P age GOVERNING BODY AGENDA Tuesday 10 September ...

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GOVERNING BODY

AGENDA

Tuesday 10 September 2013 at 2.00 pm

Large Lecture Theatre, Moor Lane Mills, Lancaster

Item Presenter Attachments

1.0. Welcome and Introductions

2.0. Apologies for absence

3.0. Declarations of Interest Recorded Declarations of Interest can be viewed on request

4.0. Minutes of the last meeting held on 16 July 2013 A Gaw Attached

5.0. Matters Arising including Review of Action Sheet A Gaw Verbal

STRATEGY

6.0. A New Clinical Strategy for Health Services in Morecambe Bay - Better Care Together Update

A Bennett Attached

GOVERNANCE

7.0. Standards of Business Conduct K Parkinson Attached

COMMISSIONING

8.0. Prescribing Strategy R Jackson Attached

9.0. 2014/15 Contracting Timetable H Fordham/ G O’Neill

Attached

10.0. Local Enhanced Services - Review 2013 H Fordham/ L Jones

Attached

11.0. Dementia Services A Bennett Attached

IMPROVING QUALITY

12.0. Quality Improvement Update K Parkinson Attached

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PERFORMANCE

13.0. Performance Report K Parkinson/ H Fordham

Attached

FOR INFORMATION

14.0. Minutes of the Quality Improvement Committee 4 June 2013

S McGraw Attached

15.0. Minutes of the Executive Team 25 June 2013 and 9 July 2013

A Gaw Attached

ANY OTHER BUSINESS

16.0. Any Other Business (by prior agreement with the Chair)

17.0. Date and Time of Next Meeting Tuesday 19 November 2013 at 2.00 pm, Main Lecture Theatre, Moor Lane Mills, Lancaster

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MINUTES OF A MEETING OF THE GOVERNING BODY

Tuesday 16 July 2013 at 2.00 pm Large Lecture Theatre, Moor Lane Mills, Lancaster

PRESENT: Dr A Gaw Clinical Chair (Chair) Mr A Bennett Chief Officer Dr C Elley GP Executive Lead - Commissioning Dr M Flanagan Secondary Care Doctor for the Governing Body Miss H Fordham Chief Commissioning Officer Dr R Jackson GP Executive Lead - Finance Mrs L Jones Executive Lead - Practice Engagement Dr M Kingston GP Executive Lead - Practice Engagement Dr J McCarthy Registered Nurse for the Governing Body Mr K Parkinson Chief Finance Officer/Director of Governance Dr D Wrigley GP Executive Lead - Public Engagement In attendance: Mrs B Carter Corporate Affairs Manager (Minutes)

Action

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WELCOME AND INTRODUCTIONS Dr Gaw (AG) welcomed members of the Governing Body and members of the public to the second meeting of the Governing Body of Lancashire North CCG (LNCCG) to be held in public. AG explained that he and the Chief Officer had arranged to meet members of the public before the meeting to answer questions relating to items on the agenda. Questions from members of the public would not be taken during the meeting. Governing Body members introduced themselves to members of the public. It was noted that due to unforeseen circumstances the meeting would not be quorate due to the absence of both Lay Members. It had been decided to proceed as normal with the meeting and any areas requiring a decision would be deferred to a later date. APOLOGIES FOR ABSENCE Apologies for absence were received from Stephen Gross, Director of Commissioning Adult Services - LCC, Sue McGraw, Lay Member and Clive Unit, Lay Member.

Subject to approval at next meeting

Agenda Item 4.0.

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DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda. AG confirmed that formal registers of interest have been developed in line with the organisation’s constitution and are available on the CCG’s website. All members of LNCCG’s Governing Body have declared any interests that are required to be declared. The registers are maintained by Barbara Carter (BC), Corporate Affairs Manager. MINUTES OF THE LAST MEETING HELD ON 21 MAY 2013 The minutes of the last meeting of the Governing Body held on 21 May 2013 were agreed as a correct record. MATTERS ARISING INCLUDING REVIEW OF ACTION SHEET Action Sheet The action sheet was reviewed and it was noted that all outstanding items were complete. CCG Plans and Prospectus Andrew Bennett (AB) reported that the CCG’s prospectus was now complete. As required by NHS England the prospectus had been published on LNCCG’s website before the end of May 2013. A NEW CLINICAL STRATEGY FOR HEALTH SERVICES IN MORECAMBE BAY - BETTER CARE TOGETHER AB explained that the report provides a summary of the current status of the Better Care Together programme and an update on key elements. The two main projects which have been taken forward within the programme relate to the development of clinical models and pre-consultation engagement with the public and other stakeholders. These had progressed well. AB confirmed that it had been agreed that further work in respect of the “out of hospital” elements of the clinical models was still required. More focus would be put on being clearer about implications and changes. AG and AB confirmed they are attending the next Lancashire Overview and Scrutiny Committee meeting where an update will be provided on the progress and engagements carried out. AB stated that based on the work so far, senior leaders have concluded that only change on a transformational scale is likely to deliver a safe, sustainable and affordable range of services. The

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following external groups are working closely with the programme:- Health Gateway Review - second review scheduled to be carried

out 15 - 18 July 2013.

National Clinical Advisory Team (NCAT). Consultation Institute. It was announced that Paul Wood had been appointed as the new Systems Director replacing Graham Wallis. Dr Elley (CE) informed members that the second NCAT informal review had been postponed in order to complete the additional work. AB confirmed that more work was required and therefore the public consultation would be delayed. A new date for the public consultation had not yet been set. AB agreed to update members at the next meeting. RESOLVED: The current position of the Better Care Together programme was noted by members of the Governing Body. CONFIRMATION OF REVISIONS TO THE CONSTITUTION AB presented the paper and stated that the CCG was required to develop a constitution as part of its development as a statutory NHS organisation. From the 1 April 2013 CCGs wishing to make amendments to their constitution require the approval of NHS England. AB confirmed that the two proposed amendments were ratified by the Membership Council at its meeting on Wednesday 3 July 2013. The following amendments are presented to the Governing Body to be recorded in public:- Amendment 1 - Sir David Nicholson wrote to all CCGs in early May 2013 on the theme of whistleblowing in the NHS regarding the use of ‘gagging clauses’ for individuals who have raised concerns about NHS care. CCGs were asked to include a statement in their constitutions that references the right of a member or employee to raise concerns in the public interest without the written approval of the Governing Body. The following statement is proposed to be included in Section 9 - The Group as Employers:- “The Group recognises and confirms that nothing in or referred to in this constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of a protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the Group, any member of its committees or sub-committees or the committees or sub-committees of its governing body, or any employee of the group or any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act.”

AB

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Amendment 2 - AG has requested a small amendment to Section 2.5.1. (page 56 of the constitution) which refers to the arrangements to apply for the term of office, eligibility for re-appointment and notice periods for all elected and lay members of the Governing Body. The proposed amendment is intended to clarify that these arrangements are identical to those set out for the role of the Chair. The proposed amendment is as follows:- 2.5.1.Term of office, eligibility for re-appointment and notice periods for all elected and lay members of the governing body, as set out for the Chair, are also set out in paragraphs 2.4.2.d) - f). Members are asked to:- Note the proposed amendments to the CCG constitution as

ratified by the CCG Membership council.

Note that the amendments have been forwarded to NHS England for consideration and approval.

RESOLVED: The above amendments were noted by members of the Governing Body. URGENT CARE IMPROVEMENT Hilary Fordham (HF) presented the paper which outlines the pressures that are currently faced by services providing urgent and emergency care. Urgent care services have attracted a high profile nationally over recent months. HF confirmed that Dr Marriott (JM) has been leading this work with colleagues from the CCG’s main partner organisations through a local Urgent Care Network. HF outlined the operational standard of 95% for patients to be seen and discharged within four hours from A&E departments. NHS England requested recovery plans to be produced if local health communities fell below the 95% target. This applied to the services commissioned by the CCG and an improvement plan has therefore been developed by the Urgent Care Network. Performance has currently improved to 96%. The plan is focused on the following three areas:- Pre-hospital services - actions to avoid patients attending A&E

unnecessarily.

Hospital flow - improve patient flow through the hospital from the time they first attend in A&E.

Discharge/out of hospital care - ensure the process is as streamline as possible to ensure patients are discharged as soon as possible.

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The plan is being monitored through the Urgent Care Network and being measured using key performance indicators. The following examples have been implemented to improve performance and relieve pressures:- REACT are a multi-agency team based at the front of the hospital

that primarily assess patients. GPs can ring direct for an assessment without the need to admit patients. This system has proved to be very successful.

Alcohol Liaison nurses to be implemented.

GPs in A&E offering expert primary care services to patients.

Dr Kingston (MK) stated that GPs in A&E work closely with the REACT team to ensure that patients who do not need to be in hospital are sent home as soon as possible. AB enquired about the impact of the difficulties with the national 111 service. HF stated that Lancashire North had been part of a local pilot for 111 when issues arose in March. It had been possible to resolve these issues with the assistance of key local services. A further clinical review of the 111 service was now taking place across the North West. Governing Body members are asked to:- Note the national requirements pertaining to A&E performance.

Note the local A&E performance position.

Note the recently developed emergency care action plan. RESOLVED: Members of the Governing Body noted the above actions. DEMENTIA SITE OPTION APPRAISAL PROCESS Kevin Parkinson (KP) updated members of the Governing Body on the dementia site option appraisal process. KP confirmed that following a public consultation, the Board of the previous organisation, NHS Lancashire, had agreed further consideration was required to determine the location of the site for the single specialist dementia in-patient facility. The eight CCGs across Lancashire are therefore working together to identify and recommend a preferred location of the site. All CCG Governing Bodies in Lancashire are being updated on the process being used to conduct this option appraisal. The outcomes of this process will come back to each CCG’s Governing Body with appropriate recommendations on a final decision. The final report will be sent to the September meeting of the Lancashire CCG Network.

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RESOLVED: Governing Body members noted the process being used for the determination of the site for in-patient services. PRESCRIBING STRATEGY AG thanked Dr Jackson (RGJ) for leading the prescribing strategy development which has a major impact on many of the patients in our area. RGJ summarised the Strategy, confirming that it seeks to support the delivery of the organisation’s strategic vision to secure safe, high quality health services within the current financial challenges facing the NHS. The four key priority areas for prescribing and medicines optimisation are:- Reduce preventable deaths and minimise the burden of disease

through the utilisation of medicines.

Minimise patient harm associated with the use of medicines.

Improve the efficiency of prescribing and reduce medicines waste.

Optimise the use of medicines. RGJ highlighted that up to 50% of medicines are not taken as intended and up to 8% of hospital admissions are due to preventable adverse effects of medicines. Concerns were raised over the increased issuing of prescriptions and it was emphasised that the CCG has to remain within budget. Over the last two years the PCT/CCG has underspent due to careful management. It was also reiterated that everyone who requires treatment receives treatment. Medicines are not rationed; patients who are high risk are put on medication to prevent further problems occurring. AB welcomed section 4. Enablers for Strategy Implementation and working with partners in the CCG. RGJ confirmed that a final draft of the Prescribing and Medicines Optimisation Strategy 2013 - 2015 had been ratified by the Membership Council at its meeting on Wednesday 3 July 2015. RESOLVED: Due to the Governing Body not being quorate, it was agreed to note the development of the CCG’s Prescribing Strategy. Formal ratification would be sought at a later date. QUALITY IMPROVEMENT UPDATE KP explained that the purpose of the report was to update members on progress against the Quality Improvement Framework since the last

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meeting as quality improvement is central to the CCG’s operation and structure. The report covers the first quarter of the year and highlights those activities which have begun during this period. Positive feedback had been received from local GPs regarding the Datix Risk Management Web reporting system with twelve out of thirteen practices using the system. The system allows early warning signs to be raised and data to be analysed. The CCG’s Quality Surveillance and Assurance Group (QSAG) have been reviewing a number of core items including the engagement and reputation tracker, serious untoward incidents, freedom of information requests, national and local survey reports. The group notifies Executives and GP leads as necessary. Further updates will be brought to the Governing Body on a regular basis. RESOLVED: Members of the Governing Body noted the progress and continue to support the approach to Quality Improvement being undertaken. CCG PERFORMANCE REPORT: MAY 2013 HF explained that the Performance Report will be presented to the Governing Body on a regular basis. The report provides an overview on the CCG’s performance at the end of May 2013 and includes a summary report, financial report, assurance framework report and a focus report. The information is continually being refined and more detailed examination of the information is undertaken on behalf of the Governing Body by the Finance and Performance Committee. As reported previously, there still remain some difficulties in accessing the range of performance information that was previously available to PCTs. This has been caused by changes in legislation in the Health and Social Care Act (2012) regarding patient confidential data (PCD). CCGs are not permitted to access PCD and actions are therefore being taken at national, regional and local levels to ensure adequate information flows can be re-established. KP informed members that it was anticipated that the CCG will achieve its overall required surplus of £1,933k by the end of the financial year. As at month 2, the CCG is reporting a £789k surplus which is made up of a programme surplus of £778k and a running costs surplus of £11k relating to current vacancies. A QIPP requirement of £4,680k in 2013/14 has been identified to achieve the financial surplus required. A £1,661k shortfall has been identified for this year and further work will be required to ensure schemes to cover the QIPP requirement are identified at an early stage.

