE at scale for primary care, pulse oximetry, support to hospices) undertaken on a lead basis by one CCG and therefore potentially distorts any attempt to show the true cost per CCG of

Area Description and material components

Corporate VTCorporate costs, largely additional staffing and some IT expenditure

AcuteAcute Healthcare, primarily DHU urgent care support and transport costs

Non-AcuteVast majority relates to Hospital Discharge Programme (National £1.3bn allocation)

Primary Care - OtherIncludes income support (QOF, CBS etc) bank holiday opening and pulse oximetry

Primary Care - GP Claims Weekly Sitrep claim form process

PrescribingIncreased cost of DOAC switches in May - declassified as COVID related in June

3

responding to the pandemic. The final 4 columns show the impact of allocating, where possible, those hosted elements more accurately to reflect the utilisation per CCG. This is done on an even split or weighted population basis for any elements where a more detailed analysis is not available. Acute, non-acute and primary care - other being the most affected areas. Covid expenditure incurred during months 7-12 will be funded via a system allocation which is based on forecasts provided as part of phase 3 planning. There are however, the following exceptions: PPE and testing centres will be procured nationally so the CCGs should not incur any expense; the Hospital Discharge Programme (HDP) continues to be reimbursed nationally as per months 1-6 albeit the funding is now only available for the first 6 weeks following discharge. 3 What is the performance against the LLR Efficiency programme? The month 6 position as reported by SRO’s at the start of October indicated year to date efficiencies of £8.664m and forecast delivery of £15.624m by the end of the year. This compares favourably against last month’s forecast of £14.62m. The main area of improvement related to Community Services Redesign, although this is slightly off set by a reduction in the forecast within Acute Care Demand Management. The table below shows the split of efficiencies between Cash releasing and cost avoidance; further details are provided in Appendix 3:

Specific points of note regarding ongoing schemes are: • Planned Care Demand Management - Patient initiated follow ups,

targeting mainly patients with long term conditions, commenced in September with follow up appointments available within a 3 - 6 month period after a procedure.

• Personalised Commissioning – CHC assessment processes resumed on

the 1st September 2020.

• Community Services Redesign - A reduction in non-elective admissions has been reported amounting to £1.5m. This cannot, at this time, be linked wholly to the CSR schemes as it is recognised that activity will have been impacted by Covid-19.

4

4 What is the Financial Forecast for the first 6 months of the year (April – September 2020)? As we are reporting on month 6, the year to date position is the same as the forecast out-turn for the first 6 months of the year. 5 What are the key risks to delivery of this forecast? This position is not risk free. Risks which may materialise over the next month can be summarised as:

• Prescribing costs are volatile, data is received two months after the end of the month to which it relates and as a consequence there are always two months of estimated spend included in the position. These estimates are based on the latest information available but the costs incurred can be significantly affected by national actions. Changes to the Cat M pricing structure have already been included within the position and NCSO pressures are likely to continue. As a response to the Covid-19 pandemic, to protect capacity in acute settings, the CCGs have increased the number of patients switched from Warfarin to DOACs and whilst estimates have been added to the financial position for the impact of these changes, these can only be confirmed on the receipt of monthly data. It is unclear at the present time what the impact will be on the prescribing spend from the second wave of Covid-19 infections.

• Baseline CHC expenditure has been materially affected by the operation of the Hospital Discharge Scheme to support the protection of capacity in acute settings during the Covid-19 pandemic. CHC assessment processes are to be reintroduced from 1st September and it will take time to deliver the backlog of assessments that will exist at that point as well as new discharges. There is likely to be a medium term pressure due to the time it will take to migrate service user packages from the current higher cost packages under the Discharge Scheme, in particular where these move to primarily Social Care and self-funded packages.

• A covid support claim process is being introduced for CCG

commissioned Care Home and Domiciliary Care providers and PHB holders. Estimates have been entered to the month 6 position but this is likely to be a volatile area going forwards.

6 Are we delivering the Better Payment Practice Code? All three CCGs are delivering on the Better Payment Practice Code (BPPC) across all four metrics. (Minimum 95% payment within 30 days both in month and cumulatively for NHS and Non NHS providers). See Appendix 4. 7 Is Cash remaining at month end within national tolerances? Each CCG is expected to hold minimal cash balances at the end of each month, (maximum 1.25% of cash drawn down in the month); ELR and LC CCGs met this expectation, however WL CCG failed this month. The reason

5

for the excess cash limit within WL CCG was due to a failure in the newly introduced payment mechanism for manual payments by SBS and the CSU. Appropriate mechanisms were not in place to enable a payment to be processed which would have brought the cash balance for WL CCG within the required levels. This has been followed up with the CSU and assurances received that this situation will not be repeated in the future. There are no implications of failing the cash target for the month. 8 Is Capital spending within allocation limits? The CCG’s have not been given any capital allocation for this 6 month period. 9 Are the CCGs operating within the Running costs allocation? The CCGs received running cost allocations totalling £9.219m for the 6 month period. Costs have been attributed to individual CCG’s in proportion to their allocation. Overall an adverse variance of £1.460m is being reported at month 6 which relates to a £1.400m redundancy provision in relation to the management of change process. This does not include any Covid expenditure as this is coded to programme infrastructure. 10 Balance Sheet (Statement of Financial Position) The £1.4m redundancy provision above has been reflected in the balance sheets for all 3 CCGs under the category ‘Current liabilities – Provisions) - see Appendix 5.

Appendices: • Appendix 1 – Summary Financial Position at Month 6 • Appendix 2 – Summary of LLR CCGs’ Covid claims from April to

September 2020 • Appendix 3 - QIPP Performance at Month 6 • Appendix 4 – Better Payment Practice Code • Appendix 5 - Balance Sheet

Recommendations:

The LLR CCGs’ Performance, Finance and Activity Committee is asked to:

• NOTE the adverse year to date position at Month 6 of £11.275m. • NOTE the anticipated receipt of additional allocations from NHSE to

support this variance to enable the CCGs to report a breakeven position.

• NOTE NHSE/I will be undertaking a robust review of the CCGs’ expenditure prior to confirming the additional allocation top-up for month 6.

• NOTE the confirmed LLR CCGs’ Covid expenditure for Months 1-6 of £30.570m and the future financial regime for months 7-12.


Reviewed by Deputy Director of Finance Contracting and Corporate Governance.

6

Aligned to Strategic Objectives

Leicester City CCG West Leicestershire CCG East Leicestershire and Rutland CCG


interest: Not applicable



As at month 6 LLR CCGs are reporting an adverse £11.275m variance against the NHSE/I break even plan. This is built up of a £3.822m adverse variance against the CCG Covid plan and £7.453m specific Covid spend.


Not applicable


Not applicable


Not applicable

SUMMARY FINANCIAL POSITION 2020/21 - MONTH 6 Appendix 1

East City West LLR East City West LLR East City West LLR East City West LLR East City West LLR£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute - NHS 108,290 125,241 127,674 361,205 108,305 125,242 127,684 361,231 15 1 10 26 19 19 19 57 (4) (18) (9) (31) Acute - Non-NHS 2,102 2,183 1,519 5,804 2,128 2,105 1,576 5,809 26 (78) 57 5 - 1 - 1 26 (79) 57 4 Acute - Urgent Care 539 342 1,730 2,611 796 50 1,663 2,508 257 (292) (68) (103) - - - - 257 (292) (68) (103) Total Acute 110,931 127,766 130,923 369,620 111,229 127,397 130,922 369,549 298 (369) (0) (71) 19 20 19 58 279 (389) (20) (130)

Mental Health - NHS 15,801 30,350 19,983 66,135 15,805 30,385 19,984 66,174 4 34 1 39 10 - - 10 (6) 34 1 29 Mental Health - Non-NHS 3,555 6,328 4,820 14,703 3,848 6,416 4,675 14,939 293 88 (144) 237 55 102 40 196 238 (13) (184) 40 Total Mental Health 19,356 36,678 24,803 80,838 19,653 36,801 24,659 81,113 297 122 (144) 275 65 102 40 206 232 21 (184) 69

Community Health - NHS 16,573 18,668 18,953 54,194 16,668 18,729 19,036 54,434 95 62 83 239 - - - - 95 62 83 239 Community Health - Non-NHS 915 1,404 1,422 3,741 968 1,425 1,463 3,857 54 21 41 116 6 - 104 111 48 21 (63) 5 Total Community Health 17,488 20,072 20,376 57,935 17,636 20,155 20,500 58,291 148 83 124 355 6 - 104 111 142 83 20 245

Total Continuing Care 17,933 17,877 20,512 56,322 20,108 18,571 22,623 61,302 2,176 694 2,111 4,980 2,093 1,092 2,435 5,621 82 (398) (324) (641) - - - - -

Primary Care Services 6,980 7,738 8,726 23,444 7,075 8,325 9,580 24,980 95 586 855 1,536 279 555 446 1,280 (184) 31 408 256 Prescribing 27,039 27,848 31,161 86,048 26,845 27,825 31,380 86,050 (194) (23) 219 2 - - - - (194) (23) 219 2 Total Primary Care 34,019 35,586 39,887 109,492 33,919 36,150 40,960 111,029 (99) 563 1,073 1,538 279 555 446 1,280 (378) 8 627 257

Total Primary Care Co-Commissioning 22,645 27,999 25,735 76,379 23,202 28,169 26,569 77,940 556 170 834 1,561 - - 215 215 556 170 619 1,346 -

Total Corporate 2,834 3,203 3,181 9,219 3,285 3,709 3,685 10,679 451 506 503 1,460 3 - - 3 448 506 503 1,457 - -

Reserves 2,248 769 3,803 6,819 2,514 1,042 4,316 7,873 266 274 514 1,054 - - 3 3 266 274 511 1,051 Other - Acute 1,545 2,349 2,681 6,575 1,548 2,349 2,789 6,686 2 (0) 109 111 - - 123 123 2 (0) (15) (13) Other - Non Acute 7,234 9,879 7,256 24,369 7,281 9,891 7,473 24,646 47 13 217 277 - - 1 1 47 13 216 275 Programme Infrastructure 554 2,392 930 3,876 565 2,431 616 3,612 11 39 (314) (264) 23 8 (200) (168) (12) 31 (114) (96) Total Other 11,581 15,388 14,670 41,639 11,908 15,714 15,195 42,817 327 325 525 1,178 23 8 (72) (41) 304 317 597 1,218

Total CCG Expenditure 236,787 284,570 280,087 801,444 240,941 286,664 285,113 812,719 4,154 2,094 5,026 11,275 2,488 1,777 3,188 7,453 1,666 317 1,839 3,822

Surplus

COVID Pressure (Log) 2,488 1,777 3,188 7,453

Actual CCG Variance 1,666 317 1,839 3,822

VARIANCE BREAKDOWN

COVID Expenditure OtherBudget Spend Variance

YEAR TO DATE (MONTH 6)

Appendix 2Summary of April COVID-19 expenditure

East City West Total East City West Total03W 04C 04V LLR 03W 04C 04V LLR

Area £ £ £ £ £ £ £ £Corporate VT 10,945 12,501 19,110 42,556 10,416 11,515 20,624 42,556 Acute 62,431 13,648 215,683 291,762 117,648 68,865 105,249 291,762 Non-Acute 298,549 247,666 272,501 818,716 234,278 279,802 304,636 818,716 Primary Care - Other 262,861 279,113 324,676 866,650 219,130 302,243 345,277 866,650 Primary Care - GP Claims 172,511 172,027 167,975 512,513 172,511 172,027 167,975 512,513 Prescribing - - - - - - - - Total 807,297 724,955 999,945 2,532,197 753,983 834,452 943,762 2,532,197 -

Percentage split across LLR 31.9% 28.6% 39.5% 29.8% 33.0% 37.3%

Summary of May COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 7,931 9,712 27,957 45,601 8,460 10,698 26,443 45,601 Acute 96,366 56,849 405,957 559,172 192,056 152,539 214,576 559,172 Non-Acute 506,737 500,220 780,523 1,787,481 521,506 453,336 812,639 1,787,481 Primary Care - Other 333,355 167,536 289,041 789,931 315,617 189,338 284,976 789,931 Primary Care - GP Claims 129,629 186,700 135,341 451,669 129,629 186,700 135,341 451,669 Prescribing 133,091 105,319 113,793 352,204 133,091 105,319 113,793 352,204 Total 1,207,109 1,026,336 1,752,612 3,986,057 1,300,359 1,097,930 1,587,768 3,986,057 -


Summary of June COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 8,196 9,269 16,347 33,812 8,196 9,269 16,347 33,812 Acute 61,047 61,264 363,153 485,464 146,717 146,934 191,814 485,464 Non-Acute 1,252,668 691,300 1,518,685 3,462,653 1,224,471 705,398 1,532,784 3,462,653 Primary Care - Other 292,583 3,588 119,656 415,827 132,983 128,221 154,624 415,827 Primary Care - GP Claims 106,021 131,697 148,025 385,743 106,021 131,697 148,025 385,743 Prescribing 133,091- 105,319- 113,793- 352,204- 133,091- 105,319- 113,793- 352,204- Total 1,587,424 791,799 2,052,072 4,431,295 1,485,296 1,016,200 1,929,799 4,431,295 -


Summary of July COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 4,835 15,083 11,466 31,384 6,029 12,695 12,660 31,384 Acute 14,692 57,400 565,976 638,068 179,930 222,637 235,502 638,068 Non-Acute 1,428,663 1,499,158 1,844,193 4,772,014 1,425,062 1,500,958 1,845,993 4,772,014 Primary Care - Other 850 83,599 271,852 356,302 58,824 153,064 144,413 356,302 Primary Care - GP Claims 83,535 151,737 117,752 353,024 83,535 151,737 117,752 353,024 Prescribing - - - 0- - - - 0- Total 1,532,576 1,806,977 2,811,239 6,150,792 1,753,380 2,041,091 2,356,320 6,150,792


Summary of August COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 37,520 10,197 55,153 102,870 27,494 34,915 40,461 102,870 Acute 8,904 66,481 264,192 339,578 76,321 133,898 129,359 339,578 Non-Acute 1,981,344 1,055,815 2,089,413 5,126,572 1,975,636 1,058,669 2,092,267 5,126,572 Primary Care - Other 8,148 27,547 59,436- 23,740- 20,555- 18,775- 15,589 23,740- Primary Care - GP Claims 90,124 203,923 177,370 471,417 90,124 203,923 177,370 471,417 Prescribing - - - 0- - - - 0- Total 2,126,040 1,363,964 2,526,692 6,016,696 2,149,019 1,412,631 2,455,046 6,016,696


Costs reported as lead CCG Actual CCG Costs





Summary of September COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 27,450 8,001 41,530 76,981 23,686 23,032 30,264 76,981 Acute 19,028 54,964 286,166 360,158 96,562 132,498 131,098 360,158 Non-Acute 2,162,944 1,193,630 2,476,842 5,833,416 2,158,899 1,171,482 2,503,036 5,833,416 Primary Care - Other 174,273 326,393 249,594 750,260 170,225 310,782 269,253 750,260 Primary Care - GP Claims 104,666 194,044 133,826 432,536 104,666 194,044 133,826 432,536 Prescribing - - - 0- - - - 0- Total 2,488,362 1,777,032 3,187,958 7,453,352 2,554,037 1,831,838 3,067,477 7,453,352


Summary of YTD COVID-19 expenditure


Area £ £ £ £ £ £ £ £Corporate VT 96,876 64,763 171,564 333,203 84,280 102,124 146,799 333,203 Acute 262,469 310,607 2,101,127 2,674,203 809,234 857,371 1,007,598 2,674,203 Non-Acute 7,630,906 5,187,789 8,982,157 21,800,852 7,539,852 5,169,645 9,091,355 21,800,852 Primary Care - Other 1,072,070 887,777 1,195,383 3,155,229 876,223 1,064,873 1,214,133 3,155,229 Primary Care - GP Claims 686,486 1,040,128 880,288 2,606,902 686,486 1,040,128 880,288 2,606,902 Prescribing 0 0 0 0 0 0 0 0 Total 9,748,807 7,491,063 13,330,519 30,570,389 9,996,075 8,234,142 12,340,172 30,570,389 -


Less Hospital Discharge Programme 6,213,860 4,275,771 7,601,188 18,090,819

Revised Total 3,782,215 3,958,371 4,738,984 12,479,570

30.3% 31.7% 38.0%



QIPP Breakdown

2020/21 Month 6 Appendix 3

BETTER PAYMENT PRACTICE CODE

2020/21 - MONTH 6 Appendix 4

A B C D E F G A B C D E F G

No of Bills Paid Within

Period


Target

% of Bills Paid Within

Target

Value of Bills Paid Within

Period


Target

% Value of Bills Paid Within

Target

Cumulative Value of Bills paid within

Target


Period


Target


Target


Period


Target


Target


TargetMonth No. No. % £'000 £'000 % % No. No. % £'000 £'000 % %

Apr 288 280 97.22 48,632 48,628 99.99 99.99 498 495 99.40 3,616 3,608 99.78 99.78May 190 190 100.00 23,558 23,558 100.00 99.99 464 460 99.14 3,152 3,147 99.84 99.81Jun 100 97 97.00 23,533 23,430 99.57 99.89 506 505 99.80 4,280 4,279 99.97 99.87Jul 140 140 100.00 23,697 23,697 100.00 99.91 529 528 99.81 3,411 3,402 99.72 99.84Aug 65 64 98.46 23,783 23,783 100.00 99.93 520 507 97.50 4,011 3,993 99.56 99.78Sep 80 80 100.00 23,651 23,651 100.00 99.94 549 533 97.09 4,929 4,891 99.21 99.66