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KP outlined the CCG’s financial risks. He explained the work which was continuing to resolve problems identified during the disaggregation and transition process from the previous PCT. AB drew attention to Annex 2 in the report which provides the Governing Body with the key performance information the CCG expects will be used to create the Assurance (assessment) Framework. NHS England will use this framework to review the CCG’s performance during 2013/14. RESOLVED: Members of the Governing Body noted the contents of the report. UPDATE ON COMMUNICATONS AND ENGAGEMENT STRATEGY Dr Wrigley (DW) updated members on the recent work and how the approach to communications and engagement is expected to develop over the next twelve to eighteen months. DW explained that focus had been on developing tools to support the CCG in listening to and involving patients and members of the wider population. DW highlighted the following specific areas in the paper:- Website - now up and running. Prospectus - there is currently a link on the website. Liaise closely with MPs and the Scrutiny Committee. Review of the Affiliate schemes. Better Care Together engagement. Lancaster Health and Wellbeing Board Partnership meetings. Maternity Liaison Committee Local Group. Communications and engagement tracker. Engagement with members of the public. Meeting with Carers Organisations. Initial meeting with colleagues from Healthwatch. Out of Hours. DW stated that the CCG is keen to engage as much as possible with local groups on key items for future development. RESOLVED: Members of the Governing Body noted the statutory requirements to engage with patients and the public, noted the CCG’s progress so far with communication and engagement and noted the proposed future action for the remainder of 2013/14. MINUTES OF THE QUALITY IMPROVEMENT COMMITTEE 30 APRIL 2013 Minutes of the Quality Improvement Committee were received for information.

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MINUTES OF THE EXECUTIVE TEAM 23 APRIL 2013, 14 MAY 2013, 28 MAY 2013 AND 11 JUNE 2013 Minutes of the Executive Committee were received for information. ANY OTHER BUSINESS There was no further business. DATE AND TIME OF NEXT MEETING Tuesday 17 September 2013 at 2.00 pm in the Large Lecture Theatre, Moor Lane Mills, Lancaster.

ACTION SHEET FROM THE GOVERNING BODY MEETING

TUESDAY 16 JULY 2013 AT 2.00 PM LARGE LECTURE THEATRE, MOOR LANE MILLS, LANCASTER

Minute Number

Action Point Action By Deadline Action/Progress Action/

Completed

64/13 A New Clinical Strategy for Health Services in Morecambe Bay - Better Care Together

A Bennett 17 September 2013

16/7/13 - Update members on the revised date for the public consultation

Agenda Item 5.0.

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AGENDA ITEM NO: 6.0

Meeting Title/Date: Governing Body - 10 September 2013

Report Title: A New Clinical Strategy for Health Services in Morecambe Bay - better care together

Paper Prepared By: Paul Wood System Director

Date of Paper: 3 September 2013

Executive Sponsor: Andrew Bennett Chief Officer

Responsible Manager:

Paul Wood System Director

Background Paper(s):

Summary of Report: This paper describes the current status of the better care together programme and provides an update on the key elements of work.

Recommendation(s): The Governing Body is asked to note the current position of the better care together programme.

Please Select Y/N

Identified Risks:

Impact Assessment: (Including Health, Equality, Diversity and Human Rights)

Strategic Objective(s) Supported by this Paper: Please Select

(X)

To Improve the health of our population and reduce inequalities in health X

To reduce premature deaths from a range of long term conditions X

To develop care closer to home X

To commission safe, sustainable and high quality Hospital Health Care X

To commission safe, sustainable and high quality Mental Health Care

To improve capacity and capability of primary care services to respond to the changing health needs of our population X

Please contact: Paul Wood, [email protected]

mailto:[email protected]

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A NEW CLINICAL STRATEGY FOR HEALTH SERVICES IN MORECAMBE BAY better care together

1. Introduction

1.1. This paper describes the current status of the better care together programme and provides an update on the key elements of work.

2. Overall Timescales of the Programme

2.1. Since the Clinical Modelling Project concluded a phase of work at the end of June 2013, the leadership teams of the three sponsoring organisations – University Hospitals of Morecambe Bay NHS Foundation Trust, and Lancashire North and Cumbria Clinical Commissioning Groups (CCGs) – have been taking stock of progress to date. They have been joined by representatives from the Local Area Teams of NHS England, and the new System Director who was appointed in mid-July. This group has also been considering feedback from the recent Gateway Review that has provided an external perspective on what additional work needs to be undertaken to help achieve the stated objectives, alongside the extensive public engagement activity around this.

2.2. Having considered all the advice and evidence, it was agreed that the original

timetable for potential consultation should now be revised. A significant range of additional work is required to examine some potential hospital service re-configuration options in a wider whole health and social care system. In addition, a range of technical feasibility work is required around a number of the proposed hospital service re-configuration options.

2.3. The new System Director, Paul Wood is in the process of reshaping and re-defining

the future work programme requirements. 3. Programme Leadership changes

3.1. In mid-July, there was a change of System Director leadership with the arrival of Paul Wood to replace Graham Wallis. Paul brings to the programme a 25 year track record of working on healthcare strategic reviews and service re-configuration/ transformation projects. His most recent experience includes assisting two other health communities (Wakefield/Kirklees and North West London Hospitals) with major service re-configuration projects.

3.2. Paul’s initial focus has been to address the immediate improvements in the

programme governance and re-design the work programme in view of the recent stocktake. In addition, a strategic leadership group including CCG Clinical Chairs and Programme Board has been recently established.

4. Clinical Modelling – Development of “out of hospital” strategic service plans

4.1. As reported to the last Meeting, at their meeting on 21 June, the better care together Clinical Strategy Steering Group received an update on the progress of the clinical modelling project which had been facilitated and project managed by external consultants (Finnamore). A workshop on “out of hospital” services was held on 26 June and a presentation of the full findings of the TNS independent research aspect of the engagement work was made to Steering Group on 10 July.

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4.2. Following these meetings it was agreed that a separate work stream would need to

be commissioned to develop CCG based locality service transformation plans around our “out of hospital” care. This work is being led by the Chief Officer of Lancashire North CCG and the Network Director of Cumbria CCG with project management and plan development support from the better care together programme team.

4.3. The initial tranche of work will take around 12-16 weeks in parallel with the technical

feasibility work required around hospital service configuration plans.

4.4. These forward looking strategic plans will build upon the existing CCGs’ “out of hospital” service commissioning work but also respond specifically to the recent The NHS belongs to the people: Call to action report. This work will also need to consider the potential impact on “out of hospital” services of the six main hospital service configurations options/scenarios and the scope for enhanced integrated service models and pathways.

4.5. These plans will then be appraised alongside the hospital service configuration in a

formal option appraisal. 5. Hospital Service Configuration option analysis

5.1. The technical assessment programme around the hospital service configuration options will comprise:

Estate facility feasibility assessment of the options and potential capital requirements Workforce re-profiling assessment of the options Patient flow impact analysis in pursuing the possible options Financial cost modelling of the options both transition and recurrent revenue cost

implications.

5.2. This work will assist with decision making around future affordability of a particular option.

6. Developing our Future A&E and unscheduled care models

6.1. Clinical engagement remains at the heart of the programme. A clinical “think tank” meeting took place on 21 August to consider the practical application of the hospital services re-configuration options and the need to focus on any particular service models/options.

6.2. This review meeting highlighted the need to re-visit and develop the future

A&E/unscheduled care model across South Cumbria and potential opportunities to improve local populations’ planned care and frail elderly pathways with the development of new service models. These opportunities would be examined in the clinical workstream groups.

6.3. It was agreed by the Clinical Reference Group to commission a specific piece of

work around potential future unscheduled service models looking at whole healthcare system workforce option availability. This work will inform the feasibility assessment of several current hospital service configuration options.

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7. Public Engagement and Communications

7.1. Following the summary presentation of the externally commissioned independent research by TNS at the 10 July Steering Group meeting, three additional reports have been prepared in relation to the engagement work to date.

7.2. The first captures all patient and public engagement activity over the last seven

months including the TNS focus groups and questionnaires, and the work done by the in-house communications and engagement team which comprised public roadshows and meetings with a wide range of stakeholder groups. This describes the key themes arising from the engagement which will be considered in detail by the clinical workstreams, and provides an important audit trail for any future consultation. This report has been broken down further into two individual reports with recommended “in hospital” actions and improvements that could take place in the short term within each of the four different clinical workstream areas, and a report with recommendations on how primary and community care could be improved for consideration by the “out of hospital” task and finish group.

7.3. These reports have been shared with the managerial leads for the programme for

initial feedback and will be taken forward by the clinical working groups when they meet in September. The communications and engagement group will also be considering these, and will monitor progress so as to prepare a range of feedback examples of how the public/ service listening has led to improvements in services. Examples of the type of improvements requested range from better communications and customer service training for staff through to the provision of reclining chairs for parents to sleep in when visiting their sick children.

8. Other engagement

8.1. Engagement has continued to take place with key stakeholders including Cumbria and Lancashire Overview and Scrutiny Committees, Cumbria and Lancashire Healthwatch, South Lakeland District Council, Planned Care focus groups and the newly formed Public Reference Group. Future engagement is being planned with Cumbria and Lancashire Health & Wellbeing Boards, Overview and Scrutiny Committees, Maternity and Paediatrics work streams, MPs, staff groups, and Local Area Partnerships.

8.2. A meeting took place with the Regional Director of Monitor on 6th August. Attended by the Clinical Chairs and Chief Officers from the 2 CCGs, the Chief Executive of the Trust and colleagues from the Lancashire and Cumbria Area Teams, this was an important opportunity to review the progress of Better Care Together and understand how Monitor will continue to work with the Trust and wider health community.

8.3. On 8 August a press release, stakeholder and staff briefing regarding the change of

timetable and scope of the programme was issued to keep key audiences appraised of progress.

8.4. The next stage of engagement activities will focus on involving the public in the “out

of hospital” work, and testing out some specific scenarios about the way that local service provision may change in the future.

8.5. The Case for Change will be further developed to incorporate the key messages

arising from the “out of hospital” and other workstreams, and will form a key part of on-going communications and engagement activity.

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9. Programme Budget for 2013/14

9.1. The System Director is putting together a programme budget which will reflect the changed status of the programme. Discussions will take place with NHS England to establish whether there is any national funding to assist with this.

10. External assurance

10.1. The programme has been working with the following bodies to obtain external assurance of the programme as it progresses

Health Gateway Review

10.1.1. The second Gateway 0 Review took place on 15-18 July 2013, with the final report being issued in early August. This highlighted areas where additional detailed work was needed before any consultation could take place.

10.1.2. The independent review of the programme activity concluded that several

areas of the programme required strengthening. These included:

Programme governance ; Programme management Work stream management Programme budget development Strategic Business Case development

10.1.3. The review team have provided the programme with eight main

recommendations to implement. The new System Director has developed an immediate action plan to address these recommendations which are currently being reviewed by the Programme Board.

10.1.4. Changes to the governance of the programme were suggested. As a result

the leadership teams of the sponsoring organisations have formed a Programme Board which meets monthly and will be responsible for driving the programme forward.

National Clinical Advisory Team

10.1.5. Following the informal NCAT visit on the 4th June 2013 the formal visit was scheduled for the 24th July 2013. This was postponed to enable all the recommendations and actions from the earlier visit to be completed. The remaining outstanding action was to request a visit from the College of Emergency Medicine [CEM], in particular Dr Taj Hassan, to evaluate the unscheduled care model, focussing on the stabilise and transfer elements. As the visit cannot be accomplished until October [due to CEM commitments] verbal advice has been obtained from the President of the College and the team is now modifying the model as a result; including working with similar health economies to refine it. A follow up NCAT visit will be arranged once this work has been completed.

Consultation Institute

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10.1.6. The programme will continue to seek advice from the Consultation Institute to ensure compliance with best practice around engagement on any changes to services and to ensure that consultation takes place as appropriate.

10.1.7. In addition to the above the programme is obtaining governance advice from

the Local Area Teams and from legal advisors as appropriate. 11. Next Steps

11.1. The programme is now being designed around the implementation of the new pieces of work to develop the evidence required to appraise and refine the options available around both hospital service configuration and “out of hospital” service programme

12. Recommendation

12.1. The Governing Body is asked to note the current position of the better care together programme.

Andrew Bennett Paul Wood Chief Officer System Director September 2013

AGENDA ITEM NO: 7.0.


Report Title: Standards of Business Conduct

Paper Prepared By: Kevin Parkinson Date of Paper: July 2013

Executive Sponsor: Kevin Parkinson Responsible Manager: Kevin Parkinson

Background Paper(s): Referenced in the report

Summary of Report:

This report seeks to describe the current public service values, which underpin the work of the NHS and to reflect current guidance and best practice to which all individuals working for or on behalf of Lancashire North CCG must have regard to in their work

Recommendation(s): To note the report being considered for approval at the Governing Body

Please Select Y/N

Identified Risks: N


N

Strategic Objective(s) Supported by this Paper: Please

Select (X)

To Improve the health of our population and reduce inequalities in health

To reduce premature deaths from a range of long term conditions

To develop care closer to home

To commission safe, sustainable and high quality Hospital Health Care

To commission safe, sustainable and high quality Mental Health Care

To improve capacity and capability of primary care services to respond to the changing health needs of our population

Please contact: Kevin Parkinson Chief Finance Officer/Director of Governance Telephone (01524) 519218

Standards of Business Conduct NHS Lancashire North Clinical Commissioning Group July 2013

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STANDARDS OF BUSINESS CONDUCT Version Version 1

Ratified By NHS Lancashire North Clinical Commissioning Group

Date Ratified

Author Kevin Parkinson Responsible Committee/ Officers Governing Body

Date Issue July 2013

Review Date December 2014

Intended Audience All Clinical Commissioning Group Staff

Impact Assessed Yes


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Further information about this document:- Document name Standards of Business Conduct

Category of Document in the Policy Schedule Corporate

Author(s) Contact(s) for further information about this document

Kevin Parkinson

This document should be read in conjunction with

Conflicts of Interest Policy Anti-Fraud and Corruption Policy

Published by NHS Lancashire North Clinical Commissioning Group

Copies of this document are available from Website: www.lancashirenorthccg.nhs.uk

Version Control: Version History

Version Number Reviewing Committee/Officer Date

1.0. NHS Lancashire North Executive Committee

NHS Lancashire North Governing Body

http://www.lancashirenorthccg.nhs.uk/


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NHS LANCASHIRE NORTH CLINICAL COMMISSIONING GROUP

STANDARDS OF BUSINESS CONDUCT PURPOSE 1. This policy seeks to describe the current public service values, which underpin the

work of the NHS and to reflect current guidance and best practice to which all individuals working for or on behalf of NHS Lancashire North Clinical Commissioning Group, referred to hereafter as the group, must have regard to in their work for the group.