Total 863 851 98.61 166,854 166,748 99.94 99.94 3,066 3,028 98.76 23,400 23,320 99.66 99.66



Period


Target


Target


Period


Target


Target


Target


Period


Target


Target


Period


Target


Target



Apr 307 301 98.05 59,457 59,454 99.99 99.99 559 558 99.82 5,743 5,741 99.97 99.97May 224 221 98.66 29,487 29,484 99.99 99.99 572 572 100.00 5,742 5,742 100.00 99.98Jun 128 124 96.88 29,929 29,920 99.97 99.99 659 657 99.70 5,731 5,650 98.59 99.52Jul 126 126 100.00 29,537 29,537 100.00 99.99 576 575 99.83 5,667 5,656 99.81 99.59Aug 71 71 100.00 29,417 29,417 100.00 99.99 464 463 99.78 4,668 4,665 99.93 99.65Sep 50 49 98.00 29,585 29,581 99.99 99.99 661 658 99.55 5,214 5,211 99.95 99.70

Total 906 892 98.45 207,412 207,393 99.99 99.99 3,491 3,483 99.77 32,765 32,666 99.70 99.70



Period


Target


Target


Period


Target


Target


Target


Period


Target


Target


Period


Target


Target



Apr 312 309 99.04 57,348 57,300 99.92 99.92 2,073 2,072 99.95 10,588 10,582 99.94 99.94May 179 179 100.00 29,117 29,117 100.00 99.95 2,746 2,746 100.00 10,910 10,910 100.00 99.97Jun 132 132 100.00 28,353 28,353 100.00 99.96 3,646 3,646 100.00 13,362 13,362 100.00 99.98Jul 92 92 100.00 28,010 28,010 100.00 99.97 2,765 2,764 99.96 11,863 11,858 99.96 99.98Aug 119 119 100.00 29,274 29,274 100.00 99.97 1,969 1,969 100.00 14,686 14,686 100.00 99.98Sep 24 24 100.00 27,054 27,054 100.00 99.98 2,752 2,749 99.89 11,126 11,082 99.61 99.92

Total 858 855 99.65 199,155 199,108 99.98 99.98 15,951 15,946 99.97 72,536 72,481 99.92 99.92

West Leicestershire CCGNHS CREDITORS NON-NHS CREDITORS

East Leicestershire & Rutland CCGNHS CREDITORS NON-NHS CREDITORS

Leicester City CCGNHS CREDITORS NON-NHS CREDITORS

BALANCE SHEET (STATEMENT OF FINANCIAL POSITION)

2020/21 - MONTH 6 Appendix 5

Mar-20 Aug-20 Sep-20 In Month Movement

Movement since opening

positionMar-20 Aug-20 Sep-20 In Month

Movement


positionMar-20 Aug-20 Sep-20 In Month

Movement


position

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Non Current Assets:Property Plant and Equipment 194 163 156 (7) (38) 58 50 48 (2) (10) 106 96 95 (2) (11)TOTAL Non Current Assets 194 163 156 (6) (38) 58 50 48 (2) (10) 106 96 95 (2) (11)Current Assets:Trade & Other Receivables 4,950 27,023 26,775 (248) 21,825 5,321 32,574 43,343 10,769 38,022 9,512 39,275 40,839 1,564 31,327Cash and Cash Equivalents 28 39 26 (14) (2) 18 40 28 (12) 10 12 368 3,141 2,773 3,129TOTAL Current Assets 4,978 27,062 26,801 (262) 21,823 5,339 32,614 43,371 10,757 38,032 9,524 39,643 43,980 4,337 34,457

TOTAL ASSETS 5,172 27,225 26,957 (269) 21,785 5,397 32,664 43,419 10,755 38,022 9,629 39,740 44,075 4,335 34,446

Current Liabilities:Trade & Other Payables (25,853) (29,216) (31,335) (2,119) (5,481) (29,680) (30,828) (31,829) (1,001) (2,149) (27,147) (31,858) (35,908) (4,050) (8,761)Provisions (216) (291) (715) (424) (499) (154) (123) (609) (486) (455) (211) (275) (758) (483) (547)Total Current Liabilities (26,069) (29,507) (32,050) (2,543) (5,980) (29,834) (30,951) (32,438) (1,487) (2,604) (27,358) (32,133) (36,666) (4,533) (9,308)

Non Current Liabilities:Provisions 0 0 0 0 0 (533) (533) (533) 0 0 0 0 0 0 0TOTAL Non Current Liabilities 0 0 0 0 (533) (533) (533) 0 0 0 0 0 0 0

TOTAL LIABILITIES (26,069) (29,507) (32,050) (2,543) (5,980) (30,367) (31,484) (32,971) (1,487) (2,604) (27,358) (32,133) (36,666) (4,533) (9,308)

ASSETS LESS LIABILITIES (Total Assets Employed) (20,898) (2,282) (5,093) (2,811) 15,805 (24,970) 1,179 10,448 9,268 35,418 (17,728) 7,606 7,409 (197) 25,138

TAXPAYERS EQUITYGeneral Fund (Opening Balance, Fixed) (13,473) (20,897) (20,897) 0 (7,424) (32,723) (24,970) (24,970) 0 7,752 (16,200) (17,728) (17,728) 0 (1,529)Income & Expenditure (year to date) (461,627) (198,358) (240,941) (42,583) 220,686 (546,915) (238,422) (286,664) (48,243) 260,251 (529,162) (235,904) (285,113) (49,210) 244,049Parliamentary Funding (year to date) 454,201 216,973 256,746 39,773 (197,455) 554,667 264,571 322,082 57,511 (232,585) 527,634 261,238 310,251 49,013 (217,383)Total (20,898) (2,282) (5,093) (2,811) 15,806 (24,970) 1,179 10,448 9,268 35,418 (17,728) 7,606 7,409 (197) 25,138

East Leicestershire & Rutland CCG Leicester City CCG West Leicestershire CCG

Statement of Financial Position

H

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Date: Tuesday 10th November 2020

Paper: H Public Confidential

Report title:

CCG Performance Assurance Report

Presented by: Hannah Hutchinson - Assistant Director of Performance Improvement, Leicester, Leicestershire and Rutland CCGs

Report author: Hannah Hutchinson - Assistant Director of Performance Improvement, Leicester, Leicestershire and Rutland CCGs Kate Allardyce – Senior Performance Manager (M&LCSU)

Executive lead: Caroline Trevithick - Executive Director of Nursing, Quality and Performance Leicester, Leicestershire and Rutland CCGs


Executive summary: 1. The report includes a high-level overview of the number of COVID-19 confirmed cases & deaths across Leicester, Leicestershire and Rutland (LLR). To 1-Nov-20 there have been 22,718 lab-confirmed reported cases of COVID-19 across LLR. Using publicly available ONS weekly data to 16-Oct-20, there have been 922 deaths of LLR residents, across all settings (hospital, care homes, hospices, own home).

2. The Board is to receive the Quality and Performance Committee’s (Q&P) summary report and an overview of monthly performance for the Leicestershire CCGs.

3. Performance data highlighted within the report captures the impact of COVID-19. The key constitutional standards and targets currently not achieving include:

• Five of the nine Cancer waiting times • Dementia diagnosis • Referral to Treatment Times, Waiting List sizes & 52 Week

Waiters • Diagnostic Testing • A&E 4 hours wait • Ambulance Wait times & Handovers • IAPT Access

4. Metrics that are achieving target: • 2 weeks for an urgent referral for breast symptoms achieved

target for all 3 CCGs for August, • Dementia rate for LC continues to achieve target in September,

80.2% against 66.7% target; • IAPT recovery rate for all 3 CCGs achieved the national target of

50% for July 20; • Ambulance Waits – Cat 1 calls from people with life threatening

illnesses or injuries - LC and WL achieved the mean and 90th centile national target.

Appendices: N/A

2


Rutland CCG


interest: N/A


N/A


N/A


N/A


N/A


N/A

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE the current performance and actions being taken for areas

where performance does not meet the required standard. • DISCUSS additional actions being taken to consider whether further

action is required to improve performance.


• This format of the performance assurance report was first reported to the March 2020 LLR Board, and most recently to the September LLR Board.

• The Quality & Performance Committee receive the CCG Performance Report on a monthly basis. Last report was presented on 3rd November 2020.

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CCG Performance Assurance Report

This report brings 2 performance elements together; • Outline of the COVID-19 Management Report provided to the Health Economy

Strategic Coordinating Group on a twice-weekly basis. • The key performance risks for Leicestershire CCGs and specific actions being

undertaken to improve performance, at Design Group level. In most cases data is to the end of August.

1. Areas of Improvement

There are measures that have achieved target which indicates the improvements made within the CCG and at system level:-

• 2 Week waits for an urgent referral for breast symptoms for 3 CCGs - Aug 20 • 31 Day waits receiving first definitive treatment within 1 month of diagnosis – LC

CCG • 31 Day waits receiving drug treatment for 3 CCGs – Aug 20 • 31 Day waits receiving radiotherapy treatment for 3 CCGs – Aug 20 • 28 Day faster diagnosis (patients told diagnosis within 28 days) for 3 CCGs – Aug 20 • Appropriate prescribing of antibiotics in primary care for 3 CCGs – Jul 20 • IAPT recovery for 3 CCGs – Jul 20 • Episodes of Psychosis treatment with a NICE recommended package of care treated

within 2 weeks of referral for 3 CCGs – Aug 20 • IAPT talking therapies – 75% of people with relevant conditions to access talking

therapies in 6 weeks for 3 CCGs • IAPT talking therapies – 95% of people with relevant conditions to access talking

therapies in 18 weeks for 3 CCGs

2. Areas of Challenge The measures that are not achieving target are detailed within section 4 of the report. The measures below which are/were close to achieving target;-

• Cancer Patient Experience 2018 – Annual Metric for ELR & WL • GP Patient Experience 2019 - Annual Metric for ELR & WL • Dementia Post Diagnostic Support 2018/19 – Annual Metric for ELR & LC • Antibiotics Resistance; appropriate prescribing of broad spectrum antibiotics in

primary care Jul 20 – ELR & WL • Maternity Experience 2018 – Annual Metric – WL

3. COVID Reporting October 2020

From April 2020 a Covid-19 Management Report has been provided to the Health Economy Strategic Coordinating Group. Various organisations were involved in its creation and content covering providers, CCGs and Local Authorities. It is co-ordinated by the CSU and continues to report twice weekly. The report provides a summary, key lines of enquiry and data on a number of covid-19 related areas.

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The report covers the following sections: • LLR COVID-19 Alert System – at 2-Nov-20 the alert level is 3b – ‘Restoration/recovery of

services, pathways or interventions classified as AMBER’ • COVID Tracker – trends on cases, deaths and excess mortality across LLR. • Bed capacity –a daily overview of admissions into UHL, discharges and bed capacity

available. • Community Infection – trends on COVID-19 related 111 calls • Workforce – a twice weekly overview of staff absences across local providers. • Provider Summary – a daily overview of cases, patient flow, bed capacity and deaths at

UHL and LPT. • Provider Summary discharges – destination and time taken for discharges • EMAS – Overview of COVID-related ambulance calls and status. • Care Homes – overview of care home tracker and EMAS calls from care homes. • Shielded patient list – detail of number of shielded patients at Local Authority level. Lab-confirmed COVID-19 cases The following graph shows number of daily reported and 7-day rolling average COVID-19 Cases across LLR, from April to October.

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COVID-19 deaths Per Week - LLR residents, by place of death

The following graph reports the number of deaths involving COVID-19, based on any mention of COVID-19 on the death certificate. These were reported as LLR residents using weekly ONS data. To 16-Oct (registered to 23-Oct) there have been a total of 922 COVID-19 deaths across LLR, 585 of these were within a hospital (63%), 258 within a care home (28%) and 79 within another setting (9%).

Covid-19 LLR deaths by setting

4. Design Group Constitutional Performance Risks

The CCGs key performance risks and associated recovery actions are presented in the following table. This is now at Design Group level, and we welcome feedback on this format of reporting for future papers.

LLR Design Group Leicestershire Actions in Place Integrated Cancer pathways

Patients seen within two weeks for an urgent GP referral for suspected cancer (Aug 20) National target of 93% ELR CCG – 89% LC CCG – 91% WL CCG – 89% LLR – 90% Patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer (Aug 20) National target of 85% ELR CCG - 76% LC CCG - 76% WL CCG - 78% LLR - 77% Patients receiving definitive treatment within 1 month of a cancer diagnosis

The 2WW performance continues to be challenging particularly within Upper and Lower GI, specifically where straight to test pathways for Endoscopy take place. Although an improving picture, this remains the primary reason for failure of this standard to date. Diagnostic activity is shifting to the Independent sector to support recovery. Verbal updates on the performance call with UHL and NHSE/I stated that the September position for 2WW was achieved with a target of 93%.

UHL has made some changes to the cancer pathways in line with the National recommendations to ensure that patients are safe and receive the time critical cancer treatments they require.

Patients are being clinically prioritised in line with the

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LLR Design Group Leicestershire Actions in Place (Aug 20) National target of 96% ELR CCG 88% LC CCG 97% WL CCG 94% LLR - 93% Patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery (Aug 20) National target of 94% ELR CCG – 78% LC CCG – 93% WL CCG – 85% LLR – 84%

guidance.

The COVID position continues to impact on the 62-day backlogs due to fewer patients being treated. Independent Sector (IS) capacity is being utilised to support the cancer pathways and this is being overseen by the IS Cell. Work currently looking at the activity/demand by tumour site and capacity available. Reviewing the gap and planning actions to address capacity needs as capacity will not be at pre-COVID levels due to social distancing, donning, and doffing of PPE and air exchange, between patients.

Integrated Primary and Community Care

Diagnosis rate for people aged 65 and over, with a diagnosis of dementia recorded in primary care, expressed as a percentage of the estimated prevalence based on GP registered populations (Sept 20) National Target >66.7% ELR – 62.3% LC – 80.2% WL – 63.8% LLR – 67.0%

ELR CCG & WL CCG - There has been an expected dip in the dementia performance over recent months, due to natural attrition rate combined with the effect of COVID-19 on services, for example: Memory Assessment Services being paused, Routine CT scanning paused, Face to face assessments commencing in August 2020, Families, carers and patients not presenting to primary care services due to the risks of COVID19.

Locally and regionally these issues have been noted and support is being provided, however it will take many months to recover to the national ambition, particularly whilst the social distancing directive remains in force and those with a memory concern in many cases falling into a shielding group.

Integrated Medicines Optimisation PLACEHOLDER

Integrated Elective Care

Referral to Treatment time (RTT) (Sept 20) National target >92% ELR – 57% LC – 54% WL – 57% LLR – 56%

Total patients waiting at end of Sept 20;

ELR – 23,061 against a target of <20,883 LC – 25,831 against a target of <23,554 WL – 27,062 against a target of <24,421 LLR – 75.954 against target of <68,858 (target based on March 20 waiting list)

The impact of the COVID-19 pandemic has led to RTT performance reducing as non-essential activity was cancelled to reduce footfall on hospital sites and free emergency medical bed capacity.

There was a rapid change to utilise telephone appointments for patients who have been clinically assessed to not require to physically attend an outpatient appointment.

Validation of the waiting list continues to align with national guidance and Trust policy.

UHL’s Weekly Activity Management meeting in place with each service to support management of their waiting list.

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LLR Design Group Leicestershire Actions in Place Day case and outpatient work continues with the Independent Sector and Alliance, with a weekly call to ensure capacity is utilised and patients are treated in order.

Patients waiting over 52 weeks for treatment (Sept 20) National target - 0

CCG Total 52+ waiters

UHL 52+ waiters

Out of County

Provider 52+ waiters

ELR 1160 1080 80 LC 1267 1252 15 WL 1193 955 238 LLR 3620 3287 333

Elective surgery was significantly impacted by COVID-19 and there continues to be limited numbers of theatre lists running. All non-urgent elective work was cancelled which led to a number of 52-week breaches. This number of 52-week breaches will have a significant impact on patient care for the foreseeable future and in turn on performance against national targets. To improve the position, UHL is having weekly meetings to determine TCI dates for patients. Most breaches are in orthopaedics followed by ENT.

The Independent Sector (IS) has started to treat long waiting patients following the prioritisation of cancer and urgent patients. Validation of the waiting list continues to align with national guidance and Trust policy, alongside a Consultant review of 52+ week patients.

Patients wating over 6 weeks for Diagnostic Testing (Sept 20) National target <1% ELR – 30% LC – 30% WL – 31% LLR – 30%

Activity has re-started and is slowly increasing following the cessation of all non-essential work; however the position will continue to be challenging over the next few months as limited amount of diagnostic patients will be seen due to social distancing and patient choice.

Patients are being managed in-line with national guidance and trust policies and the Independent sector is being utilised where possible. Speciality level plans are being developed to improve the position.