2. The group aspires to the highest standards of corporate behaviour and responsibility. Individuals working for or on behalf of the group are required to comply with this policy.

3. The policy has been informed by the Standards for Members of NHS Boards and

CCG Governing Bodies in England (2012) and the Code of Conduct and Code of Accountability in the NHS (2004).

SCOPE OF THE POLICY 4. This policy applies to the following individuals who are hereafter referred to

collectively in this policy as individuals acting on behalf of the group:-

i) members of the group; ii) members of the group’s governing body; iii) members of the group’s committees or sub-committees or of the committees

or sub-committees of its governing body; iv) its employees, including seconded, temporary staff or staff working for the

group under a contract of service or in an advisory capacity. PRINCIPLES 5. All individuals acting on behalf of the group are expected to abide by the Seven

Principles of Public Life (the Nolan Principles) set out by the Committee on Standards in Public Life (copy attached).

6. They must also:- i) uphold the values of the NHS Constitution; ii) promote equality; iii) promote human rights; iv) where appropriate, follow their professional code of conduct.


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PREVENTION OF CORRUPTION 7. The group has a responsibility to ensure that individuals acting on behalf of the group

are made aware of their duties and responsibilities arising from the Bribery Act 2010. Under this Act there are four offences:-

i) bribing or offering to bribe another person (section 1); ii) requesting, agreeing to receive, or accepting a bribe (section 2); iii) bribing or offering to bribe a foreign public official; iv) failing to prevent bribery.

8. Individuals acting on behalf of the group are required to be aware of the Bribery Act

(2010) and should also refer to paragraph 21 to 51 below for further guidance in relation to this.

COUNTER FRAUD MEASURES 9. Individuals acting on behalf of the group are required not to use their position to gain

advantage. The group works to prevent fraud and encourages individuals with concerns or reasonably held suspicions about potentially fraudulent activity or practice, to report these. Individuals should inform the nominated Local Counter Fraud Service Office (LCFS) or the group’s Chief Finance Officer immediately, unless the Chief Finance Officer or the LCFS is implicated, in which case they should report directly to the Chair or the Chief Officer who will decide on the action to be taken.

10. Individuals may also call the NHS Fraud and Corruption reporting line on free phone 0800 028 40 60. All calls are dealt with by experienced trained staff and any caller, who wishes, may remain anonymous.

11. Anonymous contact from individuals or others, who wish to raise matters of concern,

but not through official channels, will be taken seriously. The LCFS will make sufficient enquiries to establish whether or not there is any foundation to the suspicion that has been raised. Individuals should not ignore their suspicions, investigate themselves or tell colleagues or others about their suspicions.

12. Refer to Lancashire North Clinical Commissioning Group Anti-Fraud and Corruption

Policy. THE GROUP’S CONSTITUTION, INCORPORATING STANDING ORDERS (SOS), STANDING FINANCIAL INSTRUCTIONS (SFIS) AND SCHEME OF DELEGATION (SOD) 13. Individuals must carry out their duties in accordance with the group’s constitution.

The constitution sets out the statutory and governance framework in which the group operations. Individuals must at all times refer to and act in accordance with the group’s constitution to ensure that current group process is followed. In the event of doubt, individuals should seek advice from their line manager or alternatively from the group’s Chief Finance Officer. In the event of any conflict arising between the details of this policy and group’s constitution, the constitution shall prevail.


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DECLARATION OF INTEREST 14. The group has approved a policy for minimising, managing and registering potential

conflicts of interest, which could be deemed or assumed to affect the decisions made by those involved with the group. These decisions could include awarding contracts, procurement, policy employment and other decisions.

15. Individuals acting on behalf of the group should not allow their judgement or integrity to be compromised when discharging their responsibilities on behalf of the group. They should be, and be seen to be, honest and objective in the exercise of their duties and should understand fully their terms of appointment, duties and responsibilities.

16. The group’s policy, on managing conflicts of interest describes the group’s

arrangements for identifying and managing conflicts of interest, including declaring interests. Adherence to the policy is mandatory.

17. Failure to adhere to the policy, particularly concerning the declaring of interests, may

constitute a criminal offence of fraud, as an individual could be gained unfair advantages or financial rewards for themselves, or a family member/friend, their practice or practice colleague, or other associate. Any suspicion that a relevant personal interest may not have been declared should be reported to the group’s Chief Finance Officer.

18. As a general principle, anyone acting on behalf of, the group who is involved in taking

decisions, or who is able to influence a decision must declare their interests to the group.

19. The group is required to maintain a register of interests to formally record the

declarations of interest made by individuals acting on behalf of the group. The declaration form should be completed by all relevant individuals. It is available from, and should be returned to the group’s Corporate Affairs Manager.

20. All declarations of interest will be reviewed by the group’s Audit Committee, at least

annually. GIFTS AND HOSPITALITY 21. As a general principle, individuals should discourage the offer of gifts. A gift is

defined as any item of cash or goods or any service which is provided for personal benefit at less than its commercial value.

22. Where gifts of a small value (less than £10) such as diaries, calendars and small tokens are made, individuals may accept them. Offers of gifts above this value should be declined. In cases of doubt, an individual should seek advice from their line manager or alternatively from the Corporate Affairs Manager.

23. Any personal gifts of cash, or cash equivalent, eg vouchers, must be declined, whatever its value.


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24. Individuals should:-

i) report immediately all offers of unreasonably generous gifts to the Corporate Affairs Manager.

ii) return promptly any unacceptable gifts, with a letter politely explaining the terms of this policy and stating that you are not allowed to accept the gift(s).

25. Individuals acting on behalf of the group should exercise discretion in accepting

offers of hospitality from contractors, other organisations or individuals concerned with the supply of goods or services.

26. Modest hospitality provided in normal and reasonable circumstances during the course of working visits may be acceptable, although it should be on a similar scale to that which the group may be able to offer in similar circumstances, eg hospitality provided at meetings, events, seminars. In cases of doubt, the individual should seek advice from their line manager or alternatively from the Chief Finance Officer.

27. All hospitality or gifts accepted, regardless of value should be recorded in the hospitality book held by the Corporate Affairs Manager as soon as is reasonably practicable. It is not necessary to record refreshments, such as tea, coffee etc, or for course participants to record meals provided during a training event or seminar.

28. Individuals should be especially cautious of accepting small items of value, or hospitality over that afforded in a normal meeting environment (eg beverages) during a procurement process or from bidders/potential bidders. This avoids any potential claim of unfair influence, collusion or canvassing.

COMMERCIAL SPONSORSHIP 29. Individuals acting on behalf of the group may accept commercial sponsorship for

courses, conferences, post/project funding, meetings and publications if they are reasonably justifiable and are in accordance with the principles set out in this policy and their professional codes of conduct. In cases of doubt, an individual should seek advice from their line manager or alternatively from the Chief Finance Officer.

30. Permission, with details of the proposed sponsorship must be obtained from the responsible director/senior manager, or the Chair in the case of the Chief Officer, in writing in advance. A copy of the permission must be retained by the Corporate Affairs Manager who will record all permissions on a register and report them to the Governing Body at least annually.

31. As a general principle, sponsored events must always be under the control of the group. Acceptance of commercial sponsorship should:-

i) not in any way compromise commissioning decisions of the group, or be

dependent on the purchase or supply of goods or services; ii) be open to scrutiny and be a matter of public record.

32. Sponsors should not have any influence over the content of an event, meeting,

seminar, publication or training event.


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33. The group should not endorse individual companies or their products. It should be made clear that the fact of sponsorship does not mean that the group endorses a company’s products or services.

34. During dealings with sponsors, there should be no breach of patient or individual confidentiality or data protection legislation.

35. No information should be supplied to a company for their commercial gain unless there is clear benefit to the group. As a general principle, information which is not in the public domain should not normally be supplied.

36. Formal meetings of the group should not be the subject of sponsorship agreements. OUTSIDE EMPLOYMENT AND PRIVATE PRACTICE 37. Individuals acting on behalf of the group (depending on the details of their contract or

arrangement with the group as regards outside employment and private practice) are required to inform their Director, or Chair in the case of the Chief Officer, if they are engaged in or wish to engage in outside employment in addition to their work with the group.

38. The purpose of this is to ensure that the group is aware of any potential conflict of interest with their work on behalf of the group. Examples of work which may conflict with the business of the group are:-

i) employment with another NHS body; ii) employment with another organisation, which might be in a position to supply

goods and services to the group; iii) self-employment, including private practice, in a capacity which might conflict

with the individual’s work with the group, or which might be in a position to supply goods and services to the group.

39. Permission to engage in outside employment/private practice will be required in

advance by the individual and the group reserves the right to refuse permission, and if necessary to terminate its arrangement with the individual, where it believes an unmanageable conflict will arise.

INITIATIVES 40. As a general principle, any financial gain resulting from external work by an individual

working on behalf of the group, where use of group time or title is involved (eg speaking at training events, conferences, writing articles etc) and or which is connected with group business should be forwarded to the Corporate Affairs Manager.

41. Any patents, designs, trademarks or copyright resulting from the work (eg research) of an individual working on behalf of the group, carried out as part of the individual’s work with the group shall be the intellectual property of the group.


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42. An individual should seek approval from their line manager, prior to entering into an obligation to undertake external work connected with the business of the group, eg writing articles for publication, speaking at conferences.

43. Where the undertaking of external work, gaining patent or copyright of the

involvement in innovative work benefits or enhances the group’s reputation or results in financial gain for the group, consideration will be given to rewarding individuals, subject to any relevant guidance of the management of intellectual property in the NHS issued by the Department of Health.

SUPPLIERS AND CONTRACTORS OF HEALTHCARE (CLINICAL) AND NON CLINICAL GOODS AND SERVICES 44. All individuals acting on behalf of the group who are in contact with suppliers and

contractors, including external consultants, and in particular are authorised to sign purchase orders or enter into contracts for goods and services are expected to adhere to professional standards in line with those set out in the Code of Ethics of the Chartered Institute of Purchasing and with national guidance on the procurement of NHS funded services.

45. Individuals must treat all prospective contractors or suppliers of services to the group equally and in a non-discriminatory way and act in a transparent manner.

46. Subject to the provisions of the group’s policy on managing conflicts of interest,

individuals involved in the awarding of contracts and tender processes must take no part in a selection process, if a personal interest or conflict of interest is known. Such an interest must be declared to the Chief Finance Officer as soon as it becomes apparent. Individuals should not at any time seek to give undue advantage to any private business in the course of their duties.

47. The group has duties under European and UK procurement law and individuals must

comply with the group’s constitution, incorporating standing financial instructions, in relation to all contract opportunities with the group.

48. Individuals working on behalf of the group must not seek or accept preferential rates

of benefits in kind for private transactions carried out with companies with which they have had, or may have, official dealings on behalf of the group.

49. Individuals should claim expenses incurred in the course of their work for the purpose

of advising on the purchase of goods or services from the group. They should not be reimbursed by the organisation providing or bidding to provide such items to the group.

50. Every invitation to tender to a prospective bidder for group business must require

each bidder to give a written undertaking not to engage in collusive tendering or other restrictive practice and not to engage in canvassing the group of individuals working on behalf of the group concerning the contract opportunity tendered.


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COMMERCIAL CONFIDENTIALITY 51. The group should guard against providing information on the operations of the group

which might provide a commercial or financial advantage to any organisation (private or NHS) in a position to supply goods and services to the group. For particularly sensitive procurements/contracts, individuals may be asked to sign a non-disclosure agreement.

MANAGEMENT ARRANGEMENTS 52. Individuals should be aware that a breach of this policy could render them liable to

prosecution as well as leading to termination of their employment, position or arrangement with the group.

53. Individuals who fail to disclose any relevant interests as required by this policy or the group’s constitution may be subject to disciplinary action which could ultimately result in the termination of their employment, position or arrangement with the group.

54. The Chief Finance Officer is responsible for ensuring that arrangements are in place

for the implementation of this policy. COMPLAINTS 55. Individuals who wish to report, suspect or known breaches of this policy should

inform the Chief Finance Officer. All such notifications will be held in strictest confidence and the person notifying the Chief Finance Officer can expect a full explanation of any decisions taken as a result of any investigation.

FURTHER INFORMATION 56. This policy in an interpretation of guidance and is based on examples of good

practices, in addition to referring to the group’s constitution. Individuals should also refer to:-

i) The Code of Conduct for NHS Managers; ii) The Nolan Principles on Conduct in Public Life; iii) The NHS Codes of Conduct and Accountability (2004); iv) The Code of Practice on Openness in the NHS; v) Standards for Members of NHS Boards and CCG Governing Bodies in

England (2012); vi) The Associate of British Pharmaceutical Industry Coe of Practice; vii) Good Medical Practice, General Medical Council; viii) Other relevant guidance that may be produced by their own professional

bodies, the Department of Health or the NHS Commissioning Board. ix) The group’s policy on managing conflicts of interest. x) The group’s Anti-Fraud and Corruption Policy.