Acute and Tertiary Services

UHL A&E & UCC 4 Hour Wait Data source; UHL’s ED daily report as at 29/10/20. Oct 20 – 79.8% this includes ED & UCC’s activity (YTD 83.7%) ED only – 71.6% (YTD 77.2%) UCC only – 99.9% (YTD 99.9%)

Performance for October shows an increase compared to September, despite there being an increase in attendances. In response to COVID 19, pathway and site changes have been made within UHL. Admission and discharge profiles are currently having minimal delays due to UHL responding to COVID 19. Non-admitted breaches are at a lower rate than expected due to COVID 19 response, however, there has been a rise as ED attendance increases.

Handover Time between EMAS Ambulance Handovers at the LRI remained stable in August.

8

LLR Design Group Leicestershire Actions in Place ambulances & UHL A&E 30-60 mins

8.1% against zero tolerance (Aug 20)

Handover Time between ambulances & A&E over 60 mins

1.7% against zero tolerance (Aug 20)

Ambulance Waits (August 20)

Cat 1; LC and WL achieved the mean and 90th centile national target. ELR did not achieve either target.

Cat 2; Only LC achieved this target

Cat 3; None of the LLR CCGs achieved the national target

Cat 4; Only LC achieved this target

Performance declined for all six Ambulance Wait time standards in August compared to last month. It is however noted that the August performance was still better than 2019/20 performance for all six standards.

There was a 6.9% increase in calls to EMAS from LLR patients between July and August. Calls have increased month-on-month for 5 consecutive months after the fall in activity due to Covid-19; noting however that calls were 8.6% lower than August 19.

Children and Young People Pathway

Access Rates for Mental Health Services for Children and Young People: % receiving treatment by NHS funded community mental health services based on an expected prevalence (12month rolling Aug 19 – July 20) National Target >35% LLR 32%

The number of children & young people accessing community MH services has increased in 20/21 compared with 19/20, many of these contacts being online services.

Performance varies between CCGs, with Leicester City having the lowest number of contacts in the past 12 months.

Maternity Services

Smoking Status at Time of Delivery (SATOD) % women known to be smokers at time of delivery Q1 20/21 LLR 10.5% Q1 19/20 LLR 9.4%

Performance has declined slightly compared with Q1 in 19/20.

Both Leicester and Leicestershire stop smoking services are involved in the UHL mandatory training programmes for all midwives and neonatal and children’s hospital staff.

Integrated Learning Disability Services

Learning Disability Registers and Annual Health Checks delivered by GPs % of patients aged 14 years or over, on GP practice Learning Disability Registers who have received an Annual Health Check Q1 20/21 LLR 5.1% Q1 19/20 LLR 7.1%

The percentage of LDHC’s carried out in Q1 20/21 is slightly below that in Q1 19/20.

Across LLR the Learning Disability Primary Care Liaison Nurses continue to provide training to primary care staff, to increase their knowledge and confidence to support people with a learning disability to access the health check, provide support and guidance for complex patients and have re-launched the new LLR learning disability health check template and specific

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LLR Design Group Leicestershire Actions in Place guidance for implementation during the COVID 19 period.

Adult Mental Health

IAPT Access - Proportion of people that enter treatment against the level of need in the general population (YTD July 20) 17.3% target in 20/21 ELR CCG – 12.3% LC CCG – 9.5% WL CCG – 13.3% LLR – 11.6% IAPT Recovery Rate - Percentage of people who are assessed as ‘moving to recovery (July 20) >50% national target in 20/21 ELR CCG - 58% LC CCG - 52% WL CCG - 55% LLR – 55% This standard is being met.

The service has implemented a remote/home working model, offering telephone (assessment and treatment appointments) and online (IESO and Silvercloud) support. In addition, the service is implementing Microsoft Teams live events.

A text message has been sent to all patients on waiting lists to let them know the service is still open and working and that the team will be in contact soon to discuss the options open to each patient. Communication has also gone out to GPs as a reminder that the service is still open to referrals.

There is significant promotion work on social media and websites to increase referrals.

Recommendations The LLR CCGs’ Governing Bodies are asked to:

• NOTE the current performance and actions being taken for areas where performance does not meet the required standard.

• DISCUSS additional actions being taken to consider whether further action is required to improve performance.

I

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Rutland CCG



Paper: I Public Confidential

Report title:

Draft LLR CCGs Quality and Performance Improvement Strategy

Presented by: Hannah Hutchinson – Assistant Director of Performance Improvement, LLR CCGs

Report author: Hannah Hutchinson – Assistant Director of Performance Improvement, LLR CCGs

Executive lead: Caroline Trevithick – Executive Director of Nursing Quality & Performance, LLR CCGs



Executive summary: The Draft Quality & Performance Strategy for the Leicester, Leicestershire and Rutland (LLR) Clinical Commissioning Groups (CCGs) is currently in development in preparation for the move to a single commissioning organisation. It outlines the cultural shift away from monitoring performance and quality metrics in a contractual framework to performance improvement as a system, recognising the role of the strategic commissioner within the ICS. A performance framework will ultimately underpin this strategy with collective shared system outcomes that also demonstrate high quality care is being offered to the population of LLR. The paper describes the processes in place in the CCGs to fulfil the statutory function of LLR commissioners in quality assurance and acknowledges that there is duplication in the system when we look at these processes across commissioning and provider organisations. The development of the strategy for the three LLR CCGs supports strategic commissioners in their move towards the development of the Integrated Care System (ICS). This paper when finalised will be the foundation of collaboration and shared priorities.

Appendices: N/A

Recommendations:

The LLR Joint Governing Body meeting : • DISCUSS the contents of the LLR CCG Quality and Performance Strategy

and determine what additional information would be required for this to be approved in readiness for the move to a single commissioning organisation.


- CCG Quality and Performance Improvement Committee November 2020

- System Quality and Performance Improvement Group October 2020 - Nursing, Quality and Performance Improvement SMT October 2020

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interest: None


Aligns to system priorities and the 10 system expectations


Commitment for partner organisations to support the development of a system-wide quality & performance improvement approach


Focusses the system partners on quality & performance improvement to ensure alignment of patient safety strategies for the LLR population and the quality of health organisations providing care to that population


Proposal to include Healthwatch as a partner in the development of system quality & performance


Aims to reduce unwarranted variation and address equity across the system. Shared and commented on by equality leads and aligns to the Equality Strategy.



1

LEICESTER, LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS’ QUALITY AND PERFORMANCE

IMPROVEMENT STRATEGY

CONTENT OF THE STRATEGY

1. Introduction

2

2. Vision, Ambition and Aims

3

3. Clinical Leadership

5

4. What is Quality?

6

5. What is Performance Improvement?

8

6. CCG’s Collaborative Quality and Performance

Assurance / Governance

10

7. Design and enabling groups

14

8. Health Inequalities

16

9. Conclusion

18

10. Appendices

19



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1. Introduction

Delivering safe, high quality health, social care and support to patients and citizens in Leicester, Leicestershire and Rutland (LLR) is at the centre of our ambitions. Combining quality of care alongside performance improvement at System, Place and Neighbourhood levels is the driver to delivering assurance. Placing performance and quality at the centre of our plans to transform services within our nine Design Groups is crucial to delivering long term and meaningful change. The design groups are models of care at system level for transformation, service delivery and quality/ Moving away from performance monitoring to a culture of inclusivity, collaboration and sharing of funds will result in improved outcomes for patients and citizens. As strategic commissioners, the LLR Clinical Commissioning Groups (CCGs) need to balance this collaborative approach with the requirement to assure ourselves and others of the quality of our provider organisations and their ability to provide safe, high quality healthcare to our populations. This strategy describes how the CCGs will discharge this responsibility through system and CCG mechanisms and is intrinsically linked to the vision for clinical leadership across LLR. This draft Quality & Performance Strategy for the CCGs is currently in development in preparation for the move to a single commissioning organisation. It outlines the cultural shift away from monitoring performance and quality metrics in a contractual framework to performance improvement as a system, recognising the role of the strategic commissioner within the ICS. Quality is at the heart of CCG business and objectives and across LLR there is a commitment to connect people, those that work in our health and social care system as well as service users and carers in order to come together and work in partnership with a passion for improvement, across the Leicester, Leicestershire and Rutland. In order to deliver quality care within a culture of shared accountability for both quality and performance improvement, it is crucial that we have the following in place:

• Strong united system leadership and clear direction • Engagement of Design Groups with clinical leadership supported by the wider

clinical infrastructure • Improved patient safety and experience • Through the citizens’ panel, the participation of service users • Horizontal and vertical assurances of improved outcomes; and • Measurement and evaluation of the impact of a change.



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2. Vision, Ambition and Aims The System Vision is, ’to develop an outstanding, integrated health and care system that delivers excellent outcomes for the people of Leicester, Leicestershire and Rutland. In order to do this, the principles we adhere to are:

• Work as one team across boundaries, united in overcoming challenges and sharing responsibility to provide the best service and outcomes to patients. We want people to move through the system seamlessly, unaware that different organisations are working together to care for them.

• High quality, person-centred care for local people across the patch from home to hospital and back again. We want to maintain the health and wellbeing of local people, ensure the best possible outcomes for them when they need treatment or care, wherever they live throughout Leicester, Leicestershire and Rutland.

• Efficiency and best value to make the most of every pound we have to spend in Leicester, Leicestershire and Rutland by sharing resources, cutting duplication, waste and delay and innovating to overcome the challenges we face. This includes setting up new systems to care for people at home and in their local community, as well as using IT to share patient records and offer new services.

• Support and nurture a committed health and social care workforce by helping staff to develop new skills and understanding, encouraging them to be the best, promoting high morale and managing talent and resources. We will be asking staff to work in different ways, in different places and with different people and organisations. We want to give them the skills and set up the system in a way that allows them to do a great job for local people

The LLR vision is underpinned by the 10 system expectations and will dovetail into the wider system clinical leadership and quality strategy across providers. Our ambition is to optimise health outcomes and reduce health inequalities and unwarranted variation for the population of Leicester, Leicestershire and Rutland. The vision will be delivered through the creation and delivery of a person-centred leadership framework (PCLF) which is underpinned by four key enablers:

• Transformation • Integration • Communication, Engagement and Inclusion, • Multi-professional and System Leadership.



4

This work is being led by the LLR Academy to support system drivers in improved outcomes as can be seen in diagram 1. Diagram 1 – LLR Academy #moregooddays

The strategy describes the CCGs quality and performance governance structure which will be aligned to the developing system governance by:

- Aligning the quality and performance outcomes in a move towards the ten expectations (outcome measures) in Leicester, Leicestershire and Rutland;

- Integrating health and social care within a Quality and Performance framework;

- Underpinning design, delivery and outcomes of all transformation and delivery within the CCGs or the new single commissioning structure at System, Place and Neighbourhood level.



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3. Clinical Leadership

A key component in the delivery of safe, high quality care is to create agile, multidisciplinary, clinical and professional networks with involvement operationally at Place, and strategically at System level with Primary Care Networks delivering at Neighbourhood level. Clinical advice should feed into local governance and scrutiny meetings and transformation and improvement should remain clinically led and co-produced with the local population. The work led by system clinicians drives the 10 System Expectations that as a system we have committed to in order to drive our work. The LLR 10 system expectations are:

1. Safety First 2. Equitable Care for All 3. Involve our Patients and the Public 4. Have a virtual by default approach 5. Arrange care in local settings 6. Provide excellent care 7. Enhanced care in the community 8. Have an enabling culture 9. Drive technology, innovation and sustainability 10. Work as one system with a system workforce

To ensure that there is a system engagement in clinical leadership two groups have been established to ensure full engagement across all clinical disciplines and clinical executive leadership within the Integrated Care System. These are the Clinical Executive Group and Clinical Leadership Forum (see appendix 4 for further detail). Further information around clinical leadership can be found in the ICS Clinical Leadership Strategy (Note – this is to follow).



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4. What is Quality?

Since the publication of High Quality Care for All in 2008, the NHS has used a three-part definition of quality. NHS England describes this as: ‘the single common definition of quality which encompasses three equally important parts”. These are:

- Care that is clinically effective - not just in the eyes of clinicians but in the eyes of patients themselves;

- Care that is safe; and, - Care that provides as positive an experience for patients as possible.

Diagram 2 illustrates person centred care for all. This needs to include patients, the public, carers, workforce and the wider community. Diagram 2 – What is High Quality Person Centred Care? https://www.england.nhs.uk/wp-content/uploads/2016/12/nqb-shared-commitment-frmwrk.pdf

High quality care is only achieved when all three dimensions are present - not just one or two of them. The NHS Outcomes Framework (2016-7) builds on these dimensions of quality by breaking down the three quality indicators into five domains:

https://www.england.nhs.uk/wp-content/uploads/2016/12/nqb-shared-commitment-frmwrk.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/513157/NHSOF_at_a_glance.pdf



7

The Long Term Plan – https://www.longtermplan.nhs.uk/ - published in 2019, also emphasises the importance and need for transformation and developing robust systems that will be long lasting and sustainable. Quality improvement needs to be sustainable and The Kings Fund describes it as ‘the systematic use of methods and tools to try to continuously improve quality of care and outcomes for patients’. Improving quality, care and performance outcomes can be undertaken using methodologies such as Lean; PDSA (Plan, Do, Study, Act), and Six Sigma. However, whichever methodology is utilised needs to provide assurances that the process is effective, leading to a culture of continued improvement against operational and contractual commitments and within the financial envelope available to the system. The system in Leicester, Leicestershire and Rutland will develop a Quality Improvement Framework to provide assurance and accountability at “each level of the system and organisation to improve quality and encourage innovation, but sufficiently flexible with the self-similar approach to allow the best cultural fit within services and to encourage local ownership of the preferred improvement methodology” (Greater Manchester Quality Strategy 2017). According to Matthews et al 2016 the elements of a Quality Improvement Framework are:

- Define a unifying purpose; - Establish a fractal organisational structure; - Develop a common framework for understanding quality and safety; - Develop tools for communication and reporting; and - Create a system of shared leadership responsibility.

An intrinsic element of quality improvement is ensuring close working with our current regulators in a dual capacity. This includes the change in culture to support innovation and improvement through the triangulation of data and sharing of intelligence, whilst also providing the system assurance which is required in a timely manner. In order to determine if quality is improving, it is essential that services are co-produced with patients and the public and that the patient voice is heard throughout the process. Patient reported outcome measures need to be considered as part of the improvement process with learning from thematic complaints, serious incidents, surveys, audits and a wealth of other data which is available to health and social care organisations.

https://www.longtermplan.nhs.uk/



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5. What is Performance Improvement?

The performance improvement journey has been defined by The Health Foundation as having six stages. These can be seen in diagram 3 – The Improvement Journey. Diagram 3 – The Improvement Journey (The Health Foundation)

An organisational approach to improvement is one where a culture of continuous improvement and learning within the system are drivers for change. This needs the leadership, governance, financial means and clinical drivers at each level to make it a reality. For performance improvement, rather than measurement of performance to become a reality, it is empirical that there is a shared vision that is understood and supported at every level of the organisation. The Health Foundation 2020 states that “this vision is then realised through a coordinated and prioritised programme of interventions aimed at improving the quality, safety, efficiency, timeliness and person-centredness of the organisation’s care processes, pathways and systems”. According to Braithwaite et al (2017) in the British Medical Journal it is at the organisational level that it becomes possible to oversee the creation of a positive, collaborative and inclusive workplace culture, which are closely associated with improved patient outcomes. For this reason, it is crucial at system level in Leicester, Leicestershire and Rutland that the governance which wraps around quality and performance improvement is defined, shared and agreed. In addition, the system needs to consider and review performance improvement from an integrated health and social care perspective.



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In Leicester, Leicestershire and Rutland the primary purpose of a Quality and Performance Improvement Strategy is to provide the system as a whole with a structure with which to make systematic, continuous improvements to performance enabling achievement of its objectives. Through a subsequent quality and performance improvement framework, the system can then hold itself to account publically for its performance outcomes at System, Place and Neighbourhood. A joint outcomes framework will be developed from the strategy which will be a useful engagement tool to demonstrate ownership of performance and quality at every level of the system, not just the top. Shared responsibility of outcome measures will result in the patient being at the centre and a shared understanding which is clinically driven around the outcomes which can be achieved. Improving performance is at the heart of what Leicester, Leicestershire and Rutland strives to achieve and this will enable continuous improvement in delivering quality, efficient and patient-focused services through a cycle of Plan-Do-Review.