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APPENDIX A

THE NOLAN PRINCIPLES The ‘Nolan Principles’ set out the ways in which holders of public office should behave in discharging their duties. The seven principles are:- 1. Selflessness - holders of public office should act solely in terms of the public

interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

2. Integrity - holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

3. Objectivity - in carrying out public business, including making public appointments,

awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

4. Accountability - holders of public office are accountable for their decisions and

actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

5. Openness - holders of public office should be as open as possible about all the

decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

6. Honesty - holders of public office have a duty to declare any private interests

relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

7. Leadership - holders of public office should promote and support these principles

by leadership and example. Source: The First Report of the Committee on Standards in Public Life (1995).


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APPENDIX B

DECLARATION FORM: GIFTS AND HOSPITALITY Name of Recipient: Post Held:

Date of Offer: Nature of Gift, Inducement or Hospitality:

Name and Address of Person/Organisation Making the Offer:

How Linked to Role at CCG:

Accepted/Declined (and your reasons for doing so):

Signed: ……………………………………………… Date: ………………………………………………

Comments (any additional comments felt useful to note):

Authorisation of Line Manager: Signed: ………………………….. Designation: ……………………………………….. Date: ………………………….. Authorisation of Relevant Director: Signed: ………………………….. Designation: ……………………………………….. Date: ………………………….. For Office Use: Entry in Register Yes/No: Date: By: Note: This form must be completed when gifts (other than articles of low value such as diaries or calendars) or hospitality are accepted or declined. The completed and signed form must be returned to the Corporate Affairs Manager.


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APPENDIX C

SPONSORSHIP CHECKLIST AND APPROVAL FORM (£25 - £500) Instructions for Completion:- This form should be completed for sponsorship between £25 and £500 in value

which has been offered to the CCG or its employees/members.

For all sponsorship greater than £500 a more details ‘Major Sponsorship/Partnership Working Agreement Form’ (Appendix D) should be completed and sent to the Chief Finance Officer for approval prior to accepting sponsorship.

Summary of Sponsorship Offer Name and contact details of lead CCG contact liaising with commercial company

Name of potential sponsors involved and contact details

Details of proposal including the benefit to the CCG, patients and potential benefits to the sponsor. What is the money to be spent on?

Amount of funding and time period involved

Checklist

Criteria Yes/No Does the sponsorship offer comply with the rules specified in the CCG’s policy on Standards of Business conduct?

As part of the sponsorship are all medicines or products which are promoted or otherwise mentioned in line with locally agreed prescribing advice?


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Criteria Yes/No Where sponsorship is offered to facilitate the development of guidelines and protocols (and similar) will this be carried out by the appropriate CCG working group independent of the sponsors?

Is this sponsorship in line with national and locally agreed healthcare priorities?

The senior manager is to sign this off where all answers to the above checklist are ‘yes’. Signature of Line Manager: ………………………................... Date: ………………………………...................................... Approved: Yes/No Signature: …………………………………………………………. Chief Finance Officer Date: ………………………………......................................


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APPENDIX D Page 1 of 4

MAJOR SPONSORSHIP/PARTNERSHIP WORKING AGREEMENT (> £500)

This form should be used for offers of sponsorship of greater value than £500 including multi-agency projects for which the CCG is a major participant and the CCG share of sponsorship is greater than £500. The completed form should be submitted to the Chief Finance Officer. Project Summary: 1. Recipient (include lead CCG contact’s details)

2. Sponsor(s) (including contact details)

3. Details of project

4. Aims and objectives of project

5. Benefits to CCG/NHS (eg improvement in services as defined by NICE etc)

6. Benefits to sponsor

7. Start date

8. Finish date

9. Termination arrangements (The agreement should be open to early termination by the CCG)


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APPENDIX D Page 2 of 4 Resources and Costs: 1. Overall cost of partnership project?

2. What are the direct/indirect resource/cost commitments by sponsor(s)?

3. What are the direct/indirect resource/cost commitments by the CCG (if any)?

4. How will the resources/costs be monitored and recorded? How will payment be made?

5. Will sponsorship lead to higher costs elsewhere in the NHS?

6. List valid and relevant information on cost effectiveness and value for money


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APPENDIX D Page 3 of 4 Governance and Management Arrangements: 1. Who has been consulted in relation to project

and how was this done?

2. How will patients be informed of project?

3. What is the decision making process of the project?

4. What are the operational and management arrangements?

5. How does the project relate to, and align with, existing systems of care in primary and secondary care?

6. Has the project been piloted or are there plans to do this? How would this be done?

7. Has the project been compared with other proposals on offer? Please give details

8. Has an equality impact assessment been carried out? (If yes, please give details)

9. Has the sponsor read the CCG’s Standards of Business Conduct policy and agreed to abide the rules detailed in this document?

10. Does the project include the use of protocols and guidelines? Who is responsible for producing these? Please include full details of guidelines


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APPENDIX D Page 4 of 4 Data and Patient Protection: 1. Does the project involve the sharing of clinical

data at patient and/or CCG level? Has the Caldicott Guardian been consulted?

2. Are there potential conflicts of interest in relation to access to this data? Please give details

3. What arrangements have been put in place to ensure patient confidentiality and patient consent are considered?

4. Where the project includes collection of data for research purposes has this been approved by the Medical Ethics Committee?

5. Who will have access to data and in what form?

6. How will the data be used?

7. for clinical services what professional indemnity and liability arrangements will be in place?

Lead CCG Contact Signature: ……………………………………………………… Date: ………………………. Sponsor Signature: ……………………………………………………… Date: ………………………. Approved: Yes/No CCG Chief Finance Officer Signature: ……………………………………………………… Date: ……………………….

Prescribing and Medicines Optimisation Strategy

- for consultation

Dr Robin Jackson Executive Lead

Dr Kamlesh Sidhu GP Prescribing Lead

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The Challenge

Medicines the most common health intervention delivered by the NHS, BUT.... • Treatment with a medicine is not always the

answer, and may not be what the patient wants • 30-50% of medicines not taken as intended • Extensive waste of medicines, circa £300million

nationally per year • Medicines implicated in 5-8% of preventable

hospital admissions • Unacceptable levels of medication errors • Variable uptake of evidence-based medicines (NHS

Atlas of Variation) • The financial context – do more with less P

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Medicines Optimisation – a paradigm shift

• Not just about the £24 million prescribing budget (but managing the cash non-negotiable)

• Meaningful patient encounters and involvement in shared decision making

• Consider the patient experience

• Patients empowered to manage their medicines and self care

• Provide support where needed

• Deliver better value from the CCG investment in medicines

• Improve patient outcomes

• Improve the patient experience

• Reduce medicines waste • Improve medicines

safety • Prevent hospital

admissions • Integrated working

across providers of care

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Medicines optimisation

- Medicines within care pathways - Patient empowerment and support for medicines taking

Improve prescribing efficiency and reduce medicines waste

Minimise patient harm associated with the use of medicines

Use of medicines to reduce preventable deaths and minimise

the burden of disease

Partnership

working with

stakeholders

Infrastructure to

support

medicines

optimisation

Clinical

leadership and

engagement

• Improved patient outcomes • Delivery of QIPPa • Enhanced patient experience and satisfaction • Improved standards of care

Prescribing and Medicines Optimisation Strategy

a Quality, Innovation, Productivity, Prevention

Strategic Priority 1:

Reduce preventable deaths and minimise the burden of disease

• Earlier identification of unmet health need and initiation of evidence-based medicines

• Pilot an electronic audit tool to systematically interrogate the GP clinical system and identify those patients whose treatment may be optimised

• Agree a joint primary-secondary care prescribing formulary compliant with NICE guidance, and support implementation via EMIS-Web

• Practice Pharmacist supported prescribing reviews in asthma, COPD and diabetes

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Minimise patient harm associated with medicines • CCG and Practice Pharmacists to provide advice and

support for proactive implementation of patient safety advice relating to medicines

• Medication reviews prioritised for patients taking “high risk” medicines, care home residents and those on multiple medicines – supported by Practice Pharmacists

• Take action to improve medicines safety and reduce risks when patients transfer between care providers e.g. Primary care to hospital, and vice versa

• Targetted therapeutic prescribing / medication reviews e.g. NSAIDs, antibiotics

• Ongoing maintenance of RAG lists for prescribing responsibility P

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Improve prescribing efficiency and reduce medicines waste

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1.0

Inhaled Corticosteroids (Cost per Average Daily Quantity) QIPP Prescribing Profile : OCT 12-DEC 12 | (All) Practice : LANCASHIRE NORTH

Selected Practice Selected CCG Other CCGs


Improve prescribing efficiency and reduce medicines continued...

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• Generic prescribing and optimising for efficiency treatment choices e.g. Sildenafil first-line PDE5 inhibitor, citalopram in preference to escitalopram

• Review repeat prescribing systems to ensure good governance and reduce medicines waste (specific focus on care homes)

• Increase the proportion of electronic repeat prescription requests from patients, and the number of prescriptions generated electronically

• Targetted work on specific areas of prescribing including: wound management, dermatological specials and emollients, infant formula milk, oral nutritional supplements and gluten free foods


Optimise medicines use through integration with care pathways and patient empowerment

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• Clinicians to empower patients in the management of their medicines through engagement in shared decision making and utilisation of self-management plans

• Signpost those patients requiring additional support to other services e.g. Community pharmacy provided Medicines Use Review (MUR) or New Medicines Service (NMS)

• Optimise the use of inhaled medicines in respiratory disorders through improved inhaler technique

Strategic Priority: Structural Enablers

Clinical leadership and engagement

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• Clarify roles of CCG and GP Practice Prescribing Leads

• Clinicians and Practices to be encouraged to critically review their prescribing performance

• CCG to seek GP and Practice engagement in the delivery of the strategy and its objectives

• Local Pharmacy Network (LPN) to be invited to identify a representative to work with the CCG in engaging the community pharmacy sector in CCG priorities for medicines optimisation


Robust infrastructure to support medicines optimisation

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• Establish a CCG Prescribing and Medicines Optimisation Forum (encompassing the Practice Pharmacists’ Group)

• Review and clarify CCG governance arrangements for Local Decision Making in respect of medicines e.g. formulary

• Review and evaluate GP practice requirements for pharmacy support to assist in the delivery of CCG objectives

• In consultation, develop a standard Practice Pharmacist job description for those roles and functions resourced by the CCG and intended to support the delivery of CCG objectives

• Consider benefits and potential investment requirements for pharmacy support as part of a bespoke service to care home

• Embrace innovation and IT; education underpinning


Partnership working with stakeholders

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• Joint work with other commissioners: CCGs, NHS England, Lancashire County Council (Public health), Health and Wellbeing Boards

• Work across providers of care and care pathways to “do the right thing” in relation to prescribing and medicines

• Partnerships with patients and the public – seeking to consider the patient experience in its work on prescribing and medicines optimisation

• A more sophisticated model of joint working with the pharmaceutical industry that is ethical and transparent where this supports CCG objectives and priorities

Summary P

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• CCG to build on the very positive practice already evident in Lancashire North on prescribing and medicines optimisation

• Managing the money non-negotiable, but now need a greater emphasis than ever on the use of medicines to deliver improved patient outcomes, reduce waste and enhance patient experience

• Prescribing and Medicines Optimisation Strategy seeks to provide a roadmap to improving the health and experience of people of Lancashire North through the optimal use of medicines



Report Title: Draft Prescribing and Medicines Optimisation Strategy 2013 - 2015

Paper Prepared By:

Dr Robin Jackson, Executive Lead Dr Kamlesh Sidhu, Prescribing Lead Sanjay Tanna, Chair - Practice Pharmacists Group Andrew Bennett, Chief Officer Catherine Harding, Independent Pharmacist Adviser

Date of Paper: 26 June 2013

Executive Sponsor: Dr Robin Jackson Responsible Manager: Andrew Bennett

Background Paper(s): NHS Outcomes Framework 2013/14 CCG authorisation: the role of medicines management (Primary Care Commissioning, May 2012)

Summary of Report:

A CCG strategy for prescribing and medicines optimisation is presented that seeks to support the delivery of the organisation’s strategic vision to secure safe, high quality health services in partnership with professionals and patients, and to give local people the best opportunity to live longer and healthier lives. The strategy supports the continuous improvement of prescribing and the management of medicines to secure better outcomes for patients within the context of the current financial challenges facing the NHS and the CCG. Incorporated into the strategy document is a detailed implementation plan and a prescribing and medicines optimisation workplan for primary care

Recommendation(s): Approve the CCG Prescribing and Medicines Optimisation Strategy 2013 - 2015

Please Select Y/N

Identified Risks:


Strategic Objective(s) Supported by this Paper: Please

Select (X)

To Improve the health of our population and reduce inequalities in health X

To reduce premature deaths from a range of long term conditions X

To develop care closer to home X

To commission safe, sustainable and high quality Hospital Health Care X

To commission safe, sustainable and high quality Mental Health Care X

To improve capacity and capability of primary care services to respond to the changing health needs of our population X

Please contact: Dr Robin Jackson GP Executive Lead

Lancashire North CCG Prescribing and Medicines Optimisation Strategy 2013 - 2015

Version: 1.0 Final Draft, July 2013 1

PRESCRIBING AND MEDICINES OPTIMISATION STRATEGY

2013 - 2015

Version Date Change 0.1 31 May 2013 Initial draft 0.2 14 June 2013 Updated in response to comments from R. Jackson,

K. Sidhu and S. Tanna 0.3 25 June 2013 Considered by the CCG Executive 1.0 3 July 2013 Final draft considered by the Membership Council

June 2013

Consultation: LNCCG Governing Body and Membership Council

Sponsor: Dr Robin Jackson, Executive Lead

Authors: Dr Robin Jackson

Dr Kamlesh Sidhu (GP Prescribing Lead)

Sanjay Tanna (Chair, Practice Pharmacists Group)

Catherine Harding (Interim Pharmaceutical Adviser)

Improving the health and experience of people of Lancashire North through the optimal use of medicines

http://www.google.co.uk/url?sa=i&rct=j&q=lancashire+north+ccg&source=images&cd=&cad=rja&docid=KoynimIVmVp3SM&tbnid=P85wsfXRQxr4tM:&ved=0CAUQjRw&url=http://www.lancashirenorthccg.nhs.uk/&ei=4m2iUd7yEsaY0AXNtYHYBA&bvm=bv.47008514,d.d2k&psig=AFQjCNHkfroecL9hvzfYxzbe916DwmTSKw&ust=1369685821849928



EXECUTIVE SUMMARY

A strategy for prescribing and medicines optimisation in the CCG is presented that seeks to support the delivery of the organisation’s strategic vision to secure safe, high quality health services in partnership with professionals and patients, and to give local people the best opportunity to live longer and healthier lives. The strategy supports the continuous improvement of prescribing and the management of medicines to secure better outcomes for patients within the context of the current financial challenges facing the NHS.