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6. CCG’s Collaborative Quality and Performance Assurance Quality: Currently there is collaborative working across the health and social care economy to monitor and provide assurance around all NHS providers. The arrangements have been that each CCG hosted a quality contracts team who were responsible for monitoring the quality of healthcare delivery and gaining assurance that standards are continually maintained and improved. Each of the providers reported to a formal Clinical Quality Review Group meeting which took place on a regular basis. In addition, teams across the CCGs within the Nursing, Quality and Performance Directorate focused on specific areas of quality assurance including safeguarding, infection prevention and control, medicine’s optimisation, patient safety and patient experience. Now quality is an integral part of the conversations taking place within the design groups with the opportunity for further discussion through the Quality and Performance Improvement Committee. Performance: Performance management of contracts has been undertaken by the relevant CCG performance contracts team with a quality perspective taken from the Contract Quality Schedule. This approach recognises that measures are valuable indicators of quality and also a source of assurance for Governing Bodies and NHSE/I. However, metrics are only one source of intelligence. The current metrics being measured are primarily the Constitutional Performance Standards for which NHSE/I require submissions alongside the provider Quality Schedules which are contractual and contain national local indicators. The purpose of the CCGs’ governance process around performance is to have a strategic focus on seeking assurance in respect of the mandated standards and the national framework that CCGs are required to be compliant with (e.g. NHS England and Improvement Outcomes Framework). For the full performance report that the CCGs’ Governing Bodies see on a monthly basis see Appendix 1. Governance: In addition, in a move to ensure further integration individual CCG meetings have been drawn together to form the LLR CCGs’ Joint Quality and Performance Committee. The purpose of this group is to seek assurance and adopt an integrated approach to quality assurance and performance improvement ensuring the CCGs are compliant with their statutory duties and obligations. In the future this committee will need to expand to look at the wider system quality and performance priorities and have a united approach to governance and a collaborative culture. The full Terms of Reference for this group can be found in Appendix 2. The LLR CCGs’ approach to implementing the Quality and Performance Improvement Strategy will be to assess proposed policies, practices and any



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services we commission by using the Equality Impact and Risk Assessment (EIA) process alongside a Quality Impact Assessment (QIA). This enables the CCGs to show ‘due regard’ to the Public Sector Equality Duty and ensures that consideration is given prior to any policy or commissioning decision made by the Governing Bodies (or other committees) that may impact upon equality and human rights.

Integrating Quality and Performance at System level With the support of the LLR CCGs’ Governing Bodies, University Hospitals Leicester (UHL) and Leicestershire Partnership Trust’s (LPT’s) Boards the proposed governance arrangements for the Integrated Care System will include a System Quality and Performance Group. The System Quality and Performance Group will focus on quality assurance and improvement through continuously improving the performance and delivery of healthcare services with the aim of providing better outcomes to the people of Leicester, Leicestershire and Rutland, ensuring that those services delivered are of high quality, clinically safe and effective, within available resources. The purpose of the group will be to:

• Define a unifying purpose; • Develop a common framework for quality and performance improvement; • Develop tools for reporting and monitoring; • Create a system of shared leadership responsibility for population and

organisational improvement; and • Provide Quality & Performance Leadership within the Integrated Care System.

Diagram 4 – LLR Governance Structure including the Quality and Performance Group



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The full terms of reference for the System Quality and Performance Group can be found in Appendix 3. This move recognises the relationship between health and social care that are mutually accountable for opportunities to improve the quality of care and the outcomes in performance for the patient. As there is a move away from metrics to outcomes and building relationships and trust within the system, this will be underpinned by support and development for staff at all levels. Cultural change of this type requires strong leadership in relation to the importance of the vision along with person-centred values and behaviours. The CCGs’ Nursing, Quality and Performance directorate structure as part of the CCG management of change highlights the transition of work in reporting and monitoring performance metrics to performance improvement outcomes by ensuring that this function is a clinical directorate. It is crucial, as the system moves to one single commissioning organisation that the focus moves to safe, timely, effective, efficient, person-centred and equitable outcomes which are measurable and outcome focused. Measures must be localised where possible, keeping the patient and the carer at the centre at all times. This requires collaboration between the CCGs and the regulators to ensure there is an open and transparent understanding of the improvement outcomes the system is working towards at the three levels, in what time period and how these will be achieved. Phase Three Plans Based on the Phase 3 letter released by NHSE/I in August 2020 there are a number of immediate quality and performance improvement areas that will need to be addressed as a system, reported on and outcomes agreed. These include: Area of Improvement Design Group Link Restoring the full operation of all cancer services

Cancer

Recovering the maximum elective activity possible between August and winter 2020

Elective Care

Restore service delivery in primary care and community services

Primary and Community Care

Expand and improve mental health services and services for people with learning disability and/or autism

Mental Health & Learning Disabilities

Identification of patient safety specialists Patient Safety

In addition to these areas nationally requested, there is a commitment through the CCG Quality and Performance Improvement Committee to identify and prioritise



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those national targets and constitutional requirements which are not being met and also agree our local measures. Agreeing the local measures is being done through collaborative working with the design groups who are all developing their own Plan on a Page. This plan contains the outcomes they hope to achieve in their area. With the wealth of expertise from NHS colleagues in the design groups the outcomes will be determined using data from multiple sources. This triangulation of data will allow the groups to be data rich. In addition the CCG design groups outcomes there will also be work towards a system quality and performance improvement framework which system partners have agreed to embark upon. Successes will be celebrated and challenges monitored and actioned through the quality and performance improvement governance structures in place at CCG and system level.



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7. Design and Enabling Groups

Design Groups In order to enact transformation and deliver high care with improved outcomes for our population the following groups have been set up across Leicester, Leicestershire and Rutland. They are multi-disciplinary teams. Quality and Performance is an integral part of these nine design groups. The design groups are shown in diagram 5 below. Diagram 5 –LLR CCG System Design Groups

The form and function of these design groups will be developed as they are established, but all will be clinically led. In addition they will be underpinned by the 10 system outcome measures (as outlined on page 3-4). The design groups while working to transform care services also recognise the additional need to prevent disease in addition to monitoring the prevalence of disease and improve outcomes for patients with either single disease or multi-morbid conditions,



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Enabling Groups To support the Delivery Groups in their work Enabling Groups have been established that in turn will support the focus on quality and performance improvement. These can be seen in diagram 6. Diagram 6 –System Enabling Groups



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8. Health Inequalities

When reviewing performance metrics the challenges to performance have been exacerbated during 2020 by Covid-19. Covid-19 has further exposed health inequalities at every level of the system. NHSE/I has stated that the virus itself has had “a disproportionate impact on certain sections of the population, including those living in most deprived neighbourhoods. That is to say those from Black, Asian and minority ethnic communities, older people, men, those who are obese and who have other long-term health conditions and those in certain occupations”. Recovery and quality and performance improvement going forward needs to be planned in a way that inclusively supports those in greatest need. This requires collaborative working within communities at neighbourhood level to reduce health inequalities, and regularly assess progress. Population Health Management (PHM) is an approach which aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population. This includes focusing on the wider determinants of health which account for 80% of a person’s health outcomes. Public Health England state that wider determinants, also known as social determinants, are a “diverse range of social, economic and environmental factors which impact on people's health. Such factors are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life”. The King’s Fund states that health is dependent on our genes, lifestyles, environment and healthcare as can be depicted from diagram 7 by Dahlgren and Whitehead (1993) below. These factors are hugely important when considering how to improve outcomes for our population in terms of health and prevention of ill health. Diagram 7 –Broader Determinants of Health



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PHM will support LLR to use data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of the collective resources. PHM is a partnership approach across the NHS and other public services including councils, the public, schools, fire services, the voluntary sector, housing associations, social services and the police. All have a role to play in addressing the interdependencies that affect people’s health and wellbeing. Using risk stratification tools to segments the population and attributes cost, enabling the system to identify greatest opportunities for changing the delivery of care is crucial to identifying where improvements need to be made and to have an equitable system of care. There is an enabling group set in in the LLR CCGs to undertake work around risk stratification and the benefits of different tools in capturing the multidimensional nature of an individual’s health. In addition when illustrating performance and feeding back on outcomes around what is “normal” at system, place or neighbourhood levels Statistical Process Control (SPC) charts can be used. These charts provide an understanding of where the focus of work needs to be concentrated in order to make a difference as they illustrate normal (natural cause) variation and special cause variation.



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9. Conclusion “Every system is perfectly designed to deliver the results it does” - Paul Batalden, 2007 In order to have a fully functioning Quality and Performance Improvement Strategy within Leicester, Leicestershire and Rutland which serves to improve outcomes for patients and citizens quality and performance assurance must come together from a governance perspective. This uniting of common purpose must be within a system which is clinically driven, independently assured and managerially united. Improvement outcomes need to be based around a population health management approach to demonstrate care which is equitable and must be measurable, realistic, safe and effective at System, Place and Neighbourhood level. This strategy, whilst a Strategic Commissioning strategy will form the basis for the development of Quality and Performance assurance process within the Integrated Care System.



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10. Appendices

APPENDIX 1 – PERFORMANCE, FINANCE AND ACTIVITY COMMITTEE REPORT

CCG Perf Assurance LLR Board Sep20-V2.d APPENDIX 2 – CCGs PERFORMANCE & QUALITY COMMITTEE TERMS OF REFERENCE & WORK PROGRAMME

Appdx 5 - Quality and Performance Wor

Appdx 4 - Quality and Performance Term

APPENDIX 3 – SYSTEM QUALITY AND PERFORMANCE GROUP TERMS OF REFERENCE

Terms of Reference LLR System Q&P V1 O APPENDIX 4 – CLINICAL EXECUTIVE GROUP & LEADERSHIP FORUM Clinical Executive Group

• Using organisational positions to inform and drive system strategy

Clinical Executive membership

• Support for design group clinical leads to lead design groups • LLR Academy Leadership/endorsement

Empowering clinical leads/unblocking barriers

• Ratifying the developments from the wider clinical leadership group

Endorsing the strategic direction

•Managing interdependencies between Design Groups •Formal Clinical sign off and recommendation to System Operational Group/System Executive

Oversight & approval of clinical pathways

• Managing the interface between primary, community and secondary care

TCS Process oversight

• Clinical strategy to inform LLR strategy

Chair to sit on System Operational Group



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Clinical Leadership Forum

• Multi professional engagement across health & social care

Wide MDT membership

Leadership – Nurse, AHP, Consultant, Pharmacist, GP

• Wide involvement across clinicians to develop the clinical leadership strategy

• Engine Room for ICS – clinical innovation

Developing the strategic direction for clinical leadership

• Link to TCS work – source task and finish group members to resolve issues

• Engages with organisational clinical forums e.g. CCG Clinical Reference Group, UHL Clinical Senate, LPT Clinical Groups , AHP Forum

Problem solving across organisations/pathways/professions

• Input to the LLR Academy • Develop the organisational development plan for person-centred

leadership

OD/Clinical Leadership Development

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Rutland CCG


Date: November 2020 Paper: J Public Confidential

Report title:

Update on the Leicester, Leicestershire and Rutland Learning Disability Mortality Review (LLR LeDeR) Programme

Presented by: Paula Vaughan, Head of Commissioning (All Age Mental Health, Learning Disability, Autism, Dementia)

Report author: James Lewis, Lead Commissioner (Working Age Adults), Leicestershire County Council Wendy Pinson, Senior Quality Nurse, West Leicestershire CCG Paula Vaughan, Head of Commissioning (All Age Mental Health, Learning Disability, Autism, Dementia)

Executive lead: Caroline Trevithick, Executive Director of Nursing, Quality and Performance, LLR CCGs


Executive summary: The CCGs are part of a system collaborative who have a responsibility to deliver timely and transparent LeDeR (learning from deaths of people with a learning disability) reviews. CCG and Local Authority colleagues are working together to deliver both a robust LeDeR process for new reviews, but also to ensure that a backlog of 45 outstanding reviews are completed by the end of the 2020 calendar year. This report and accompanying appendix is presented to provide LLR CCGs’ Governing Body with an update on current progress.

Appendices: • Appendix 1 – LLR LeDeR Performance Update ‘Priority Reviews’

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • NOTE the work being undertaken to complete LeDeR ‘priority reviews’ by

December 11th and the current projected completion of 92%.


None.

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interest: None


• Improve outcome and experiences for patients • Reduce health inequalities


The Learning Disability & Autism Executive, through NHSE and other sources, has committed £112,731 to ensure the successful delivery of the LeDeR programme in LLR. This is supplemented by officers who support delivery as part of their substantive posts. In addition, LLR has been allocated £57,961 from NHSE/I for the 2020/21 financial year: £38,315 to help embed ‘Learning into Action’; £19,646 to support the completion of ‘priority reviews’.


The LeDeR programme will highlight any opportunities to improve quality and safety for people with learning disabilities


The involvement of family, friends and wider carers is an integral part of the LeDeR process; it is critical in the production of a comprehensive and person centred LeDeR review.


The LeDeR Programme will support the delivery of responsibilities under the Equalities Act by identifying and addressing the health inequalities that people with a learning disability experience.

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Update on the Leicester, Leicestershire and Rutland Learning Disability Mortality Review (LLR LeDeR) Programme Executive Summary

1. The CCGs are part of a system collaborative who have a responsibility to deliver timely and transparent LeDeR (learning from deaths of people with a learning disability) reviews.

2. CCG and Local Authority colleagues are working together to deliver both a robust

LeDeR process for new reviews, but also to ensure that a backlog of 45 outstanding reviews are completed by the end of the 2020 calendar year.

3. This report and accompanying appendix is presented to provide LLR CCGs’

Governing Body with an update on current progress.

Background

4. In July 2020 the LLR CCGs’ Governing Body approved the publication of the first LLR LeDeR Annual Report. This report highlighted progress to date in implementing the programme and an early indication of the ways in which local health and social care services can be improved for people with a learning disability.

5. In August NHSE/I informed local system’s that it was expected that all LeDeR

reviews referred before July 1st (‘priority reviews’) would be complete by 11 December 2020. LLR CCGs are accountable to the NHSE/I Learning Disability & Autism Programme to meet this target.

6. Poor historic performance means that this target represents a significant challenge

for LLR. Because of this, NHSE/I have levelled considerable scrutiny and attention of LLR performance, including additional reporting requirements.

Current Position

7. Significant progress is, and has been made (Appendix 1). This progress has been achieved with additional managerial and administrative focus on the project (some funded via the TCP budget), additional local scrutiny and focus, and the introduction of process-based tracking.

8. The LeDeR Leadership team is currently projecting that 92% of ‘priority reviews’ will be complete by the December deadline, and this figure is being revised, typically upwards, on a weekly basis.

9. The most significant issues that are hindering LLR performance are:

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• The variance in quality of reviews that are being submitted for approval by the North of England Commissioning Support Unit (NECS). Poor quality reviews are requiring significant revision and additional work before they meet LLR quality standards, this slows down progress. • The volume of Quality Assurance (QA) activity required to ensure that reviews meet appropriate standards before they are approved.

10. The LLR LeDeR leadership team has put in place mitigations and actions to limit the

impact of these issues including support for reviewers, additional QA capacity and regular partnership meetings with the other provider of reviews (NECS).

Recommendations

11. The LLR CCGs’ Governing Bodies are asked to:

• NOTE the work being undertaken to complete LeDeR ‘priority reviews’ by 11 December 2020 and the current projected completion of 92%.

LLR LEDER trajectory progress 3 November 2020

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LEDER Headlines • LLR has seen a significant improvement in performance over the last twelve months (Slide 5). The speed at which reviews are complete has increased

whilst quality has remained high. • That being said, there are three years worth of poor performance that needs to be overcome. • The current projection is that LLR will complete 92% of reviews referred before June 30th by December 11th. This breaks down as 95% of LLR managed

reviews; 83% for NECS managed.

Progress See Slide 4

Next steps to ensure delivery of trajectory • As described in risks & mitigations.

High level risks & Mitigation

Risk Mitigation

QA Capacity • Use of NHSE/I money to fund QAers

Quality of NECS reviews • Detailed feedback on each review with clear expectations • Regular discussions with NECS

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LEDER

Date LLR Complete + QA NECS Complete + QA Total Complete + QA

24/09/20 61% 35% 52%

08/10/20 64% 31% 56%

22/10/20 72% 41% 61%

03/11/20 82% 69% 79%

Date LLR Complete NECS Complete Total Complete

24/09/20 60% 22% 50%

08/10/20 61% 25% 52%

22/10/20 62% 25% 53%

03/11/20 70% 33% 61%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LLR Complete % NECS Complete % Total complete %

Projection to 90% Projection to 100%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LLR Complete + QA% NECS Complete + QA Total Complete + QA %Projection to 90% Projection to 100%

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LEDER

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Awaiting Allocation % In Progress % Complete

K To Follow

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Rutland CCG


interest: None identified for the purposes of the assurance report. Any conflicts arising in respect of CRG items were manged as per LLR COI Policy.


At present each CCG has its own Board Assurance Framework; however, going forwards any risk that impacts on LLR Strategic Objectives will be reported and aligned to the Board Assurance Framework where appropriate


None identified.

Name of meeting: LLR CCGs’ Joint Governing Body

Date: Tuesday 10th September 2020

Paper: L Public Confidential

Report title:

Clinical Reference Group Highlight Report

Presented by: Mayur Lakhani, Chair WLCCG Azhar Farooqi, Chair LCCCG Vivek Varakantam, Chair ERLCCG

Report author: Michele Morton, Senior Committee Clerk

Executive lead: Rachna Vyas, Executive Director, Integration & Transformation, LLR CCGs


Executive summary: This highlight report provides a summary the key issues discussed by the CRG when it met on 2nd & 21st July, 6th & 18th August, 3rd & 15th September and 6th and 20th October 2020. The Clinical Reference Group (“CRG”) has been established as a joint advisory group of NHS Leicester City Clinical Commissioning Group, NHS East Leicestershire and Rutland Clinical Commissioning Group, and NHS West Leicestershire Clinical Commissioning Group, collectively referred to as the Leicester, Leicestershire and Rutland Clinical Commissioning Groups (“LLR CCGs”). The CRG provides support and clinical commissioning advice to the Governing Bodies of the CCGs and the committees of the CCGs. The CRG acts in an advisory capacity only and it has no delegated authority from the three CCGs.

Appendices: None.

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be ASSURED of the actions of the CRG


Documents key issues considered by the CRG from July to October 2020.

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-


None identified


None identified

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LEICESTER CITY, WEST LEICESTERSHIRE AND EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS

Clinical Reference Group – Highlight report

2nd & 21st July, 6th & 18th August, 3rd & 15th September and

6th and 20th October 2020. 1. Introduction

This highlight report provides a summary of the key issues discussed by the CRG. The CRG has been established as a joint advisory group of NHS LLR CCGs. The CRG provides support and clinical commissioning advice to the Governing Bodies of the CCGs and the committees of the CCGs. The CRG acts in an advisory capacity only and it has no delegated authority from the three CCGs.

2. Scope This highlight report covers key issues that were discussed at the CRG when it met by MSTeams on 2nd & 21st July, 6th & 18th August, 3rd & 15th September and 6th & 20th October 2020. 2nd July CRG Meeting – Key Issues

3. 10 System Expectations A presentation was given on the 10 System Expectations – emphasising the importance of a clear strategy for implementation to ensure system buy-in within the context of commissioning, financial flows and all GP colleagues:

• Safety first approach • Equitable care for all • Involve our patients and public • Have a virtual by default approach • Arrange care in local settings • Provide excellent care • Enhanced care in the community • Have an enabling culture • Drive technology, innovation and sustainability • Work as one system with a system workforce

Comments were collated and fed into the design groups who were working on the detail. Action: CRG members RECEIVED and COMMENTED on the 10 System Expectations and their associated actions. Comments would be forwarded for consideration and inclusion by the Design Group.

4. EMAS Presentation A summary presentation was given that outlined the EMAS response to Covid-19 and highlighted the positive impact primary care had contributed to achievement of national response standards. CRG considered how their response to Reset, Restore & Recover for new models of working in primary care could continue to support EMAS clinical model.

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Further dialogue was invited between ambulance crews and primary care on how to work better. EMAS indicated feedback had been positive from crews (often band 4 technicians) who had appreciated advice and guidance from GPs. Action: CRG members RECEIVED a presentation from EMAS.

5. Restoration Plan for Primary Care A presentation was given that covered the following: • Current position - attitude and relationships had been good. Working came from a

place of a shared problem. Everything else flowed from there. • The use of business intelligence (capturing data to inform the recovery cell and inform

plans at PCN, place and practice level). • Workforce risk assessment / resilience predominantly at PCN/ practice level. • Current services under review for shielded patients – close working with the national

team to ensure communications were clear. • Financial claims process under review and work continued with CDs to better

understand business continuity plans and the support required for practices, specifically in the context of any future outbreaks.

• Recovery Plan – all details captured in a single document Action: CRG members RECEIVED a presentation on the Restoration Plan for Primary Care. 21st July CRG Meeting – Key Issues

6. Think 111 First A report was received that provided CRG members with a briefing on what Think 111 First was, that included a summary of the LLR project structure, and feedback was sought on the key outcomes and principles for the LLR pathway. A full discussion ensued where it was felt the initiative would support the whole health economy in LLR as patients became more familiar with technology. Action: CRG members RECEIVED the report and fed back on the key outcomes and principles for the LLR pathway.

7. Virtual Wards (Standard Proforma for Pilot sites Remote monitoring with oximetry) A report on virtual wards was received that outlined details on the increasing community of practice emerging, with multiple sites around the country wishing to help organisations develop the best model of care for monitoring patients in the community with confirmed or probable Covid-19 infection – belief was that more could be done to support patients, especially those at higher risk of complications, and national guidance developed for remote monitoring - working with NIHR and Imperial partners to evaluate all early test sites willing to be part of the project to support learning and dissemination of best practice. Action: CRG members SUPPORTED the proposal to develop the best model of care for remote monitoring of patients in the community with confirmed or probable Covid-19 infection.

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6th August CRG Meeting – Key Issues

8. Third Phase Response to Covid 19 A letter was presented on the third and final phase of NHS Response to Covid-19 as the main business for LLR and every health economy in England, in that it put forward return to normal NHS working in terms of activity and bed occupancy. Key highlights:

• The driver behind the directive was concern over waiting lists. • Primary care responsibility for backlog. • A strong secondary care focus for reducing waiting lists.

CRG were informed of work taking place through the System Planning Operational Group and the design groups to make progress on the above that would include financial allocations. Action: CRG members RECEIVED and DISCUSSED the Third Phase Response to Covid 19.

9. Ageing Well CRG received a presentation on progress towards Community Service Redesign (CSR) and the national expectations around Ageing Well and the Long Term Plan. A key to success was the integration of primary and community services at Neighbourhood level, whilst also providing a new and different offer in respect of rapid response in the community for an integrated two-hour and two-day response from community services and reablement. Main comments from the group included: • Workforce issues that existed and a long waiting list for community therapies; the

waiting list being much longer in city than in county. A question was raised on how the redesign could improve and treat inequality in waiting lists.

• It was suggested an evaluation and adjustment of services be made accordingly if inequalities with virtual service provision were identified, particularly with elderly groups.

Action: CRG members RECEIVED the presentation on Ageing Well.

10. Falls Review A presentation was given on a recent falls review that made a number of short term and long term recommendations for future falls delivery across LLR. The LLR current offer was complex and multifaceted, with differential outcomes across city and county areas. A number of non-recurrently invested services required decision on reinvestment and as such CCC had requested a clinical review of the current LLR falls pathways. It was noted the presentation had shown the complexity of the falls support service and the importance was stressed of having a consistent service across LLR. Action: CRG members received the presentation on the falls review and gave support to the recommendations outlined.

11. Covid-19 Recovery Pathway A joint piece of work was introduced that was to look at a Covid recovery pathway for patients specifically affected by Covid, as a local response to the document released by

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NHSE/I in June 2020 entitled “The aftercare needs of inpatients recovering from Covid-19”. The ask of the document had been taken forward locally to provision of a broader model which encompassed community patients, i.e. those who weren’t actually admitted into hospital, in order to ensure that their recovery needs were also looked after. Notably highlighted was:

• Low level needs could include reassurance, advice, remote consultations and/or signposting to the new NHSE website “Your Covid recovery”.

• Medium level needs could be picked up by core teams in the Community, Home First, Community Therapy or other services.

• Severe level needs could include severe fatigue or unresolved respiratory problems

Action: CRG members NOTED and SUPPORTED the work taking place.

12. LLR CCG Commissioning Stance for Lycra Garments CRG were apprised of the need for a consistent approach to the commissioning of Lycra garments and as such the CCG was being asked to clearly stipulate that LLR would not commission Lycra Garments. Any requests for such items will be referred through Individual Funding Requests. The following points were raised:

• CRG sought reassurance the change would not create any increase in inequalities. • Suggested it would be useful to have triage criteria and guidelines to avoid making

a referral if criteria not met. • There had been a good evidence based review and the proposal was a sensible

way forward. Action: CRG members: REVIEWED the paper and agreed to recommend that Lycra garments were not routinely commissioned based on the literature review. RECOGNISED that IFR requests might be submitted for garments.

13. Pathway for Unwell Children CRG considered information sent from the national pathway team for NHS 111 i.e. NHS Pathways that described imminent changes to the management of unwell infants under 10 days old. Information was being shared with clinical leads across the CCGs and feedback gathered as part of a consultation process Action: CRG RECEIVED and SUPPORTED the paper with a strong suggestion of taking forward a suggested audit. 18th August CRG Meeting – Key Issue

14. Developing of Covid-19 Screening Programme for Returning University Staff and Students Professor Nigel Brunskill, UHL Director and Director of LHAP attended and gave a presentation on a Covid-19 programme being developed at the University of Leicester, to commence at the beginning of October 2020. Professor Brunskill outlined the details of a pilot programme of returning students, a swab testing programme, a test using saliva as a diagnostic media, none of which were designed to increase workload in primary care.

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Action: CRG members RECEIVED the presentation. 3rd September CRG Meeting – Key Issues

15. Design & delivery of phase 3 and beyond A presentation was given on the design and delivery of phase 3 and beyond. It included the current position, purpose of the design groups (covering 36 pathways) and how they would translate into system delivery objectives. CRG were informed of the status of each design group and a full discussion took place with regard to how the programmes would fit and work with the IT Programme Board and Digital Innovation Hub. CRG members noted they would receive a presentation on each of the individual design groups at future meetings. Action: CRG members RECEIVED the presentation on Design & delivery of phase 3 and beyond.

16. Care Home Template Development CRG members were informed of an upcoming change to the SMR (Structured Medication Review) template. The template would support the SMR element of the enhanced health in care homes network DES, but also could be used for any kind of medication review. An opportunity was given to comment and add to the content which included details such as type of clinician carrying out the review; how patients were taking medication; drug interactions; blood checks; plans for emergency prescribing/anticipatory prescribing; safety issues/risks. A request was also made that the template be linked to Care Plans. It was felt the template would help to harmonise prescribing across the CCGs. Action: CRG CONTRIBUTED to and SUPPORTED the Care Home Template.

17. Support for IPoorly Child Symptom Seeker An item was received on the iPoorly app, a video enhanced child symptom checker app co-developed with and for parents and professionals to facilitate recognition of the sick child. The application was the result of 10 years of development of rigorous evidence, systemic and qualitative in nature, utilised to develop clinical guidelines and pathways in recognising and spotting the sick child under 5 years of age, to support parent’s when making clinical judgements and to help them know when to seek help and at what level of urgency. The application would help with prevention work around winter planning, difficult periods of the year and with reduction of ED attendances. CRG members felt it would be important for the application to be tested out on a diverse and substantial sub-section of the population, to ensure it was the most appropriate one. Notably amongst vulnerable groups, BAME community and digitally challenged groups. It was felt LLR had a good mix of population for testing and was highly appropriate to have local involvement. Action: CRG members RECEIVED the report and SUPPORTED the endorsement of the CCG’s in being named as one of the three healthcare groups involved in the feasibility and project development of the ipoorly application.

8

15th September CRG Meeting – Key Issues

18. Cancer Workstream A presentation was received on the Phase 3 LLR System Covid Plan for Cancer that included: • Key achievements • 2 WW Referral Recovery (and by tumour site) • 62 Day recovery / 104 Day recovery • August and September predicted performance and Cancer Trajectory. • Activity Forecast – best, most likely and worse case scenarios. • Independent Sector – national contract in place with IS providers to support recovery. • Endoscopy, Transformation and Screening Update (cervical, bowel, breast). • Issues for discussion and escalation.

CRG agreed on the possibility of developing a more flexible approach for deprived areas to enable better access to secondary services, for example, offering transport, different appointment times, without compromising the nine protected characteristics. CRG felt it would be beneficial to carry out a deep dive into the 52 week waiters to find out what the issues were, for example importance of attending appointments or any other underlying issues and to use lessons learned from the Leicester city lockdown for sending out robust communications out to the right target population. Action: CRG members RECEIVED and noted the update on the Cancer Workstream.

19. Elective Care Discussion A discussion was held on the current challenge with Elective services – referral management and patients waiting more than 52 weeks. Key discussion highlights were: • A debate was held on the usefulness of A&G versus RSS and it was concluded that

both functions had a place within the system for a variety of purposes. • IT functions had been under-utilised and more A&G IT solutions in other parts of the

country existed, though work continued on systmone availability in UHL. Further work was needed to encourage consultants to use systmone.

• The group agreed it was important to know how many patients had visited surgeries and that a prioritisation exercise be carried out as a systemwide response. A solution could include the enhancement of PALs teams to provide clear communications.

Action: CRG members RECEIVED an Elective Care presentation.

20. Dementia Prevalence Rates and Memory Assessment Services A report was received that indicated in line with the national picture, the dementia diagnosis prevalence rates had declined between April 2020 and July 2020 for all 3 LLR CCGs. The number of referrals into the memory assessment service had declined particularly for April and May 2020. Of most concern was the screening capacity and a discussion was held on the possibility of using out of area facilities, or hiring mobile scanners from the independent sector for additional diagnostic capacity.

9

The paper outlined the issues involved during the pandemic and work programmes planned and being developed to mitigate some of those issues, working towards different methods of service delivery and a ‘new normal’. It was agreed to approach the population health management team for information on patients who needed a diagnosis – noting that some people might not need medical input. Action: CRG members RECEIVED and DISCUSSED the Dementia Prevalence Rates and Memory Assessment Services. 6th October CRG Meeting – Key Issues

21. Workload Transfers A report was received that outlined in recent weeks, the question of workload transfers at interfaces of health and care that had arisen at a number of fora. The questions had become more urgent in the context of Covid-19 which required changes in the model of care. Agreement had been reached with LPT, UHL and Associate Medical Directors to carry out the necessary work on transfers, which would ultimately be down to funding and capacity. CRG members felt the initiative would provide leadership and governance. It would require more resource and the importance was acknowledged of circulating the agreed principles more widely amongst relevant networks. Progress would be fed through formal governance and the proposal would be discussed by the Strategic Operational Group. Action: CRG members RECEIVED, DISCUSSED and COMMENTED on the Workload Transfers discussion paper and agreed to receive a progress report in three months.

22. CCG Clinical Lead sign off for PRISM pathways The PRISM operational group sought guidance as to how to identify and expedite sign off from those leading for CBT, Psychodynamic Therapy and Asperger’s (ASD). That would allow those clinical referral pathways to be published (subject to CSO sign off) for the benefit of LLR GP practices and its patient population. Action: CRG members RECEIVED the CCG Clinical Lead sign off for PRISM pathways and: AGREED to send an updated clinical leads list through to HIS. CONFIRMED it was the responsibility of the relevant clinical leads to sign off the PRISM pathways. CONFIRMED CRG sign off could be used as an exception. 20th October CRG Meeting – Key Issues

23. Planned Care CRG members received an update on progress with planned care that included information on: • Elective Care – 52+ Week Waits • Key specialities including (Orthopaedics, General surgery, Ophthalmology, Urology,

ENT, Outpatients)

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• National Guidance on management of long waiters • Management of 40 plus weeks • Outpatients - GP Referral patterns • Phase three plans – best, worse and likely case scenarios had been worked through

to the middle of 2021 Assurance was given that arrangements were in place to support the backlogs, both in the City and County areas. Reference was made to minor surgery, joint injections etc being carried out and implications that might have for primary care. Practices were finding it difficult to receive payments for those extra procedures and a proposal for a Local Enhanced Service Model to bridge that gap was being worked up. Action: CRG members RECEIVED the presentation on Planned Care

24. Development of a Joint Collaborative Commissioning Strategy SEND, across LLR A joint commissioning strategy SEND was received that had been developed across LLR following a number of inspections undertaken by the Department of Education and Ofsted, covering the work of the three CCG’s and local authorities. The strategy identified a common vision across LLR that read ‘‘we will work together across Leicester, Leicestershire and Rutland to improve the outcomes for children and young people with SEND’’. It listed 7 priorities to address over the coming 3 years. It was anticipated that an engagement exercise would occur in December 2020 through to late January 2021 following approval by all 6 partners. Analysis of results would take place for early February with approvals sought in February/March. Launch was anticipated in April 2021 provided no significant changes in direction were needed.

Action: CRG members: SUPPORTED the draft joint SEND commissioning strategy for engagement. SUPPORTED the engagement approach and plan. Recommendation The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be ASSURED of the actions of the CRG.

M

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Rutland CCG


interest: Declarations of interest were declared and managed within the Audit Committees meetings in common. There are no specific conflicts to raise in respect of this report as it is to receive for information.


Not applicable in relation to this report, however the three LLR CCGs Governing Body Assurance Frameworks were an agenda item at the meeting.


None identified.


None identified.


Not applicable.


Not applicable in relation to this report.



Paper: M Public Confidential

Report title:

Summary report from the Audit Committee meetings in common (September 2020)

Presented by: Warwick Kendrick, Independent Lay Member, ELR CCG Audit Committee Chair

Report author: Daljit K. Bains, Head of Corporate Governance

Executive lead: Nicci Briggs, Executive Director of Finance, Contracts and Corporate Governance


Executive summary: This report provides a summary of the key areas of discussion and outcomes from the LLR CCGs Audit Committees meetings in common held in September 2020. The report also covers items for escalation and consideration by the Governing Bodies ensuring that they are alerted to emerging risks or issues.

Appendices: None

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE the report.


Not applicable

2

SUMMARY REPORT FROM THE AUDIT COMMITTEE MEETINGS IN COMMON 10 November 2020

Introduction 1. This report provides a summary of the key areas of discussion and outcomes from the

LLR CCGs’ Audit Committee meetings held in common in September 2020. The report also covers items for escalation and consideration by the Governing Bodies ensuring that they are alerted to emerging risks or issues. The following provides a short summary of the key areas of discussion.

2. Grant Thornton (External Auditors) – the external auditors presented the respective CCG updates noting that the 2020/21 audit reviews are likely to commence in November 2020 and looking ahead the audit plan will be presented in January 2021.

3. 360 Assurance Internal Audit Progress Reports – the Internal Auditors provided the

Audit Committees with an update on the internal audit planned audit reviews for 2020/21 noting the reduced number of days planned for the work. It was noted that a number of the audits will be completed in the latter half of the year given the current focus on the pandemic and recognising it will be a challenging time for both staff across the CCGs and the auditors.

4. Follow-up of internal audit recommendations (management report) – the Committee

received an updated position of internal audit actions that are outstanding across the LLR CCGs, and also received assurance that work was progressing well to ensure completion of outstanding actions.