Informed by recommendations from national, authoritative bodies with respect to best practice in prescribing and medicines optimisation it will provide assurance to the CCG Governing Body and facilitate performance management of this important area for which the CCG is responsible. It will build on the clinical leadership and engagement between primary and secondary care, ensuring safety, quality and medicines optimisation across the whole patient pathway.

CCG ambitions for prescribing and medicines optimisation are described by four key priority areas, underpinned by a further three priorities considered to be enablers to their achievement.

The strategy for prescribing and medicines optimisation in the Lancashire North CCG recognises the positive practice that already exists in delivering efficient, quality, safe prescribing and supporting the management of medicines. Building on an existing culture of engagement within the CCG membership on this important agenda the strategy seeks to take the CCG from its current strong base in medicines management to become an

Priorities for prescribing and medicines optimisation

1. Reduce preventable deaths and minimise the burden of disease through the utilisation of medicines – helping people to live longer and more healthy lives through the targeted use of evidence-based medicines

2. Minimise patient harm associated with the use of medicines – promoting the safe use of medicines and reducing serious medication errors and preventable hospital admissions associated with medicines.

3. Improve the efficiency of prescribing and reduce medicines waste – delivering best value from the CCG resource available for medicines.

4. Optimise the use of medicines by considering medicine issues integral to care pathways, and empowering patients to actively contribute to decisions about their medicines

And to achieve the above the following enablers are underpinning priorities:

5. Clinical leadership and engagement to support delivery of the prescribing and medicines optimisation strategy

6. A robust, well-developed infrastructure to support medicines optimisation 7. Partnership working with key stakeholders with an interest in medicines

optimisation



exemplar for medicines optimisation when benchmarked against others. The CCG recognises its role in providing leadership in the health and social care system to improve the health and experience of people of Lancashire North through the optimal use of medicines, but is cognisant of the necessity to do this in partnership – with health professionals, health care providers, patients, Lancashire County Council (via the Health and Wellbeing Board), the Lancashire Area Team of NHS England, and the NHS Lancashire Commissioning Support Unit.

A strategy implementation plan to deliver the priorities is outlined that describes detailed actions necessary to support the delivery of the prescribing and medicines optimisation strategy (Appendix 1). Those elements of the strategy that are particularly relevant to GPs and the primary care team are summarised separately within Appendix 3 which also includes more detailed information on the prescribing and medicines optimisation workplan for 2013/14.

The newly formed CCG Prescribing and Medicines Optimisation Forum will be responsible for the detailed implementation of the strategy and oversight of the workplan, and the CCG Executive will monitor and oversee progress on behalf of the CCG Governing Body, providing further leadership and direction where this is warranted.



CONTENTS

Page

1. Introduction 5

2. Background 5

2.1 Financial context 6

2.2 Medicines optimisation 6

3. Priorities for prescribing and medicines optimisation 9

3.1 Reduce preventable deaths and minimise the burden of disease through the utilisation of medicines

11

3.1.1 Effective implementation of NICE guidance 11

3.2 Medicines safety – keeping patients safe 11

3.2.1 Systems supporting safe transfer of care between providers 12

3.3 Improve the efficiency of prescribing and reduce medicines waste 13

3.3.1 Financial and budgetary control 13

3.3.2 High cost drugs 14

3.3.3 Tackling medicines waste 14

3.4 Optimise the use of medicines by considering medicine issues integral to care pathways and empowering patients to actively contribute to decisions about their medicines

15

4. Enablers for strategy implementation 16

4.1 Clinical leadership and engagement 16

4.2 Infrastructure to support medicines optimisation 17

4.2.1 Governance arrangements 17

4.2.2 Prescribing and pharmacist support 18

4.2.3 Information and knowledge management, communication, education and training

19

4.3 Working in partnership 19

5. Conclusion 20

6. Supporting documents 21

7. Glossary 23

Appendix 1 – Strategy implementation plan 24

Appendix 2 - NICE Key therapeutic topics: Medicines management options for local implementation (2013)

29

Appendix 3 - Primary care prescribing and medicines optimisation workplan 2013 - 2014

32

Appendix 4 – Relationship map for CCG medicines optimisation governance and leadership arrangements

36



LANCASHIRE NORTH CCG PRESCRIBING AND MEDICINES OPTIMISATION STRATEGY 2013 – 2015

1. INTRODUCTION

A strategy for prescribing and medicines optimisation in the CCG is presented that seeks to support the delivery of the organisation’s strategic vision to secure safe, high quality health services in partnership with professionals and patients, and to give local people the best opportunity to live longer and healthier lives. The strategy supports the continuous improvement of prescribing and the management of medicines to secure better outcomes for patients within the context of the current financial challenges facing the NHS. It forms a significant component of the overarching CCG QIPP programme, delivering efficiencies from the utilisation of medicines through Quality, Innovation, Productivity and Prevention. Informed by recommendations from national, authoritative bodies with respect to best practice in prescribing and medicines optimisation it will provide assurance to the CCG Governing Body and facilitate performance management of this important area for which the CCG is responsible. It will build on the clinical leadership and engagement between primary and secondary care, ensuring safety, quality and medicines optimisation across the whole patient pathway.

Patients of the NHS have a right to expect that the decision to prescribe any medicine is based on best evidence, in accordance with national authoritative guidance where this exists, and that the benefits outweigh the risks. The strategy recognises that increasingly patients should be empowered to actively contribute to decisions about their medicines use, and be better supported to get the best possible outcomes from their medicines. A shift in emphasis from medicines management to a more person-centred approach referred to as medicines optimisation is described, with the aim of delivering best value from the considerable financial investment made in medicines by the CCG.

2. BACKGROUND

Medicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. In an era of significant economic, demographic and technological challenge it is crucial that healthcare commissioners and patients get the best quality outcomes from medicines. The prescription of a medicine remains the most common therapeutic intervention delivered by the NHS, and expenditure on medicines represents the second largest NHS budget cost after staffing. However, there is a growing body of evidence demonstrating the urgent need to get the fundamentals of medicines use right. The Department of Health’s Chief Pharmaceutical Officer Dr Keith Ridge has highlighted the following concerns relating to medicines utilisation in practice: 30 to 50% of medicines are not taken as intended; UK literature suggests that between 5 to 8% of hospital admissions are due to preventable adverse effects of medicines; patients receive insufficient supporting information regarding their medicines; medication errors across all sectors and age groups is at an unacceptable level; medicines wastage in primary care is estimated to be in the order of £300 million per annum with half of this being avoidable; there is unjustifiable variation in the uptake of evidence based medicines as depicted by the NHS Atlas of Variation; and the real threat presented by antimicrobial resistance and healthcare associated infections.



2.1 Financial context

As of 1 April 2013 the CCG became responsible for commissioning hospital and community services for the population of Lancashire North and for managing the budgets associated with expenditure on medicines (approximately 15% of the CCG’s total budget of £197 million in 2013/14). These budgets include primary care prescribing (prescribing by GPs and other suitably qualified staff they may employ), prescribing attributed to commissioned community services e.g. district nursing, and costs associated with the use of high-cost specialist medicines that are excluded from hospital tariff payments but which are associated with services commissioned by the CCG. Medicines supplied by providers as part of an episode of care under the Payment by Results tariff that are not high-cost drugs specifically excluded from tariff are funded from within the price paid by the CCG for the contracted procedure, admission, etc.

With advancements in medical practice and evidence-based care and an ageing population it is unsurprising that the volume of medicines prescribed by the NHS is increasing. Prescription items dispensed in England increased by 3.8% in 2011 when compared with the previous year, with the average number of items per head of population per year being in excess of 18 (Source: Prescriptions Dispensed in the Community: England statistics for 2001 to 2011, NHS Information Centre (2012). Yet despite the increase in the volume of prescriptions, primary care prescribing costs have largely been contained. This is predominantly as a result of the loss of patency on branded medicines with large market shares and the subsequent sharp fall in prices of these medicines with the availability of generic alternatives. This trend is likely to continue given that nine of the current top 20 selling branded products are to lose patent exclusivity between 2012 and 2015 with a predicted £3.4 billion of cumulative savings to the NHS due to the availability of generic medicines (Source: The Office of Health Economics, June 2012 in a report prepared for the ABPI).

The impact of the CCG resource allocated for expenditure on medicines goes far beyond cost containment of the Primary Care prescribing budget. The impact of costs is substantial given the levels of drug wastage, the ongoing opportunities for standardisation of prescribing practice in accordance with best evidence, the high numbers of preventable medicine-related emergency hospital admissions, and an annual growth in expenditure on specialist, high cost drugs in the order of 7%.

The Government has indicated its intent to introduce value-based pricing for branded medicines supplied to the NHS from January 2014. Such an approach links the price of a medicine to cost-effectiveness based on clinical evidence and outcomes. Specific details of this development and any implications for the CCG prescribing budget are currently unknown, but it is anticipated that the new pricing scheme will only apply to new medicines coming to market following the introduction of the scheme.

2.2 Medicines optimisation

The overarching aim of the strategy is to improve the safety and outcomes achieved from the investment in and use of medicines across health care sectors by “optimising” their use in a more effective way. Medicines optimisation has been described as an approach to



ensuring patients get the best possible health outcomes from their medicines, whilst organisations make the best use of their medicines resource. The transactional costs and procurement of medicines is an important consideration that calls for sound management. However the more transformational approaches to medicines use and involving patient and public in a more meaningful way will be crucial to changing how medicines are used, perceived and optimised. This all needs to be set in the context of patient safety, good governance and adherence to relevant legislation.

Medicines optimisation provides the opportunity for a shared approach to medicines use, providing patients with better access to support for medicines taking. It offers the potential to improve the safe use of medicines in all care settings, harnessing the expertise of professionals and patients working together. By focussing on patients and their experiences, the goal is to help patients to: improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety. Ultimately, medicines optimisation will deliver better value for money from the significant investment the CCG makes in medicines each year (£25.9 million in Primary Care Prescribing in 2013/14).

Improved medicines optimisation has the potential to have a high impact in terms of patient experience and health outcomes. Examples of how medicines optimisation might contribute to each domain of the NHS Outcomes Framework are described in Table 1.

Table 1 NHS Outcomes Framework and contribution of medicines optimisation

Domain 1 Preventing people from dying prematurely

Supporting earlier diagnosis and the initiation of medicines proven to reduce mortality

Structured patient reviews and active identification of patients that may benefit from evidence-based prescribing interventions

Ensuring people have access to the right treatment when they need it, including medicines and treatments recommended by the National Institute for Health and Care Excellence (NICE)

Domain 2 Enhancing quality of life for people with long-term conditions

Utilisation of medicines with proven benefit to improve quality of life for patients (e.g. as per Patient Reported Outcomes Measures, or adding “life to years”)

Smooth transition when patients move between care settings, including interventions to reduce medicines reconciliation errors and ensuring medicines and medicine-related services are optimised during transition

Domain 3 Helping people to recover from episodes of ill health or following injury

Provision of support where appropriate to assist patients to manage their medicines

Reduce emergency readmissions to hospital where medicines-related factors are a contributory cause

Domain 4 Ensuring that people have a positive experience of care

Empowerment of patients to be involved in decisions made about their medicines and treatment

Consideration of individual patient factors and experience and the implications for optimising medicines use

Domain 5 Treating and caring for people in a safe environment; and

Reducing incidence of healthcare associated infections and the emergence of antimicrobial resistance

Minimising medication errors resulting in serious harm



protecting them from avoidable harm

and the creation of a culture of learning from patient safety incidents

Delivery of medicines optimisation will require a different, multi-organisational approach in future. Relationships will need to be built between other organisations in the new commissioning system including with neighbouring CCGs, NHS England (Area Team and Specialist Commissioning), the Local Authority, the Health Wellbeing Board and providers of Commissioning Support. Strong clinical leadership within the CCG, making strategic links and inspiring, innovating and motivating clinical colleagues in primary and secondary care will be a critical success factor in the CCG’s potential to deliver strong performance in medicines optimisation for the benefit of patients.



3. PRIORITIES FOR PRESCRIBING AND MEDICINES OPTIMISATION

CCG ambitions for prescribing and medicines optimisation are described by four key priority areas, underpinned by a further three priorities considered to be enablers to their achievement. These are described in detail below and presented diagrammatically in Figure 1

Priorities for prescribing and medicines optimisation

1. Reduce preventable deaths and minimise the burden of disease through the utilisation of medicines – helping people to live longer and more healthy lives through the targeted use of evidence-based medicines

a. Incorporate evidence based guidance on prescribing and medicines utilisation into care pathways and seek to systematically identify those patients whose treatment may be optimised in accordance with best evidence.

b. Implement a primary care prescribing formulary via the GP clinical system EMIS Web that supports adherence to NICE guidance and is integrated with secondary care

2. Minimise patient harm associated with the use of medicines – promoting the safe use of medicines and reducing serious medication errors and preventable hospital admissions associated with medicines.

a. Implement the recommendations from the Royal Pharmaceutical Society Report Keeping patients safe when they transfer between care providers – getting the medicines right to minimise the well-documented medicines risks associated with the movement of patients from one care provider to another.

b. Promote a culture of learning from medication incidents through incident reporting and the sharing of lessons learnt.

c. Improve assurance of standards for pharmacy services and medicines management in commissioned services.

d. Deliver improved patient safety and reduce medicines risk and hospital admissions through Practice Pharmacist interventions targeting the vulnerable including: the elderly, those on multiple medicines, residents of care homes, and those taking “high risk” medicines.

3. Improve the efficiency of prescribing and reduce medicines waste – delivering best value from the CCG resource available for medicines.

a. Deliver efficiencies in prescribing through the implementation of NICE Guidance and disinvestment in medicines and devices where the evidence does not support the level of resource invested.

b. Optimise systems for prescribing and medicines supply that consider the patient experience, ensure safety and minimise waste. Specific attention to be given to repeat prescribing and systems of prescribing and supply for residents of care homes.

4. Optimise the use of medicines by considering medicine issues integral to care pathways, and empowering patients to actively contribute to decisions about their medicines

a. Increase patient involvement in decisions about their medicines and treatments with the aim of promoting self-care, improving understanding and concordance with treatment, and reducing waste.

b. Improve patient access to support for medicines taking where needed.



A strategy implementation plan to deliver the priorities is outlined in Appendix 1. Detailed actions are described that support the delivery of the prescribing and medicines optimisation strategy. Specific elements of the CCG Prescribing and Medicines Optimisation Strategy that are particularly relevant to primary care and primary care clinicians are summarised in the 2013/14 workplan outlined in Appendix 3. GPs, Practice Pharmacists, Practice Nurses, Community Pharmacists and the wider primary care team have an important contribution to make to the delivery of the strategy and the achievement of the CCG’s challenging efficiency targets.

Figure1: Prescribing and medicines optimisation strategy priorities

And to achieve the above outcome focussed goals the following enablers are underpinning priorities:

5. Clinical leadership and engagement to support delivery of the prescribing and medicines optimisation strategy

6. A robust, well-developed infrastructure to support medicines optimisation 7. Partnership working with key stakeholders with an interest in medicines optimisation



3.1 Reduce preventable deaths and minimise the burden of disease through the utilisation of medicines

The strategy aims to ensure not only that prescribing is cost-effective, but also safe and of high quality so that medicines use is optimised and unmet pharmaceutical need is met on an individual and population basis. This fits clearly with putting clinicians at the centre of commissioning, improving patient outcomes, preventing hospital admissions and treating patients within their communities. Earlier identification of unmet health needs and initiation of evidence based pharmacological treatments will save lives and prevent or delay future ill-health thereby preventing expensive hospital admissions and associated health and social care costs.

Recognising the additional costs associated with increased prescribing and use of medicines to treat unmet health need and/or as a result of the emergence of new, innovative medicines to treat existing conditions the CCG’s prioritisation and financial planning process will incorporate consideration of the financial risks associated with prescribing budgets and the use of medicines.

Utilisation of an electronic audit tool linked to GP clinical systems to systematically identify potential patients for review whose treatment may be optimised will be piloted with a view to rolling out the intervention across the CCG. Medication reviews undertaken in primary care provide an opportunity to identify opportunities to optimise therapy and, in consultation with the patient, amend therapy to ensure that prescribing standards are met.

3.1.1 Effective implementation of NICE guidance

The CCG will promote innovation by actively supporting the implementation of guidance from the National Institute for Health and Care Excellence (NICE). The prescribing of treatments of proven benefit approved by NICE will be monitored in commissioned services, and peer review of prescribing performance within Primary Care undertaken. NICE recommended treatments (as specified in Technology Appraisal Guidance) will be incorporated into a joint CCG and health economy prescribing formulary within three months of the NICE determination, and advice from NICE embedded within the content of care pathways and treatment guidelines. A requirement to publish local formularies came into effect in April 2013. The CCG will work with neighbouring CCGs and its main provider of hospital services to ensure that this requirement is met.

When making positive determinations, NICE is increasingly issuing a recommendation that a medicine is considered a treatment option, leaving the positioning of treatments within the care pathway to clinical opinion. The CCG is aware that as a result of innovation and advancement in practice there may be occasions when the CCG, supported by clinical and patient opinion, would wish to prioritise an alternative treatment to the NICE approved option, where the alternative option has not been considered by NICE. Where this is the case the CCG policy for the commissioning of medicines will be adhered to.

Implementation of NICE guidance and the prescribing formulary will be facilitated through IT decision support (embedded formulary within the GP clinical system), and monitored in primary care through review of prescribing data and benchmarking at CCG level and



individual GP Practice level, facilitation of clinical audit, peer review and incorporation of prescribing standards into contracts.

3.2 Medicines safety – keeping patients safe

Medication incidents account for in excess of 10% of all patient safety incidents reported to the NHS National Reporting and Learning System representing the second largest category of incidents reported, second only to patient accidents which form in excess of 30% of all reports (Source: Cousins D et al, 2012). Although the actual figures vary in published literature it is known that a significant number of preventable hospital admissions (around 1 in 25) are associated with problems with medication. Common causes are associated with the prescribing process, patient adherence problems, or deficiencies in the monitoring of medication. Those at increased risk include the young, the elderly, those on multiple medicines and those taking “high risk” medicines. It is also known that residents of care homes are a particularly vulnerable group.

Causes of medication error are multi-factorial and complex but there are several strategies available to improve the safety of prescribing, a number of which may be realised without major investment. The CCG prescribing and medicines optimisation strategy will promote the adoption of interventions known to reduce the risk of medication errors and improve patient safety, support the implementation of medication safety alerts, encourage incident reporting, and promote a culture of shared learning from medication incidents. In so doing patient harm will be minimised, treatment outcomes improved and preventable hospital admissions reduced. Known strategies of benefit include: educational initiatives; information technology and clinical decision support to help prescribers make the right choices; pharmacist support and targeted medication reviews for high risk patients; and improved two-way communication at the GP – hospital interface.

Controlled drugs have the potential to be misused and for this reason they are governed by legislation over and above Prescription Only Medicines. Whilst they are essential therapies for e.g. patients with severe pain, they also have the potential to cause significant harm and are one of the classes of medicine commonly associated with medication incidents. The CCG recognises its role in the oversight of good governance with respect to controlled drugs and will actively participate in the Lancashire Local Intelligence Network (LIN) for Controlled Drugs, reporting concerns to the LIN’s Accountable Officer for Controlled Drugs.

3.2.1 Systems supporting safe transfer of care between providers

A specific focus of the strategy will be to improve systems for communication across the primary and secondary care interface with the CCG’s main providers of hospital services, implementing the recommendations from the report published by the Royal Pharmaceutical Society (2012) Keeping patients safe when they transfer between care providers – getting the medicines right. Core principles and responsibilities published by the RPS and endorsed by other professional royal colleges underpin the safe transfer of information about medicines whenever a patient transfers care providers, at any point in the care pathway. To support implementation of the core principles and responsibilities, content for transfer records has been developed. This outlines recommended core information about medicines that should be transferred when patients move from one care provider to another. The CCG will work with GPs, hospital providers, community pharmacists and other key stakeholders to



improve the quality of information relating to medicines that moves with the patient when they transfer between providers of care, using the contractual process where appropriate to do so.

An integrated prescribing formulary with secondary care, and guidance for clinicians on the appropriate care setting for the prescription and supply of medicines otherwise referred to as a RAG (Red, Amber, Green) list for prescribing responsibility will facilitate safe prescribing across the primary-secondary care interface. Where it has been agreed that responsibility for the prescribing of specialist medicines may be transferred to primary care with the GP’s agreement (Amber medicines) the prescribing of these therapies will be underpinned by guidance and shared care agreements as appropriate. The CCG will work with primary care providers to understand and respond to workload implications of changes in care pathways.

The appointment of an expert pharmacist to the CCG management team and the service agreement with the CSU medicines management team will ensure that the CCG has access to expert advice on the legal, safe and secure handling of medicines for all services both provided and commissioned by the CCG. CCG contracts with secondary care providers will incorporate quality standards relating to the safe and secure handling of medicines, the delivery of pharmacy services (including standards for the supply of Homecare medicines), and medicines utilisation. Opportunities for incentivising the development of practice beyond that which could reasonably be expected to be delivered within core contracts will be explored with providers.

3.3 Improving the efficiency of prescribing and reducing medicine waste

3.3.1 Financial and budgetary control

Lancashire North has a track record in delivering financial and budgetary control in primary care prescribing through the engagement of member GP Practices and investment in a dedicated team of Practice Pharmacists providing advice and support to GPs and other primary care clinicians on the utilisation of the prescribing budget.

The CCG will routinely review its core spending on medicines with a view to disinvesting in those medicines where the evidence relating to improvement in patient outcomes does not support the level of resource invested.

Opportunities to optimise the use of medicines and deliver efficiency savings will form an integral part of the CCG QIPP plan and will reflect the content of the prescribing and medicines optimisation strategy for the prioritisation and disinvestment of medicines and related services. Based on prescribing costs in 2011-2012 and 2012-13 it is estimated that QIPP savings of £2 million (when compared to the 2012-13 prescribing budget) can be achieved in 2012-13 without compromising patient care.

The primary care prescribing and medicines optimisation workplan (Appendix 3) will target those key therapeutic areas suggested by NICE as options for local implementation (Appendix 2) where the CCG’s performance is below the national upper quartile. This is in addition to other locally determined priorities that together will contribute to the achievement of the planned savings in primary care prescribing costs.



Systems for ensuring the cost-effective use of medicines and budgetary management will include: mechanisms for reviewing expenditure and prescribing data; peer review and the availability of prescribing support and advice; implementation of a primary care prescribing formulary; active planning for future developments and investment requirements; and robust management of expenditure associated with high cost drugs excluded from provider tariff payments.

GP Practice prescribing budgets will be allocated using a fair and transparent process and Practices will be expected to manage within their annual allocation and demonstrate general adherence to CCG prescribing guidance. GP Practice engagement in maintaining and improving financial and budgetary control will be facilitated through the provision of a Practice Pharmacist resource.

Working with the CSU, opportunities for efficiencies in the supply and procurement of medicines (including rebate arrangements) will be explored where these have the potential to improve patient care and deliver value for money e.g. supply of medicines through Homecare. In so doing advice will be sought from clinicians and patient views canvassed. Any changes to practice will be lawful and in accordance with national guidance where this exists. Supply of medicines commissioned through Homecare services will be reviewed to ensure compliance with the recommendations of the Hackett Report Homecare Medicines “Towards a vision for the future” (Department of Health, 2011).

In 2013/14 the contract for enteral nutrition supplements (tube feeds and sip feeds) held by the CCG’s main provider of Dietetic services will be reviewed in conjunction with the commissioning of an enhanced Dietetic service in order to ensure that all prescribing of nutrition supplements is appropriate and represents value for money.

3.3.2 High cost drugs

Whilst growth in primary care prescribing costs is expected to be contained over the next two years, growth in the cost of specialist, high cost medicines excluded from tariff is currently running at 7%. NHS England through its specialist commissioning function is responsible for commissioning many categories of high cost drugs, but there are still significant financial pressures associated with those therapies for which the CCG is the responsible commissioner, notably in the specialties of rheumatology and ophthalmology. Delivering efficiencies in the procurement and utilisation of high cost drugs is a priority for the CCG working with other CCGs and providers of specialist services in Lancashire. Leadership and management of this collaborative workstream will be undertaken by the CSU on behalf of the CCG with CCG oversight. Not only is the management of high cost drugs a financial risk, but it also represents an organisational reputational risk, particularly in relation to the handling of Individual Patient Funding requests. Again the CCG recognises the benefits of collaboration with other CCGs in this important area of high risk work with the agreement of common commissioning policies and processes, and administration of this function being supported by the CSU.

3.3.3 Tackling medicines waste

The NHS is facing financial challenges as never before, with the additional demands of an ageing population and potential increases in cost associated with new and innovative developments in healthcare. It is therefore appropriate that waste associated with medicines



in the NHS is minimised. Research commissioned by the Department of Health identified existing good practice in the NHS for managing the problem of medicines wastage, but then further identified opportunities for people to be better supported in taking their medicines as prescribed – helping to improve their long-term health outcomes and ensuring better value for the NHS.

Recommendations pertinent to CCGs as commissioners and primary care are identified in the report Improving the use of medicines for better outcomes and reduced waste (Department of Health, 2012). As part of the CCG prescribing and medicines optimisation strategy the CCG will seek to implement the relevant recommendations from this report. Recognising that the bulk of medicines supplied in primary care are obtained through the repeat prescribing process, good practice guidance in repeat prescribing that takes into consideration the patient experience will be developed and implemented, and the proportion of regular medicines supplied through the mechanism of repeat dispensing increased. GP practices will be encouraged to accept electronic requests for repeat prescriptions and to increase the proportion of prescriptions generated electronically where this is the wish of the patient (as specified by the Electronic Prescription Service)

Prescribing and medicines supply for residents of care homes will be a specific focus of the 2013/14 workplan, with work being undertaken during 2013/14 to identify the scale of the challenge and quantify what is achievable within the resources available.