5. LLR CCGs’ Board Assurance Framework (BAF) 2020/21 – a progress update was

noted in respect of the LLR CCGs’ BAF and in addition the Committee were informed that work was underway to develop directorate level risk registers that mirror the new directorate structures.

6. Losses and special payments 2020/21 – details of losses and special payments were noted.

7. Detailed financial policies waiver register 2020/21 - details of financial policy waivers were noted (where applicable).

8. Under a confidential matter the Committee noted the work in progress to further

strengthen the conflicts of interest arrangements and contracting arrangements. An update against the action plan was presented providing assurance to the Committees that actions had been implemented to strengthen internal processes.

N

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Implications

a) Conflicts of interest:

Declarations of interest were declared and managed within the Primary Care Commissioning Committee meetings in common. There are no specific conflicts to raise in respect of this report as it is to receive for information.


Aligned to risks detailed on respective Board Assurance Frameworks and operational level risk registers.


none


none

e) Patient and public

none



Paper: N Public Confidential

Report title:

Summary report from the LLR CCGs Primary Care Commissioning Committee (PCCC) meetings held in common on 6 October 2020

Presented by: Nick Carter, Independent Lay Member, LC CCG

Report author: Mandeep Thandi, Corporate Affairs Project Officer, ELR CCG

Executive lead(s): Nicci Briggs, Executive Director of Finance, Contracting and Corporate Governance Rachna Vyas, Executive Director of Integration and Transformation

Action required: Receive for information only:

Progress update:


Executive summary: This report provides a summary of the key areas of discussion and outcomes from the LLR CCGs’ Primary Care Commissioning Committee meetings held in common on 6 October 2020. The report also covers any items for escalation and consideration by the Governing Bodies ensuring that the Governing Bodies are alerted to emerging risks or issues.

Appendices: None

Recommendations:

The LLR CCGs’ Governing Bodies are asked to:

RECEIVE the report.


n/a

2

involvement


Not reviewed in relation to this summary report as individual reports presented to the PCCCs would have considered and taken due regards to the Public Sector Equality Duty as required.

3

Summary Report from the LLR CCGs’ Primary Care Commissioning

Committee (PCCC) meetings held in common on 6 October 2020

1. This report provides a summary of the key areas of discussion and outcomes from the LLR CCGs’ Primary Care Commissioning Committee meetings held in common on 6 October 2020. The report also covers any items for escalation and consideration by the Governing Bodies ensuring that the Governing Bodies are alerted to emerging risks or issues.

2. The following provides a short summary of the key areas of discussion, and minutes from the meeting are available upon request.

3. Finance update including Primary Care Funding streams review - The Committee

received an updated summary and forecast of the spend on Covid.

4. Primary Care Estates Strategy – an update on the development of the Primary Care estate strategy and implementation plan were presented. It has been a number of years since the last detailed primary care estate review took place and in line with the LLR Primary care strategy published in July 2019, an estates review and plan is considered key to supporting primary care and Primary Care Networks (PCNs) in the development of a commissioning strategy. A surveyor has been commissioned to deliver the baseline analysis and report. Committee members were provided with assurance that all void spaces in practices will be reviewed.

5. General Practice Quality – High level report - It was noted that there are currently 13 practices receiving enhanced support and monitoring by the CCG. Fifty-six GP practices have received a CQC inspection, with 85.6% being rated as outstanding or good overall. It was noted that there are 8 practices receiving enhanced monitoring and/or support. The main issues within the eight practices relate to patient experience, service delivery, CQC inspections, contractual and specific staffing challenges. An action plan has been implemented in order to support the practices.

6. Dr R Kapur and Partner – Brandon Surgery: Additional Premises Request – the Committee approved the Practice’s request to have two additional rooms on the same floor in order to meet high patient demands.

7. GP Survey – Patient Experience Scores (PES) 2020 – A report was presented

regarding the recent PES scores (August 2020) that were published following the national GP PES national survey which was carried out at the start of 2020. It was noted that a detailed analysis of the 2020 PES scores will be conducted across LLR in order to identify trends, areas of best practise and undertake a triangulation exercise. Once the plan is developed, a further report will be presented to PCCC.

8. Leicester, Leicester and Rutland hot hub service - The latest position on the development of the hot hub service across LLR was presented. There has been positive engagement from PCN leads and clinical staff and a total of 9 applications have been received. With the exception of one PCN, all PCNs will be mobilising the hot hub service on 19 October 2020. It was noted that the existing contract with DHU to deliver the hot hub service will remain for weekends only.

9. Christmas and New Year 2020/21 cover arrangements for practices within LLR

CCGs – the Committees approves the proposal for practices to close at 16:00 – 18:30 on Christmas Eve and New Year’s Eve and sub contract to DHU.

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10. International GP Programme in LLR - The programme was paused during Covid, and has subsequently been closed. In total, 13 International GPs were recruited across LLR. It was noted that an exit strategy for the LLR IGP programme management involvement is being compiled.

11. Training Hub update – an update on the training hub was provided noting that the Training Hub now brings together all three local training hubs under one banner.

12. Primary Care Cell update – It was noted that from the onset, March 2020, of the Covid-

19 pandemic, LLR CCGs established a Clinically Led Primary Care Cell, with representation from Board GPs and PCN Clinical Directors. The Committee applauded the positive collaboration between the various organisations involved in the primary care cell.

13. The work within the Primary Care Cell has included:

Supporting transition to a new model for primary care including new services such as hot hubs, and shielding, practice and PCN workforce risk assessment and business continuity planning.

Effective communication with general practice including daily updates and daily reporting on operational and PPE status.

Rapid mobilisation of IT solutions including distribution of hardware.

PPE solutions and financial claims process to support transformation. 14. LLR PCN Development Update – The members received an update regarding PCN

development. 15. Leicester City CCG 20/21 FDR/PMS Reinvestment – The LC CCG PCCC members

received an update regarding the CCG 2020/21 FDR/PMS reinvestment and noted that the 2019/20 FDR/PMS monies have been paid however there was a delay in the 2020/21 payments as a result of Covid-19.

Recommendations: The Leicester, Leicestershire and Rutland CCGs Governing Bodies are requested to:

RECEIVE the report.

O

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Rutland CCG

Implications a) Conflicts of interest: These are managed during the meetings and appropriate steps are

taken. b) Alignment to Board

Assurance Framework

Individual reports to the Collaborative Commissioning Committee are aligned to risks within respective CCG Board Assurance Frameworks.


None


None


None


Not undertaken in respect of this report, however would be undertaken in relation to the reports presented to the Committee.



Paper: O Public Confidential

Report title:

Summary Report from the Collaborative Commissioning Committee (joint committee) held on 17 September 2020

Presented by: Professor Mayur Lakhani, Clinical Chair, West Leicestershire CCG

Report author: Jayshree Raval, Commissioning Collaborative Support Officer

Executive lead: Sarah Prema, Executive Director, Strategy and Planning, Leicester, Leicestershire and Rutland CCGs


Executive summary: This report is from the Collaborative Commissioning Committee (CCC), which is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West Leicestershire CCG and NHS Leicester City CCG. The CCC supports joint decision making and undertakes collective strategic decisions on those areas where authority has been delegated by the respective CCG Governing Bodies.

Appendices: • N/A Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE the Summary Report from the Collaborative Commissioning

Committee held on 17 September 2020 Report history and prior review:

• N/a

2

LEICESTER LEICESTERSHIRE AND RUTLAND GOVERNING BODIES MEETING 10th November 2020

Highlight Report from the Public Collaborative Commissioning Committee (CCC) held 17 September 2020

Introduction 1. The purpose of this report is for Collaborative Commissioning Committee (CCC) to

provide the Governing Body with an update on decisions made and escalate risks and issues identified.

2. CCC is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West

Leicestershire CCG and NHS Leicester City CCG. CCC’s role is to:

• Support CCGs to create a financially sustainable health system in LLR, working beyond organisational boundaries to make best use of the public purse;

• Provide a forum where commissioners can agree and align priorities and identify opportunities for further collaboration and consistency.

3. The CCC meeting held on 17 September 2020 considered the following items on the

public agenda.

4. Mental Health Support Teams (NHSTs) in School Programme: The committee were informed that the Mental Health Support Teams in Schools (MHST) initiative is part of the government’s commitment to Transform Children and Young People’s (CYP) Mental Health Provision, and is part of the NHS Long Term Plan.

5. It was highlighted that this was a follow up report from the July 2020 meeting which

presented an update on the progress made and the proposed governance structure for programme delivery. It was reported that a Project Management Plan for the mobilisation of LLR’s wave 3 MHSTs was submitted mid-September 2020 which built in collaboration with LPT, Relate Leicestershire and commissioning leads from LLR’s CCGs.

6. It was reported that project planning including the agreement of key roles in project

planning, development, mobilisation and continuity have been agreed between partners and the CCGs over a series of local meetings. NHS England and NHS Improvement (NHSE/I) have been kept up to date with progress, issues and mitigations as part of CYP and Mental Health monthly check-in meetings. NHSE/I are supportive of the system’s approach to lead provider and provider collaborations. CCC members received the report and noted the progress update since the presentation of the report in July 2020.

Leicester Leicestershire and Rutland CCGs’ Governing Bodies are requested to:

• RECEIVE the report from the Collaborative Commissioning Committee.

P

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Rutland CCG

Implications a) Conflicts of interest: These are managed during the meetings and appropriate steps are

taken. b) Alignment to Board

Assurance Framework

Individual reports to the Commissioning Committee are aligned to risks within respective CCG Board Assurance Frameworks.


None


None


None


Not undertaken in respect of this report, however would be undertaken in relation to the reports presented to the Committee.



Paper: P Public Confidential

Report title:

Summary Report from the Commissioning Committee (joint committee) held on 15 October 2020

Presented by: Ms Fiona Barber, Independent Lay Member, East Leicestershire and Rutland CCG


Executive lead: Sarah Prema, Executive Director, Strategy and Planning, Leicester, Leicestershire and Rutland CCGs


Executive summary: This report is from the Commissioning Committee (CC), which is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West Leicestershire CCG and NHS Leicester City CCG. The Committee supports joint decision making and undertakes collective strategic decisions on those areas where authority has been delegated by the respective CCG Governing Bodies.

Appendices: • N/A Recommendations:

The LLR CCGs’ Governing Bodies are asked to: • RECEIVE the Summary Report from the Commissioning Committee held

on 15 October 2020 Report history and prior review:

• N/a

2


Highlight Report from the Public Commissioning Committee (CC) held 15 October 2020

Introduction 1. The purpose of this report is for Commissioning Committee (CC) to provide the

Governing Body with an update on decisions made and escalate risks and issues identified.

2. CC is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West

Leicestershire CCG and NHS Leicester City CCG. The committee’s role is to:

• Support CCGs to create a financially sustainable health system in LLR, working beyond organisational boundaries to make best use of the public purse;

• Provide a forum where commissioners can agree and align priorities and identify opportunities for further collaboration and consistency.

3. The Commissioning Committee meeting held on 15 October 2020 considered the

following items on the public agenda.

4. Veteran Referral Report: The purpose of this report was to provide update on the various programmes and the timelines for implementation in terms of ensuring that the LLR veteran population have access to priority healthcare for conditions associated with their time in service. It was reported that the LLR CCGs have yet to sign the pledge and move forwards supporting the LLR practices in progressing with veteran care.

5. It was highlighted that as part of this programme, the following solutions will be taken in

2 phases. In phase 1, communications will take place with GP practices to increase the level of coding within primary care and to encourage veteran status to be included as an additional comment on referral letters. In phase 2 which is a long terms approach is to review each PRISM pathways to include this information at the time of referral if this is applicable. It was reported that there are approximately 288 PRISM pathways which is a huge undertaking but would ensure that this key information forms part of the referral. In addition this would also be applied to any new pathway built and also those coming up for renewal. Committee members welcomed and received the report.

6. Mental Health Act Assessment Digital Support (S12 Solutions): It was reported that

there is a national plan to digitalise other parts of Mental Health Act (MHA) in order to improve the MHA assessment team process to get better patient outcomes and at the same time reduce system pressure through more efficient ways of working. It was highlighted that funding will be provided by NHS England and NHS Improvement for the 1st year to implement the changes.

7. The committee members were informed that the S12 Solutions is a MHA assessment

management App and the website has been designed by a practising AMHP, to replace current manual processes and paper claim forms and it was therefore proposed to approve the purchase and implementation of the S12 Solutions App. The members supported the App to streamline the process, however queried if there are any hidden costs associated with the App. The committee members approved the purchase of the

3

App subject to providing assurances that there would be no hidden costs associated with App as this could potentially impact financially.

8. Pathway 3 - extension to the contract: It was reported that the Pathway 3 contract

went live from the 1st July 2018. It is a 3 year contract with a 2 year extension option. The committee members were informed that the provider has performed well since the start of the service in July 2018 achieving positive outcomes for patients and there have been no reported quality issues or concerns with the service. The recommendation to the committee was to approve a 2 year extension to ensure the continuity of service in supporting discharges and flow in secondary care is maintained.

9. The committee members noted that there was an imbalance of the referrals between the

providers and asked what actions were being undertaken. The members were assured that work is already underway in relation to looking at the referral pathway to ensure referral criteria are being adhered to and patients are referred via the appropriate pathways. With that committee members approved the recommendation to extend the contract for the Langdale Care Home for 2years.

Leicester Leicestershire and Rutland CCGs’ Governing Bodies are requested to:

• RECEIVE the report from the Commissioning Committee.

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Implications


None identified for the purposes of the assurance report. Any conflicts arising in respect of IGQC items were manged as per LLR COI Policy.




None identified.

d) Quality and patient safety

The report provides the Governing Body with a summary of the actions of the IGQC, a subcommittee of the Governing Board with delegated authority to



Paper: Q Public Confidential

Report title:

Integrated Governance and Quality Committee Highlight Report

Presented by: Nick Carter, Independent Lay Member, LCCCG

Report author: Stuart Fletcher, Head of Corporate Governance, WLCCG Michele Morton, Senior Committee Clerk

Executive lead: Caroline Trevithick, Executive Director, Nursing, Quality and Performance, LLR CCGs


Progress update:


Executive summary: This highlight report provides a summary the key issues discussed by the IGQC when it met on 7th July, 4th August and 1st September 2020. The IGQC has delegated authority to monitor quality and performance within provider organisations and to provide assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust. Further to this the report will provide assurance that when risks or challenges have been identified within provider organisations that the CCG has taken appropriate actions to confirm effective oversight and to ensure that patients are protected from harm.

Appendices: None.

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be ASSURED of the actions of the IGQC in respect to monitoring quality and performance and providing assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust across the LLR.


IGCQ meetings are held monthly.

2

implications monitor quality and performance within provider organisations and to provide assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust. Further to this the report will provide assurance that when risks or challenges have been identified within provider organisations that the CCG has taken appropriate actions to confirm effective oversight and to ensure that patients are protected from harm.


None identified


None identified

3

LEICESTER CITY, WEST LEICESTERSHIRE AND EAST LEICESTERSHIRE AND

RUTLAND CLINICAL COMMISSIONING GROUPS

Integrated Governance and Quality Committee – Highlight report

7th July, 4th August and 1st September 2020

1. Introduction

This highlight report provides a summary the key issues discussed by the IGQC, a subcommittee of the Governing Board with delegated authority to monitor quality and performance within provider organisations and to provide assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust. Further to this the report will provide assurance that when risks or challenges have been identified within provider organisations that the CCG has taken appropriate actions to confirm effective oversight and to ensure that patients are protected from harm.

2. Scope

This highlight report covers key issues that were discussed at the IGQC when it met by MSTeams on 7th July, 4th August and 1st September 2020. 7th July IGQC Meeting – Key Issues

3. Quality Report for Commissioned Services – Exception Report

A report provided the IGQC with a summary of provider quality by exception across the provider contracts through the system and offered assurance in relation to the oversight and ongoing monitoring with providers to support risk reduction and ongoing quality improvements. Information was received on:

Harm reviews.

Virtual clinical quality review meetings continued with UHL, LPT and smaller providers

Positive discussions had taken place with providers on how they were dealing with staff health and wellbeing, notably in the context of a potential second Covid-19 surge and also the approach of Winter pressures. Information had been shared on what action UHL were taking to promote health and wellbeing for all staff as part of their regular staff bulletins.

UHL had been involved in some of the drugs being trialled as part of the management of Covid-19 (recording the highest number of people on some of the trials).

LPT had published their annual quality accounts.

Work continued with care homes, particularly with regard to IPC training. As at 7th July 2020 184 care homes had received training. In light of the recent Leicester outbreak, homes that had previously declined the offer of training had been asked to reconsider and consequently taken up the offer. A move had recently been made to approach care agencies in respect of raising infection control awareness.

Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee: • RECEIVED the exception report

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4. Patient Safety Covid-19 – Update The IGQC was presented with a position statement of LLR CCGs’ against the Covid-19 update and the work undertaken with provider organisations across the system to offer assurance to maintain patient safety. The NHS National Patient Safety Team had issued a Patient Safety Covid-19 update of key information for all providers and CCGs during the unprecedented times. Key points of note were:

The information was a snapshot of the position at the beginning of June 2020.

Many processes were beginning to be reinstated and staff that had been deployed to work on Covid-19 were beginning to return to their substantive roles.

Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee: • RECEIVED the Patient Safety Covid-19 Update

5. Serious Incident Policy The Serious Incident Policy that had been updated in line with the LLR CCGs review processes was received. The policy provided structured guidance for staff to follow should they have a Serious Incident to report. IGQC members noted it had been anticipated that the proposed Patient Safety Framework and accompanying systems would have been released by NHS National Patient Safety Team and changes incorporated into the policy. The publication of the Patient Safety Framework had however been delayed until 2021 due to the Covid-19 pandemic. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee: • APPROVED the Serious Incident Policy 4th August IGQC Meeting – Key Issues

6. Integrated Patient Experience and Engagement A presentation was given that focused on an on-line survey that had taken place from 29th April – 7th June 2020, with an aim to improve the care provided during the very difficult time to ease daily pressure and improve the health and wellbeing of the people of LLR. An intention was also to shape, with people, how services would be designed and delivered in the future. User and carers were asked for their views via an online survey developed in partnership with Healthwatch Leicester and Leicestershire, and Healthwatch Rutland. Notably work continued with the voluntary and community sector colleagues (group created during Covid-19) to better engage non-digital people. Contact was made in people’s homes on a regular basis and also with local area co-ordinators together with people working at grass roots level, reaching out to older people in households to ensure they were being supported. On request a further update on positive progress was provided at the September IGQC meeting. That included working with IMT to gather national and local statistics. Also work with GPs and the Alliance to better understand experiences of digital engagement, including virtual consultations. A deep dive would be finalised in September prior to the start of further research. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee: • RECEIVED and NOTED the Integrated Patient Experience and Engagement report

5

7. Quality Report for Commissioned Services A summary was received of provider quality across the provider contracts throughout the system and it offered assurance in relation to the oversight and ongoing monitoring with providers to support risk reduction and ongoing quality improvements. The report covered provider contracts currently monitored by the three LLR CCGs. Of particular interest was:

Virtual clinical quality review meetings were being held with UHL and LPT and going very well, with good feedback from providers. They gave an opportunity to ensure quality discussions continued, particularly around patient safety.

A CPA policy review was planned and further assurance was expected on how individuals were managed who were at risk of relapse, placed out of area or at risk of placement breakdown.

IPC training had increased significantly in nursing and residential care homes Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the Quality Report for Commissioned Services

8. Patient Safety Report – Quarter 1 An update was given on patient safety that included the management of Serious Incidents and GP concerns submitted to the Patient Safety Team during Quarter 1 (Q1) of 2020/21. In particular an increase was noted in the number of delays in reporting to the CCG from LPT. A meeting with the directors was planned following a conversation with the patient safety team, to determine what actions would be taken to address the situation. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the Patient Safety Report – Quarter 1

9. Cumberlege Summary Report – First Do No Harm The findings and recommendations were received of a government review, ‘First Do No Harm - The Report of the Independent Medicines and Medical Devices Safety Review.’ As a result the Medicines Optimisation Team were scrutinising the safety alerts dating back to 2018 and were also looking at recommendations around the use of the yellow card system. IGQC members felt the report was a good one that required organisations to act on an individual patient level and to develop to become a better listening NHS. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the Cumberledge Summary Report – First Do No Harm

10. Pathway for Unwell Children This was an initiative being implemented nationally in the autumn 2020 and advised of changes to NHS Pathways for NHS111 and 111 Online for all unwell infants under 10 days old. The view of the CCG would be fed into the process and a small focus group would be collating and feeding through responses. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the proposed amendments to Pathway for Unwell Children and;

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AGREED to convene a small task group to form a view based on clinical views from IGQC and CRG.

11. Safeguarding Report – Quarter 1 The safeguarding report provided information on the critical messages, emerging safeguarding themes and the implementation of local and national safeguarding issues to protect vulnerable people. Two items of note were highlighted; current capacity in the safeguarding team and implementation of the child protection information sharing project and reliance on NHS Digital. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED and NOTED the report and critical messages.

ENDORSED the arrangement for the next steps in the items described in the paper.

12. Domestic Abuse Commission/LLR CCGs’ engagement in local DA A report received explained that the Domestic Abuse Commissioner’s Office for England and Wales commissioned a mapping exercise that concluded in May 2020. It included information about the extent to which CCGs across England and Wales influenced the commissioning of domestic abuse services. LLR CCGs had contributed to that mapping exercise. The findings of the mapping exercise highlighted similarities in the representation and engagement of the LLR CCGs in influencing the commissioning of DA services which was in alignment with CCGs nationally. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED and NOTED the findings of the report. 1st September Meeting – Key issues

13. Research and Development Annual Report

A first annual report on R&D to the three CCGs covering the year 2019/20 was received. The data reported was determined by the Quarter 4 research recruitment reports of the East Midlands Clinical Research Network (CRN). (01.04.2019 to 31.03.2020). IGQC colleagues highly commended the report and said there were many positives that reflected well on LLR from a regional perspective. In particular they were impressed with the level and quality of the LLR Data for some of the Research projects. Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the report on the progress of R&D as assurance that the CCGs were fulfilling their responsibilities for research.

14. Perinatal Mortality Report

IGQC members were informed of a UHL Perinatal Mortality Review held. Observations had been made across both sites (Leicester General Hospital and Leicester Royal Infirmary). The Trust would be reporting back to the LMNS Board on the findings and reports would continue to provide oversight to the IGQC regarding the matter. With regard to the BAME community the IGQC asked that an equality impact assessment took place to ensure all staff were trained in equality and diversity and that there had been no unconscious bias that might have contributed to some situations.

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Recommendation: The LLR CCGs’ Integrated Governance and Quality Committee:

RECEIVED the report.

NOTED the contents of the report and the measures put in place by the Trust in relation to investigation and reporting of findings to the Trust internal committees and to the LLR LMNS Board.

NOTED that LLR LMNS would continue to provide oversight to the IGQC regarding this matter.

15. Quality Report for Commissioned Services

Key highlights from the 1st September meeting were:

UHL snap audit on stroke care – IGQC members stressed the importance of continuing to strive towards 100% achievement of targets, particularly stroke and Fractured Neck of Femur care, and agreed a system approach needed to be adopted.

One Never event had occurred that resulted in no patient harm, however a review was being carried out.

Freedom to speak up (quarter 4 and 1 data). A very positive report that demonstrated how UHL was listening to and acting upon concerns raised through a number of mechanisms

LPT – a virtual CQC visit was undertaken and the final report was awaited.

Mental Health rehabilitation and work being carried out in conjunction with Nottingham Healthcare. This showed how service users are being supported to access activities to support their mental health rehabilitation. Future reports will contain soundbites giving service users’ feedback and response to the rehabilitation activities they have received.

Virtual Clinical Quality Review Group meetings had been held with DHU and EMAS.

TASL continued to provide timely support to patients discharged at UHL.

Care Homes – some concerns had been raised with regard to quality monitoring. IGQC members noted local authority officers were in regular contact with care homes throughout Covid-19 and quality visits would depend on which homes were allowing people to physically visit.


RECEIVED the Quality Report for Commissioned Services

16. Personalisation – a number of issues were considered:

IGQC members approved the Hosted Commissioner Standard Operating Procedure that outlined the national Host Commissioner Guidance and LLR CCGs implementation of it. The Host Commissioner Guidance relates to people with a Learning Disability (LD), Autism Spectrum Condition (ASC) or both who are inpatients within a specialist mental health unit.

Proposal for the use of Personalised Care funding for an online Mental Health offer - and the requirement to use some of the additional personalised commissioning project money to increase the on-line offering for mental health support as we move into the recovery phase of Covid. The proposal was supported and IGQC members were reassured that implementation of the offer would not create inequalities amongst different groups of people.

LLR CCG commissioning stance for Lycra Garments and the need for an LLR CCG consistent approach that Lycra Garments will not be routinely commissioned. This was approved subject to the production of a robust implementation and communication plan to ensure a sensitive transition.

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RECEIVED and COMMENTED on the proposals outlined in the report

NOTED that a separate recommendation to approve the use of funding would be made to the Clinical Commissioning Committee

17. A number of annual reports and business plans were received at the August and

September meeting as follows

Looked After Children (LAC) – Annual Report

Leicester City Local Safeguarding Children’s Partnership Annual Report

Leicester Safeguarding Adults Board (LSAB) Annual report 2019/20

LLR Strategic Plan and Individual Board Business Plans – this high-level statement of vision and priorities over the next five years was approved.

Research and Development Annual Report.


RECEIVED the above reports for information.

18. Recommendation The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be

ASSURED of the actions of the IGQC in respect to monitoring quality and performance and providing assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust across the LLR.

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Implications


None identified for the purposes of the assurance report. Any conflicts arising in respect of Q&P items were managed as per LLR COI Policy.



c) Resource and financial

None identified.



Paper: R Public Confidential

Report title:

LLR CCGs Quality and Performance (Q&P) Committee Highlight Report

Presented by: Wendy Kerr, Independent Lay Member, WLCCCG

Report author: Michele Morton, Senior Committee Clerk

Executive lead: Caroline Trevithick, Executive Director, Nursing, Quality and Performance, LLR CCGs


Progress update:


Executive summary: This highlight report provides a summary of the key issues discussed by the Q&P Committee when it met on Tuesday 6th October 2020 for the first time. The Q&P has been established as a joint committee of NHS Leicester City Clinical Commissioning Group, NHS East Leicestershire and Rutland Clinical Commissioning Group, and NHS West Leicestershire Clinical Commissioning Group, collectively referred to as the Leicester, Leicestershire and Rutland Clinical Commissioning Groups (“LLR CCGs”). The Q&P Committee will support joint decision-making on those matters delegated to it where the Governing Bodies of the CCGs have agreed to undertake collective strategic decision making. The Scheme of Reservation and Delegation sets out those areas where authority has been delegated to the Q&P Committee by the three CCGs.

Appendices: None.

Recommendations:

The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be ASSURED of the actions of the Q&P in respect to monitoring quality and performance and providing assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust across the LLR.


Q&P meetings are held monthly.

2

implications


The report provides the Governing Body with a summary of the actions of the Q&P, a subcommittee of the Governing Board with delegated authority to monitor quality and performance within provider organisations and to provide assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust. Further to this the report will provide assurance that when risks or challenges have been identified within provider organisations that the CCG has taken appropriate actions to confirm effective oversight and to ensure that patients are protected from harm.


None identified


None identified

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LEICESTER CITY, WEST LEICESTERSHIRE AND EAST LEICESTERSHIRE AND

RUTLAND CLINICAL COMMISSIONING GROUPS

LLR CCGs Q&P Committee – Highlight report

6th October 2020

1. Introduction

This highlight report provides a summary the key issues discussed by the Q&P, a subcommittee of the Governing Board with delegated authority to monitor quality and performance within provider organisations and to provide assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust. Further to this the report will provide assurance that when risks or challenges have been identified within provider organisations that the CCG has taken appropriate actions to confirm effective oversight and to ensure that patients are protected from harm.

2. Scope

This highlight report covers key issues that were discussed at the Q&P when it met for the first time by MSTeams on 6th October 2020. Key Issues from the 6th October meeting

3. Q&P Committee Terms of Reference and Work Programme

The terms of reference were received that included the work programme to the newly formed Q&P. This was following the strengthening of the collaborative governance arrangements which were approved by the LLR CCGs’ Governing Bodies in September 2020. The work programme would be updated further to incorporate the details for the lead officers in the next few weeks. The terms of reference and the work programme were presented for information and would be reviewed at agreed intervals by the Corporate Governance Team, in conjunction with the Executive Director of Nursing, Q&P (the Executive lead for the Committee) and the Committee members. Recommendation: The LLR CCGs’ Q&P Committee:

RECEIVED the terms of reference and work programme.

4. Performance Improvement Report

A performance improvement report was received that included levels of current performance across a number of nationally defined metrics. The paper also reported on the latest available LLR position for each metric contained within the NHS Oversight Framework 2019/20 and provided localised actions for those indicators RAG-rated as red. It also covered performance on Cancer and Mental Health (MH) metrics that were not contained within the Oversight Framework, but that the committee should be sighted on. Of particular note: Positive Improvements:

a small increase in the percentage of patients being treated within 18 weeks of referral in August.

a small improvement in the % of diagnostic tests being carried out within 6 weeks at the end of August.

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a reduction in the number LD Inpatients since Q1 (53 adults at the end of June 20, 46 at the end of Sept 20), however that still remained over agreed target of 40 at the end of September.

Decline in recent performance:

a reduction in patients being diagnosed with Dementia through primary care in August (NHSE/I had acknowledged that nationally).

an increase in the overall number of patients waiting for elective treatment at the end of August.

an increase in number of patients waiting for treatment longer than 52 weeks at the end of August.

a decline in September performance for 4hr A&E waits at UHL, compared to August, back to levels last seen in February 20.

Recommendation: The LLR CCGs’ Q&P Committee: RECEIVED the CCG Performance Assurance Report DISCUSSED other areas of interest for future reports and how future reporting could

be provided to the Q&P Committee. DISCUSSED areas of concern and where further dialogue was required with system

Design Groups around performance improvement.

5. Quality Report for Commissioned Services report

A report was received that provided the Q&P Committee with a summary of provider quality for the provider contracts across the system and offered assurance in relation to the oversight and ongoing monitoring to support risk reduction and ongoing quality improvements. A lengthy discussion took place on the types and levels of issues that should be considered at the new Q&P. Comments would be collated by senior nursing officers that would help to shape future reports. Recommendation: The LLR CCGs’ Q&P Committee:

RECEIVED and ACCEPTED the report

DISCUSSED areas and levels (documented above) of reporting for consideration in the future.

6. Patient Safety Specialists

An outline was given on the requirements and purpose of Patient Safety Specialists, the key requirements of the role, and the NHS England and NHS Improvement National Patient Safety Team’s expectations of how they would work in their own organisations, as well as working with local, regional and national partners. The initiative was positive and individual contacts allowed for regional and national teams to disseminate learning and training facilities. Q&P members noted the NHS intention to focus on patient safety and that the LLR patient safety team was working collaboratively with a number of other teams and providers, with an ambition to be a part of design and delivery groups. National teams had already begun to send out key messages from their conversations and discussions and that would accelerate over the coming weeks. Recommendation: The LLR CCGs’ Q&P Committee:

RECEIVED and noted the content of the report for information.

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7. UHL Notification of Increase in number of women presenting with Concealed

/Denied Pregnancy

UHL Midwifery had advised that there appeared to be a significant increase in concealed/denied pregnancies between July and August 2020. The situation was being closely monitored by UHL. Work had commenced to understand whether lack of access to services during Covid-19 was a contributory factor in the women not accessing maternity services during pregnancy. Q&P members commended the report and the deep dive into certain cases. They felt at the start of Covid-19 some services such as contraception services might have been stopped and they queried whether that could have had an impact on pregnancies. The group said it would be important to avoid more cases over the next six months and ensuring appropriate access in future would be very important. Within that context a further report was requested with a focus on access to services. Recommendation: The LLR CCGs’ Q&P Committee:

NOTED the work undertaken and next steps and advised on any additional work required by the Q&P Committee.

8. Infection Prevention and Control Report

An Infection Prevention and Control Report was received that provided a summary of LLR Infection Prevention and Control Teams activity for 2019/2020. It included the overall number of cases of Healthcare Associated Infections (HCAI) across LLR CCGs. Updates were provided on:

HCAI

Covid-19

TB

Sepsis

Quality

Primary Care

A discussion was held on reporting methods and routes for Covid-19 outbreaks which resulted in a request for a high level Covid-19 summary as part of the quarterly Infection Prevention and Control report to the Q&P Committee. Recommendation: The LLR CCGs’ Q&P Committee:

RECEIVED the content of the report.

9. Transforming Care Partnership

The Q&P Committee were apprised of delivery on three key performance indicators used by NHS England/Improvement to measure the Transforming Care performance. A position statement was provided on the:

Trajectory

Annual Learning Disability Healthchecks

Learning Disabilities Mortality Review (LeDeR) Programme

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Q&P Committee members noted the primary care cell had asked practices to prioritise work with people with learning disabilities but said there was considerably more work to be carried out other than the standard health checks.

Q&P felt the timeliness of annual health checks should be a priority and were informed that the primary care learning disability liaison nurses worked well with the register, owned jointly between health and local authorities. Information now included the prevalence of patients in each practice and confidence had grown. Recommendation: The LLR CCGs’ Q&P Committee:

APPROVED the action plans outlined to redress performance that included: o Weekly performance review meetings with Leaders for each of the three

performance areas to provide assurance on actions and support resolution of any issues

o CCG to share current LD Health Check performance data with practices to agree their recovery plan for any underperformance and identify support requirements to inform CCG action plan

o A deep dive into the LeDeR allocation process and oversight

10. LedeR (learning from deaths of people with a learning disability) Report

A report was received explaining that CCGs were part of a system collaborative who had a responsibility to deliver timely and transparent LeDeR reviews. CCG and Local Authority colleagues were working together to deliver both a robust LeDeR process for new reviews, but also to ensure that a backlog of 54 outstanding reviews were completed by the end of the 2020 calendar year. The Q&P noted further processes had been introduced to ensure robust tracking of each review and they acknowledged the importance of having such arrangements in place that would require manning. A progress report was requested in two months to ensure there was no experience of deterioration in performance due to funding. Recommendation: The LLR CCGs’ Q&P Committee:

RECEIVED the update on the LLR LeDeR review programme.