The patient dimension of tackling medicines waste is recognised by the strategy where it is considered in detail in the following section.

3.4 Optimise the use of medicines by considering medicine issues integral to care pathways and empowering patients to actively contribute to decisions about their medicines

It is inevitable that the re-design of care pathways will result in some medicines previously prescribed, administered and supplied by specialist services being made available to patients in primary care via their GP and community pharmacist. In considering the commissioning of services and the corresponding patient pathway, medicines optimisation issues will be factored into the design of the care pathway at an early stage to ensure any legal, quality and safety, and resource implications are given due consideration.

A significant number of prescriptions written by prescribers are never presented for dispensing, or never collected. Of those prescriptions that are dispensed and collected a significant number are never taken, with many others partly taken or taken inappropriately. Patient education and empowerment to discuss the benefits of their medication with clinicians is central to medicines optimisation and reducing waste. Improving patient understanding and concordance with their medication is key to medicines optimisation.

Patients will be actively engaged by prescribers in shared decision making about their medicines, informed by evidence of benefits and risks utilising patient decision aids where these exist. Where patients are having difficulty managing their medicines the cause of their difficulty will be assessed and they will be signposted to receive additional support as necessary. Pathways for medicines optimisation will be put in place for those patients at high risk of readmission due to medication-related problems following discharge from hospital.

http://www.connectingforhealth.nhs.uk/systemsandservices/eps



4. ENABLERS FOR STRATEGY IMPLEMENTATION

The strategy recognises that delivery of the four main priorities requires the right environment, described in this section as enablers for strategy implementation. Three enabling priorities are described that include: clinical leadership and engagement; infrastructure requirements; and working in partnership.

4.1 Clinical leadership and engagement

Strategic clinical leadership of prescribing and medicines optimisation will facilitate continued clinical engagement from GP Practices and secondary care so ensuring the delivery of safety, quality and value for money in medicines optimisation across the whole patient pathway. The Executive Lead of the CCG Governing Body with overall responsibility for prescribing and medicines optimisation is the Executive lead for Finance and Contracting. The CCG has identified a GP clinical lead for Prescribing and Medicines Optimisation and is seeking to appoint a senior pharmacist to the role of Senior Manager for Medicines Optimisation / Head of Medicines Optimisation. Responsibilities of the clinical leads include leading the development of the medicines optimisation strategy for the CCG; ensuring the principles of medicines optimisation are integrated with the core commissioning business of the CCG and factored into service redesign and care pathway development; contribution to processes for the prioritisation and commissioning of medicines and provision of feedback to the CCG Governing Body ensuring due governance in the agreement of CCG medicines policy; act as a champion for evidence-based practice in the context of medicines optimisation; oversight of CCG and GP Practice performance against CCG plans and management of the resource available for prescribing; provide leadership to facilitate improvement in the quality of primary care prescribing; promote innovation and the uptake of NICE-approved medicines in accordance with NICE guidance; and ensure compliance with the NHS Constitution and Statutory responsibilities associated with medicines optimisation such as processes for handling Individual Funding Requests.

The clinical leads maintain communication and engagement on the medicines optimisation strategy with all member GP Practices through designated prescribing leads within each GP Practice and an active network of Practice Pharmacists who are best placed to provide advice and support, and contribute to work undertaken on shared priorities agreed between member Practices and the CCG. Clinicians are provided with benchmarked data on prescribing performance and peer review is encouraged.

The act of prescribing, medicines supply and administration is a multidisciplinary process. For the CCG to be successful in the implementation of its medicines optimisation strategy a multidisciplinary, cross-sector approach will be required.

Although nationally contracted community pharmaceutical services are to be commissioned by the NHS England Lancashire Area Team, an effective relationship with community pharmacy will be instrumental in supporting the delivery of the CCG medicines optimisation strategy. The CCG will seek to engage the local pharmacy profession in the delivery of CCG priorities for medicines optimisation, recognising the important contribution of this sector to health improvement. The Local Pharmacy Network will be invited to identify a community



pharmacist representative to advise the CCG on its medicines optimisation strategy and opportunities for engaging the community pharmacy sector in the delivery of CCG priorities.

4.2 Infrastructure requirements to support medicines optimisation

An organisational competency framework to ensure the effective delivery of medicines management (optimisation) functions and responsibilities by primary care commissioning organisations was published by the National Prescribing Centre in 2011. Using the associated self-assessment tool the CCG assessed its position against the framework in early 2012 to help identify gaps and define its requirements for support and advice. Further to CCG authorisation the self assessment exercise will be repeated to identify whether there remains any competency gaps that may impede the effective delivery of the CCG’s medicines optimisation functions.

New information management systems and a medicines management team will be provided by the Lancashire Commissioning Support Unit (CSU) to advise prescribers and deliver information on GP Practice prescribing patterns to achieve cost effectiveness, safety and quality. Through a service agreement the CSU will provide significant assistance to the CCG in respect of horizon scanning, financial planning and the managed introduction of new medicines; management of high cost drugs; development of commissioning policies for specialist medicines; handling of Individual Funding Requests; and contract management (otherwise referred to as Provider Relationship Management).

Successful delivery of the strategy and the programme of work associated with medicines optimisation is largely dependent on the local relationship between the CCG, individual GP Practices and their teams, and the network of Practice Pharmacists who provide practical support to assist in strategy implementation. Each GP Practice will have the opportunity to engage in CCG work on medicines optimisation through representative membership on the CCG Prescribing and Medicines Optimisation Forum and receipt of minutes from the meetings.

Prescribing and medicines management data can be used to identify variation in practice. Via the GP Prescribing Lead, the Senior Manager for Medicines Optimisation and the network of Practice Pharmacists, opportunities for best practice in prescribing and medicines optimisation will be spread across the CCG GP Practice membership. A role of Practice Pharmacists is to interpret the data for clinicians in primary care, advise on any action to be taken in response to the data, which may include the provision of Practice support, and spread best practice. Inter- GP Practice variation will be reviewed by the CCG Prescribing Lead and senior manager for Medicines Optimisation and individual Practices advised to make the necessary changes to improve the efficiency, safety and quality of prescribing as appropriate. Agreement will be reached with the Lancashire Area Team of NHS England with regard to the use and interpretation of the National Data Set and benchmarking. The Local Medical Committee will provide further advice and assistance in cases where inappropriate prescribing may form part of wider concerns about the capabilities of an individual doctor or Practice.

4.2.1 Governance arrangements

The NHS Constitution requires NHS commissioners to have robust, transparent arrangements in place for the managed entry of new drugs. Working with clinicians and



taking into consideration the patient and public perspective the CCG will make decisions relating to the commissioning and utilisation of medicines in a manner that is robust, rational and defensible. Building on existing health economy arrangements the CCG will cooperate with neighbouring CCGs and provider organisations through the Lancashire Medicines Management Group (LMMG) www.lancsmmg.nhs.uk and the University Hospitals of Morecambe Bay (UHMB) Drug and Therapeutics Committee to facilitate a shared approach to medicines use, integrating medicines into care pathways and promoting inter- and intra-professional collaborative working within the Lancashire health and social care system. Not only is this in the best interests of patient care, but such an approach has the potential to deliver economies of scale, enhance quality and robustness of decision making, and promote equity in access to medicines. The CCG and relevant clinicians and stakeholders (including patient groups) will have had the opportunity to input to recommendations made by the LMMG and therefore, in principle, the CCG will seek to routinely adopt the recommendations from the LMMG, of which the CCG is a member. The CCG will only deviate from this position by exception, and with good cause. The UHMB Drug and Therapeutics Committee (with CCG membership) is responsible for agreeing the inclusion of medicines into the local prescribing formulary based on CCG endorsed LMMG recommendations and decisions from the Cumbria Area Prescribing Committee.

The CCG will establish a Prescribing and Medicines Optimisation Forum through the formalisation and remit expansion of the current Practice Pharmacists’ Group. Chaired by the GP Prescribing Lead the group will oversee implementation of the prescribing strategy, advise the CCG Executive on matters relating to prescribing and medicines optimisation, and act as the link between the CCG and member GP Practices and their Practice Pharmacists. The relationship between CCG clinical leads and its Officers, member GP Practices and Practice Pharmacists, and wider stakeholders (organisations and groups) is presented diagrammatically in Appendix 4.

4.2.2 Prescribing and Pharmacist support

Significant investment has been made by the CCG to make pharmacist support available to GP Practices. Pharmacists working as integral members of the Practice team are well placed to advise GPs and Practice staff on safe, high quality, cost-effective prescribing and deliver clinical interventions to individual patients to optimise their use of medicines. There is an expectation linked to the receipt of funding from the CCG that GP Practices will engage in the delivery of CCG prescribing and medicines optimisation priorities, supported by the Practice Pharmacist workforce. Utilisation of the pharmacist resource available to Practices to assist in the delivery of the CCG strategy for prescribing and medicines optimisation for this purpose will be reviewed and evaluated, and recommendations made for 2014 – 2015 requirements. Without pre-empting the outcome of the review, this may include further investment in the service and opportunities to develop skill mix and service efficiency.

The CCG has recognised the potential benefits of closer cooperation between primary and secondary care and delivering seamless care across the hospital – primary care interface. The potential benefits of an Interface Pharmacist are being explored with the University Hospitals of Morecambe Bay as the CCG’s main provider of hospital services.

Opportunities for improving outcomes and reducing requirements for hospital-based care for residents of care homes links with CCG priorities. There is significant scope to optimise

http://www.lancsmmg.nhs.uk/



medicines use for residents of care homes, and reduce medicines waste. As part of a CCG programme of work on care homes consideration will be given to any investment that may be required in medicines optimisation and pharmacy support services targeted at this patient group.

4.2.3 Information and knowledge management, communication, education and training

Information technology and innovation will be embraced to support the delivery of the medicines optimisation strategy, to deliver improvements in prescribing practice and the rapid adoption of evidence based pharmacological interventions. Content relevant to the delivery of the priorities for medicines optimisation will be incorporated into the CCG education strategy, and effective communication across primary and secondary care and with patients will be a fundamental component of strategy implementation.

4.3 Working in partnership

Successful delivery of the CCG strategy for prescribing and medicines optimisation will be dependent upon successful partnership working with other organisations involved in the commissioning of health and public health services, providers of service and patient and their representatives. These include NHS England (Lancashire Area Team and specialist commissioning), the Local Professional Networks, the Lancashire Commissioning Support Unit, and the public health function based within Lancashire County Council.

Medicines are important for improving the overall public health of the population. The Joint Strategic Needs Assessment (JSNA) should take into account the opportunities to improve health and reduce variation in prescribing and medicines optimisation. Links with the Local Authority and the Health and Wellbeing Board are necessary to ensure that commissioned public health services that depend upon the prescription of a medicine by GPs are coherent, safe and do not adversely impact on the ability of the CCG to manage its prescribing budget.

The White Paper “Equity and excellence: Liberating the NHS” outlined the significance of putting patients at the heart of the NHS. Medicines optimisation mandates a new relationship with patients and places emphasis on the importance of the patient experience. The CCG will actively seek to engage the views of patients in the medicines commissioning process and actively support the development of treatment pathways and interventions that are personalised and acknowledge the importance of individual patient views and experience.

The prescribing and medicines optimisation strategy calls for a more sophisticated model of joint working with the pharmaceutical industry to get best value, quality and outcomes for patients and the public. Primary Care Commissioning has acknowledged joint working as an enabler of clinical commissioning highlighting the contribution joint working can make in addressing the QIPP challenge, supporting local health service improvement led by CCGs and their constituent General Practices, and focusing on the most effective use of NHS resources and value for money. Any joint working agreements between the CCG and a commercial organisation will be transparent and consistent with the CCG values and priorities, undertaken in accordance with Department of Health and ABPI rules and CCG policy. The CCG recognises that advice on the potential benefits and risks of individual joint working proposals may be sought from the CSU medicines management service.



5. CONCLUSION

The strategy for prescribing and medicines optimisation in the Lancashire North CCG recognises the positive practice that already exists in delivering efficient, quality, safe prescribing and supporting the management of medicines. Building on an existing culture of engagement within the CCG membership on this important agenda the strategy seeks to take the CCG from its current strong base in medicines management to become an exemplar for medicines optimisation when benchmarked against others. The CCG recognises its role in providing leadership in the health and social care system to improve the health and experience of people of Lancashire North through the optimal use of medicines, but is cognisant of the necessity to do this in partnership – with health professionals, health care providers, patients, Lancashire County Council (via the Health and Wellbeing Board), the Lancashire Area Team of NHS England, and the NHS Lancashire Commissioning Support Unit.

Success in the delivery of the strategy and its priorities will be assessed through regular reporting to the CCG Executive on behalf of the Governing Body.