11. Leicestershire & Rutland Safeguarding Adults Board Annual Report 2019-20

Recommendation: The Leicestershire & Rutland Safeguarding Adults Board (LRSAB) Annual Report 2019-20 was received for information.

12. Recommendation

The LLR CCGs’ Governing Bodies are asked to: RECEIVE the report and be ASSURED of the actions of the Q&P in respect to monitoring quality and performance and providing assurance to the Governing Body that appropriate systems for ensuring patient safety and clinical quality are robust across the LLR.

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Implications


These would be managed during the meeting and appropriate actions would be taken to mitigate conflicts should there be conflicts at any point during the meeting.


Individual reports to the Performance, Finance and Activity Committee are aligned to risks within respective CCG Board Assurance Frameworks.


None


None


Date: 1Oth November 2020

Paper: S Public Confidential

Report title:

Summary Report from the Performance Finance and Activity Committee (PFAC) meeting held on 24 September 2020

Presented by: Warwick Kendrick, Chair, East Leicestershire and Rutland CCG


Executive lead: Caroline Trevithick, Executive Director of Nursing, Quality and Performance, Leicester, Leicestershire and Rutland CCGs


Progress update:


Executive summary: This report is from the Performance, Finance and Activity Committee (PFAC) that has been established as a joint committee of NHS Leicester City Clinical Commissioning Group, NHS East Leicestershire and Rutland Clinical Commissioning Group, and NHS West Leicestershire Clinical Commissioning Group, collectively referred to as the Leicester, Leicestershire and Rutland Clinical Commissioning Groups (“LLR CCGs”). The PFAC will support joint decision making on those matters delegated to it where the Governing Bodies of the CCGs have agreed to undertake collective strategic decision making.

Appendices: N/A

Recommendations:


RECEIVE the summary report and take assurance from the Performance, Finance and Activity Committee held on 24 September 2020.


2

implications


None


Not undertaken in respect of this report, however would be undertaken in relation to the reports presented to the group.

3


Highlight Report from the Performance Finance and Activity Committee (PFAC)

24 September 2020

Introduction 1. The purpose of this report is for the Performance Finance and Activity Committee

(PFAC) to provide assurances to the Governing Bodies on the delivery of the annual commissioning programme.

2. The Committee has oversight and seek assurance in respect of provider contract management, provider performance including performance of primary care providers through assurance reports and dashboards. Seek assurance in relation to the delivery of services provided to the CCGs through the contractual performance.

3. The Committee will have a strategic focus on seeking assurance in respect of the mandated standards and the national framework that CCGs are required to be compliant against (e.g. NHS England and Improvement Outcomes Framework). In addition, the Committee will also be responsible for ensuring delivery against the financial plans and transformational delivery plans, and where activity is not on track assurance is sought and advice offered in respect of remedial actions required.

4. The key areas of discussion and outcomes from the PFAC meeting held on 24

September 2020 are summarised below. 5. Finance Report Month 5: It was reported that the LLR CCGs are reporting a year to

date adverse expenditure variance of £6.378m against the NHS England and NHS Improvement break-even plan. It was highlighted that this was a built up of a £1.884m favourable variance against the CCGs’ COVID-19 plan, £2.245m pressure due to the NHS England and NHS Improvement allocation reduction for month 5 and £6.017m specific to COVID-19 spend.

6. It was noted that the CCGs have received additional allocations to fund COVID-19 expenditure incurred up to month 4. In addition this is also to offset the reported overspends in relation to the NHS England and NHS Improvement budget alignment exercise and any operational variances. PFAC members were informed that this amount included £1.8m funding for West Leicestershire CCG which was excluded from the month 3 retrospective adjustments.

7. Furthermore it was reported that the revised financial regime for months 7 to 12 have recently been issued with national guidance and allocations which is currently under review in terms of identifying what implications could potentially be encountered. In addition a draft allocation has been assumed within the returns to NHS England and NHS Improvement to cover the reported £6.378m overspend, allowing a breakeven forecast to be declared at this point. NHS England and NHS Improvement will be reviewing the CCG’s expenditure prior to confirming the additional allocation top-up funding.

8. LLR Programme Management Office (PMO) Efficiency Report 2020/21: It was

reported that at month 4 LLR CCGs were forecasting delivery of 16.5m however at month 5 the forecast has deteriorated slightly to £14.6m. The main areas of movement are Out of Area, the Independent Sector activity reductions and Medicines Management.

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9. The monthly assurance exercise has highlighted a delivery of £13.9m QIPP savings at Month 5 of which £6.4m will not be cash releasing in 2021/21. PFAC members to note that 50% of forecast efficiencies are not cash releasing in 2020/21 however do create additional capacity. Furthermore it was highlighted that the majority of original planned schemes have submitted a workbook and at Month 5, the LLR CCGs are reporting an under delivery of £15.756m against the £30.158m plan, of which £6.7m relates to efficiencies originally unidentified.

10. It was reported that with the system entering Stage 3 of the COVID-19 recovery process, schemes are expected to resume execution in delivering efficiencies. As a result of the block contract arrangement across various services, respective schemes impacted by the contractual change are deemed to deliver cost avoidance benefits rather than be cash releasing. It was reported that there is an expectation that NHS England and NHS Improvement will require CCGs to refocus and deliver 2020/21 efficiency savings as the NHS recovers from the COVID-19 crisis. The majority of the schemes identified in the efficiency plan have submitted a completed workbook with projected trajectories for delivery. It should be noted that the capacity released by a number of these schemes, will be required to provide recovery of the waiting list positions in the short to medium term. PMO managers are continuously liaising with SROs and project leads to identify the likely impact of COVID-19 on each scheme.

11. LLR CCGs Performance Assurance Report: The September report provided LLR

CCGs position for each metric contained within NHS Oversight Framework 2019/20. Similar to last month it was reported that there is still no update from NHS England and NHS Improvement on the NHS Oversight Framework dashboard due to prioritisation of the COVID-19 response and therefore no further updates have been made to the dashboard. PFAC members noted that the performance framework continues to be monitored.

12. The report indicated key points to note and monthly changes with regards to the current

performances. It was reported that a decline in performance is noted for 4hr A&E waits in comparison to the performance in July 2020. In terms of Cancer 62-day waits, improvement have been seen in performance for all 3 CCGs however, performance remains under the national target. Performance target for the Cancer 2 weeks wait for an urgent GP referral for breast symptoms has achieved for all 3 CCGs. Under Mental Health Out of Area Placements (OOAP), the local data suggests that there are no OOAP. The CCGs are now leading on the correction of the Mental Health Service Data Sets (MHSDS) submissions with LPT as the local data differs from the national data which NHS England and NHS Improvement use for assurance on performance.

13. Under the RTT 52-week waiters it was noted that large number of breaches will have a significant impact on patient care for the foreseeable future and in turn on performance against national targets. It was reported that the Independent Sector (IS) have started to treat long waiting patients following the prioritisation of cancer and urgent patients. The Weekly Activity Management meeting has restarted with each service to support management of their waiting list.

14. LLR CCGs Contract Activity Report: The report highlighted that with the exception of

NHS 111 and the Clinical Navigation Hub, demand for all other services has reduced in response to COVID-19 pressures. It was highlighted that the providers have reviewed their service portfolios in line with NHS England and NHS Improvement guidance and are developing plans to bring back as much capacity as possible. Some services remain temporarily suspended, whilst others are being partially delivered, and/ or delivered in an

5

alternative way. Essential and urgent cancer services continue to be delivered, albeit in some cases with alternative diagnostic and treatment options. The providers are now in a recovery and restoration phase and the key activity flows are being reviewed to understand which services can restart.

15. Furthermore it was noted that all IS providers with bed capacity are working to a nationally agreed contract with payments covering their costs, made directly by NHS England and NHS Improvement. These arrangements are in place until the end of November 2020 as a minimum and a national framework arrangement for IS capacity thereafter is expected.

16. Summary of LLR Service Changes Arising out of COVID-19 Pandemic: The report

provided an update in relation to the service changes that are currently being implemented by the LLR Providers as a result of managing the COVID-19 crisis. It was highlighted that a programme of work has been set up across LLR to maintain an oversight on the changes and develop a plan of action for implementation of services as part of restoration and recovery.

17. The committee noted that the recovery and restoration dashboard is under development which will cover the key specialities. Furthermore the committee also noted that review of the services is underway for innovation and transformation and support of service delivery. Lastly the system is preparing for the 2nd surge without impacting on progress made to support recovery and restoration.

18. Phase 3 LLR System COVID Plan for Cancer: The committee received a presentation which outlined the key achievements in terms of restoration and recovery of the cancer services. It was reported that Cancer referrals are on an increase, however robust harm review processes are put in place to ensure clinical contacts are maintained with all the patients waiting. Furthermore it was highlighted that all patents are categorised against 4 priority scores to ensure that most urgently referred patients are seen first.

19. In addition all pathways are being reviewed and updated in line with the National and Society guidance which was released during COVID-19. It was reported that a review of rapid actions with all tumour sites are underway to enable further recovery. In summary it was noted that the LLR CCGs have seen an increase back to normal monthly referral levels from June 2020 however it is statistically difficult to confirm if the service has returned back to the normal levels or is it trying to catch-up on the delayed referrals due to COVID-19 crisis. The Committee members were assured that this is under review and a continuous monitoring of the referral process is ongoing.

RECOMMENDATIONS

LLR CCGs’ Governing Bodies are requested to:

RECEIVE the summary report and take assurance from the Performance, Finance and Activity Committee held on 24 September 2020.

T

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Implications


These would be managed during the meeting and appropriate actions would be taken to mitigate conflicts should there be conflicts at any point during the meeting.


Individual reports to the Finance and Activity Committee are aligned to risks within respective CCG Board Assurance Frameworks.


None


None



Paper: T Public Confidential

Report title:

Summary Report from the Finance and Activity Committee (F&A) meeting held on 29 October 2020

Presented by: Zuffar Haq, Chair of meeting, Leicester City CCG


Executive lead: Nicci Briggs, Executive Director of Finance, Contracting and Corporate Governance, Leicester, Leicestershire and Rutland CCGs


Progress update:


Executive summary: This report is from the Finance and Activity Committee (F&A) that has been established as a joint committee of NHS Leicester City Clinical Commissioning Group, NHS East Leicestershire and Rutland Clinical Commissioning Group, and NHS West Leicestershire Clinical Commissioning Group, collectively referred to as the Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs). The F&A committee will support joint decision making on those matters delegated to it where the Governing Bodies of the CCGs have agreed to undertake collective strategic decision making.

Appendices: N/A

Recommendations:


RECEIVE the summary report and take assurance from the inaugural Finance and Activity Committee held on 29 October 2020.


2

implications


None


Not undertaken in respect of this report, however would be undertaken in relation to the reports presented to the group.

3


Highlight Report from the Finance and Activity Committee (F&A)

29 October 2020

Introduction 1. The purpose of this report is for the Finance and Activity Committee (F&A) to provide

assurances to the Governing Bodies on the delivery against the financial plans and

transformational delivery plans.

2. The Committee has oversight and seek assurances in relation to income and expenditure against planned income and expenditure. Also to monitor activity against planned activity making recommendations to the CCGs’ Governing Bodies for corrective action should excess variances in activity or expenditure occurs.

3. The Committee will have a strategic focus on seeking assurance of delivery against the financial plans and efficiency / transformational delivery plans. Where activity is not on track, assurance to be sought in respect of remedial actions.

4. The key areas of discussion and outcomes from the F&A meeting held on 29 October 2020 are summarised below.

5. Finance Report Month 6: It was reported that the LLR CCGs are reporting a year to date adverse expenditure variance of £11.257m against the NHS England and NHS Improvement break-even plan. It was highlighted that this was a built up of a £3.822m adverse variance against the CCGs plan and £7.453m specific to COVID spend. It was noted that the CCG finance regime for the first 6months of the year has been predicated on the operation of block payments with the NHS providers. The committee members were informed that an LLR system plan for month 7 to 12 has been produced and submitted to NHS England and NHS Improvement. This plan has been derived from the system plan and it forms the basis of the budgets against which expenditures will be monitored for the remainder of the financial year.

6. It was noted that the main areas contributing to the £3.822m adverse variance against the CCG plan are Corporate, Primary Care Co-Commissioning and overspend of Reserves. It was highlighted that a draft additional allocation has been assumed within the returns to NHS England and NHS Improvement to cover the reported £11.275m overspend, allowing a breakeven forecast to be declared at this point. NHS England and NHS Improvement will be undertaking a robust review of the CCGs’ expenditure prior to confirming any additional allocation top-up. In addition it was noted that the CCGs have been reimbursed up to month 5 and awaiting final confirmation for month 6

7. In terms of LLR Efficiency Programme it was reported that at month 6 the Senior Responsible Officers (SROs) indicated that efficiencies of £8.66m will be achieved at year to date and forecasted £15.62m achievement by the end of the year. The areas of improvement were highlighted as the Community Services Redesign, slightly off set by a reduction in forecast within Acute Care Demand Management. The report also highlighted some of the risks that could materialise in the coming months, mainly under prescribing, CHC baseline expenditure and COVID claims.

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8. The CCGs received a running cost allocation of £9.219m for the 6 month period however there is an overall adverse variance of £1.460m which relates to redundancy provision in relation to the management of change process. This does not include any COVID expenditure as this is coded to programme infrastructure.

9. Month 7 to 12 CCGs and LLR System Financial Plan: The presentation highlighted

the CCGs position as reduced by £3.2m in order to deliver a break-even position following scrutiny by NHS England and NHS Improvement. This reduction was enabled from more accurate forecast expenditure for CHC and a small reduction of the contingency. It was highlighted that the plan is based on: a) Restoration and reset of priorities; b) Maintaining a safe response to COVID; c) Preparedness for winter d) Reducing harm through investments in key priorities

10. Furthermore it was stated that the system gap of £31.5m has reduced from the £36.9m

set out in the submission on the 5th October 2020 following the reduction in the CCG plans and revised UHL deficit. The system deficit of £31.5m is likely to make the LLR system as an outlier in comparison to other STPs in the region but is largely driven by the 52 week challenge at UHL, additional resource for restoration and opening of winter escalation capacity.

11. The key areas of risks highlighted were mainly under COVID, Independent Sector, delivery of QIPP efficiencies and hospital discharges. In terms of next steps it was highlighted that the plan is to: a) Deliver cost efficiencies which are in the plans; b) Ensure to minimise the scale of the financial deficit; c) Ensure alignment with SDF funding and guidance; d) Monitor implementation of plans and refining the financial forecasts on a monthly

basis to year end; e) Identify the recurrent impact of these plans on the 2021/22 financial year.

12. LLR CCGs Contract Activity Report: It was reported that the LLR teams are working

towards in quantifying the gaps in the current capacity in order to meet the planning requirement target. In addition to bring forward mitigations and transformation plans to maximise safe care over the remainder of the 2020/21. Furthermore it was highlighted that many of the non-acute contracts are agreed on a multi-year basis and therefore have pre-existing activity plans in place for 2020/21. These are not being re-set following the Phase 3 guidance, however systems are asked to maximise the use of out of hospital service.

13. It was noted that the impact of COVID-19 has led to high numbers of weekly breaches at UHL and it is anticipated that this will increase even more by the end of October 2020. The committee members were assured that plans to mitigate this growth are being developed jointly by system partners. It was highlighted that some of the reporting of key activity flows for all the acute contracts were suspended to allow providers to focus resources on responding to COVID pressures. These flows are being reinstated where possible and the local information shared across the LLR system was detailed in the report.

14. All Independent Sector providers with bed capacity are working to a nationally agreed contract, with payments covering their costs, made directly by NHS England and NHS Improvement. These arrangements are in place until the end of November 2020 as a minimum, and a national framework arrangement for IS capacity thereafter is expected.

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15. LLR Personalisation Team Finance and Activity Report: The purpose of this report

was to provide the committee members an update in relation to Continuing Health Care (CHC) and S117 packages of care and the compact of COVID-19. It was highlighted that due to COVID, new ways of working were developed to ensure that reviews could take place safely to provide continuity of care for the LLR patients. It was stated that in September the national framework was reinstated which meant that the Midlands and Lancashire Commissioning Support Unit (MLCSU) would receive Fast Tracks and Checklists as had happened prior to the suspension in March. The MLCSU also receive Home First referrals for patients deemed to be at the End of Life (EoL) from the acute settings to facilitate rapid discharge via a discharge 2 Assess (D2A) process funded by the health.

16. Under the S117 aftercare, it was reported that in April 2020 the Personalised Commissioning Team were given the line management responsibilities for the S117/AHP case managers and administration team. This was part of the wider reorganisation of the CCG and was designed to help align the S117/AHP team as part of the Personalised Care agenda. In terms of the costs it was highlighted that the costs of these placements are outside of the allocated budget to the Leicestershire Partnership Trust (LPT) and therefore the CCGs have a separate budget allocated for these packages of care. This direct commissioning responsibility is associated with additional clinical, financial and contractual management which is currently provided through case managers and financial and contractual staff within the S117/AHP service.

RECOMMENDATIONS

LLR CCGs’ Governing Bodies are requested to:

RECEIVE the summary report and take assurance from the Finance and Activity Committee held on 29 October 2020.