6. SUPPORTING DOCUMENTS

Department of Health. Homecare Medicines “Towards a vision for the future”. November 2011. http://media.dh.gov.uk/network/121/files/2011/12/111201-Homecare-Medicines-Towards-a-Vision-for-the-Future2.pdf

Department of Health. The NHS Outcomes Framework 2013/14. November 2012. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127106/121109-NHS-Outcomes-Framework-2013-14.pdf.pdf

Department of Health. Improving the use of medicines for better outcomes and reduced waste – an action plan. December 2012 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126846/Improving-the-use-of-medicines-for-better-outcomes-and-reduced-waste-An-action-plan.pdf.pdf

Department of Health and the ABPI. Moving beyond sponsorship: interactive toolkit for joint working between the NHS and the pharmaceutical industry (Gateway Ref: 14600). http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/joint%20working%20toolkit%20dh.abpi.pdf

General Medical Council, Good practice in prescribing and managing medicines and devices, February 2013 http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp

King’s Fund. Transforming our health care system – ten priorities for commissioners. April 2013 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf

National Audit Office. Prescribing costs in primary care. May 2007. http://www.nao.org.uk/wp-content/uploads/2007/05/0607454.pdf

National Institute for Health and Clinical Excellence. GPG1: Developing and updating local formularies. December 2012. http://www.nice.org.uk/mpc/goodpracticeguidance/GPG1.jsp?domedia=1&mid=94AE6F5D-98F5-3A41-D703F943B9672F0A

National Institute for Health and Clinical Excellence. Medicines management options for local implementation. January 2013 http://www.nice.org.uk/media/8AA/C0/Key_therapeutic_topics_full_document.pdf

National Prescribing Centre. An organisational competency framework to ensure the effective delivery of medicines management functions and responsibilities: a guide for commissioning consortia boards. 2011. Accessible at: http://www.npc.nhs.uk/qipp/resources/consortia_board_guide_diagnostic_tool_june_2011.pdf

Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines. May 2013 http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

http://media.dh.gov.uk/network/121/files/2011/12/111201-Homecare-Medicines-Towards-a-Vision-for-the-Future2.pdf

http://media.dh.gov.uk/network/121/files/2011/12/111201-Homecare-Medicines-Towards-a-Vision-for-the-Future2.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127106/121109-NHS-Outcomes-Framework-2013-14.pdf.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127106/121109-NHS-Outcomes-Framework-2013-14.pdf.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126846/Improving-the-use-of-medicines-for-better-outcomes-and-reduced-waste-An-action-plan.pdf.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126846/Improving-the-use-of-medicines-for-better-outcomes-and-reduced-waste-An-action-plan.pdf.pdf

http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/joint%20working%20toolkit%20dh.abpi.pdf

http://www.networks.nhs.uk/nhs-networks/joint-working-nhs-pharmaceutical/documents/joint%20working%20toolkit%20dh.abpi.pdf

http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf

http://www.nao.org.uk/wp-content/uploads/2007/05/0607454.pdf

http://www.nice.org.uk/mpc/goodpracticeguidance/GPG1.jsp?domedia=1&mid=94AE6F5D-98F5-3A41-D703F943B9672F0A

http://www.nice.org.uk/mpc/goodpracticeguidance/GPG1.jsp?domedia=1&mid=94AE6F5D-98F5-3A41-D703F943B9672F0A

http://www.nice.org.uk/media/8AA/C0/Key_therapeutic_topics_full_document.pdf

http://www.npc.nhs.uk/qipp/resources/consortia_board_guide_diagnostic_tool_june_2011.pdf

http://www.npc.nhs.uk/qipp/resources/consortia_board_guide_diagnostic_tool_june_2011.pdf

http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf



Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers – getting the medicines right. June 2012 http://www.rpharms.com/current-campaigns-pdfs/rps-transfer-of-care-final-report.pdf

The Health and Social Care Information Centre. Prescriptions Dispensed in the Community: England: Statistics for 2001 to 2011. 2012. Accessible at: https://catalogue.ic.nhs.uk/publications/prescribing/primary/pres-disp-com-eng-2001-11/pres-disp-com-eng-2001-11-rep.pdf

http://www.rpharms.com/current-campaigns-pdfs/rps-transfer-of-care-final-report.pdf

http://www.rpharms.com/current-campaigns-pdfs/rps-transfer-of-care-final-report.pdf

https://catalogue.ic.nhs.uk/publications/prescribing/primary/pres-disp-com-eng-2001-11/pres-disp-com-eng-2001-11-rep.pdf

https://catalogue.ic.nhs.uk/publications/prescribing/primary/pres-disp-com-eng-2001-11/pres-disp-com-eng-2001-11-rep.pdf



7. GLOSSARY

CCG Clinical Commissioning Group

CSU NHS Staffordshire and Lancashire Commissioning Support Unit

LPN Local Pharmacy Network

NICE National Institute for Health and Care Excellence

NPC National Prescribing Centre

RAG Red, Amber, Green list for prescribing responsibility

RPS Royal Pharmaceutical Society

UHMB University Hospitals of Morecambe Bay NHS Foundation Trust



ACTIONS TIMESCALE RESPONSIBILITYa

Priority 1: Reduce preventable deaths and minimise the burden of disease 1.1 Incorporate evidence based guidance on prescribing and medicines utilisation into clinical guidelines and consider integral to the development of care pathways through the commissioning process. Where NICE guidance exists, this will be incorporated into pathways, service specifications and local guidelines.

Ongoing Senior Manager-Medicines Optimisation GP Prescribing Lead

1.2 Production and dissemination of GP Practice benchmarking data on the quality and safety of prescribing using robust comparator indicators where these exist, incorporating adherence to NICE guidance where applicable.

Ongoing Senior Manager-Medicines Optimisation CSU medicines management and business intelligence Practice Pharmacists

1.3 Pilot a software tool to interrogate GP clinical systems to systematically identify opportunities to optimise therapy for individual patients to be piloted. Tool to be rolled out to all Practices in the CCG if evaluation of the pilot is positive

From September 2013 CCG Executive member for Finance and Contracting GP Prescribing Lead Practice Pharmacists

1.4 Review primary care prescribing in the following therapeutic areas, supported by Practice pharmacists as part of the 2013-14 work plan:

Asthma – review of therapy and step-down of treatment where appropriate in accordance with BTS Guidance

COPD – patients prescribed triple therapy to be targeted for review Diabetes – implementation of NICE guidance with respect to treatment

choices; rationalisation of blood glucose testing meters Other long terms conditions where there is an opportunity to standardise

therapy in accordance with current best evidence and guidance in agreement with individual GP Practices

April 2013 to March 2014 Senior Manager-Medicines Optimisation GP Prescribing Lead GP Practices Practice Pharmacists

1.5 Implement a primary care prescribing formulary via EMIS Web that supports adherence to NICE guidance and is integrated with secondary care.

March 2014 Senior Manager-Medicines Optimisation GP Prescribing Lead GP Practices and Practice Pharmacists

Priority 2: Minimise patient harm associated with the use of medicines 2.1 Implement significant national patient safety alerts relating to medicines used in primary care, supported by Practice Pharmacists with appropriate GP and CCG oversight of overall performance.

Ongoing Senior Manager-Medicines Optimisation Practice Pharmacists to support; CSU to provide relevant prescribing data CCG Prescribing Forum

Appendix 1



2.2 Promote a culture of learning from medication incidents through CCG promotion of incident reporting and investigation, and promulgation of lessons learnt.

Ongoing Senior Manager-Medicines Optimisation Quality and Safety Committee

2.3 Agree a CCG process for reporting and investigation of concerns relating to poor performance adversely impacting on medicines optimisation or patient care

September 2013

CCG Executive

2.4 Incorporate quality standards relating to the safe and secure handling of medicines, transfer of information relating to medicines including the core data set, delivery of pharmacy services, handling of Homecare medicines (Hackett Review recommendations), and medicines utilisation into secondary care provider contracts; opportunities for incentivising the development of practice beyond that which could reasonably be expected to be delivered within core contracts to be explored.

January 2014 (for 2014-2015 contracting round)

CSU Executive Lead for Medicines Management CCG Senior Manager-Medicines Optimisation

2.5 Prioritise medication reviews by Practice Pharmacists for patients registered with GP Practices taking “high risk” medicines, residents of care homes and those individuals prescribed multiple medicines with the aim of minimising harm, improving patient outcomes and improving the efficiency of prescribing

Ongoing Practice Pharmacists GP Practices

2.6 RAG list for prescribing responsibility to be reviewed for completeness and standardised where possible across Lancashire. Gaps in shared care guidance that may exist to be flagged and a plan put in place for development as part of an agreed programme of work.

August 2013 Lancashire Medicines Management Group GP Prescribing Lead Senior Manager-Medicines Optimisation

2.7 Establish a time-limited working group reporting to the UHMB Drug and Therapeutics Committee and the CCG Prescribing Forum to oversee the implementation of the recommendations from the RPS report Keeping patients safe when they transfer between care providers – getting the medicines right (2012)

From October 2013 Senior Manager-Medicines Optimisation Chief Pharmacist UHMB

Priority 3: Improve the efficiency of prescribing and reduce medicines waste 3.1 Promote generic prescribing where it is clinically appropriate, particularly for those medicines where there are significant savings to be made e.g. through current or imminent loss of patent

April 2013 onwards Senior Manager-Medicines Optimisation GP Prescribing Lead Practice Pharmacists

3.2 Implement the 2013-2014 Primary Care Prescribing and Medicines Optimisation workplan (Appendix 3), to include the targeting of the key therapeutic areas suggested by NICE (Appendix 2) where the CCG’s performance is below the national upper quartile.

April 2013 onwards Senior Manager-Medicines Optimisation GP Prescribing Lead Practice Pharmacists GP Practices



3.3 Explore opportunities for efficiencies in the supply and procurement of medicines (including rebate arrangements) where these have the potential to improve patient care and deliver value for money e.g. supply of medicines through Homecare.

Ongoing CSU Executive Lead for Medicines Management Senior Manager-Medicines Optimisation

3.4 Undertake a review of UHMB contracting arrangements for PEG feeds and oral nutritional supplements alongside the commissioning of an enhanced Dietetic service in order to ensure that all prescribing of nutrition supplements is appropriate and represents value for money.

March 2014 Executive Lead for Finance and Contracting

3.5 Explore efficiencies in the commissioning and management of specialist, high cost drugs in collaboration with other CCGs in Lancashire and with the leadership and support of the CSU medicines management service.

Ongoing CSU Executive Lead for Medicines Management Senior Manager-Medicines Optimisation GP Prescribing Lead

3.6 Develop and implement Good Practice Guidance in Managing Repeat Prescribing to ensure that repeat prescribing processes do not inadvertently contribute to medicines waste. Consider the patient experience as part of the development process.

December 2013 Senior Manager-Medicines Optimisation Practice Pharmacists GP Prescribing Lead Local Pharmacy Network

3.7 Increase the proportion of repeat prescription requests submitted electronically by patients to their GP practice, and the number of prescriptions generated electronically where this is the wish of the patient (as specified by the Electronic Prescription Service)

March 2014 Senior Manager-Medicines Optimisation GP Practices Practice Pharmacists Local Pharmacy Network

3.8 Implement relevant recommendations identified in the report Improving the use of medicines for better outcomes and reduced waste (Department of Health, 2012) including:

Targeted medication reviews by Practice Pharmacists of care home residents and patients prescribed multiple medicines

Review the facility for bulk prescribing in long-term facilities and publicise best practice to care home owners

GPs and pharmacists to reduce waste arising from the addition of “as required” medicines to administration support systems, and through individual supply of liquid preparations

Commissioning intentions for medicines supply from secondary care to be tailored to promote the use of Patient’s Own Drugs (PODs) and avoid

March 2014 Senior Manager-Medicines Optimisation Practice Pharmacists GPs and Practice Team CSU Executive Lead for Medicines Management




excessive supplies being made on discharge from hospitals

3.9 When the outputs of the Safety of Medicines in Care Homes Project http://images.myhomelifeessex.org.uk/Medication-Safety-in-Care-Homes-Newsletter-3-June-2012.pdf are available, consider the recommendations and the processes required for implementation

March 2014 (dependent upon report

publication date)

Senior Manager-Medicines Optimisation GP Prescribing Lead CCG Prescribing Forum

Priority 4: Optimise the use of medicines by considering medicine issues integral to care pathways and empowering patients to actively contribute to decisions about their medicines 4.1 Agree with provider services robust, patient-focussed outcome measures which can then be incorporated into commissioning arrangements

December 2013 CSU Executive Lead for Medicines Management Senior Manager-Medicines Optimisation

4.2 Agree and implement a patient pathway to refer suitable patients recently discharged from hospital to community pharmacists for a post-discharge Medicines Use Review (MUR), working with GPs, community pharmacists and the Lancashire Local Pharmacy Network.

March 2014 Senior Manager-Medicines Optimisation Chief Pharmacist UHMB Chair, Lancashire LPN

4.3 Implement patient self-management plans with a focus upon medicines adherence within care pathways as an integral part of the personalised care planning process

Ongoing 2013 - 2015

Senior Manager-Medicines Optimisation CSU Medicines Management Clinicians Commissioners

4.4 Identify patients with multiple, complex long term conditions who could benefit from additional support to help them take their medicines effectively and with their consent, refer where appropriate for a Medicines Use Review (MUR) by a community pharmacist or a Dispensing Review of the Use of Medicines (DRUM)

Ongoing

Practice Pharmacists GP Practice team Local Pharmacy Network

Priority 5: Clinical leadership and engagement 5.1 Develop and agree Role Outlines for CCG Prescribing Lead and nominated Prescribing Leads within individual Practices.

September 2013 CCG Executive GP Prescribing Lead

5.2 Encourage GPs and GP Practices to take responsibility for critically reviewing their prescribing performance, seeking support and advice if needed with the aim of delivering safe, evidence-based prescribing and delivering best value from the prescribing budget.

Ongoing GP Prescribing Lead Senior Manager-Medicines Optimisation

5.3 Invite the Local Pharmacy Network to identify a community pharmacist representative to advise the CCG on its medicines optimisation strategy and opportunities for engaging the community pharmacy sector in the delivery of CCG priorities

October 2013 CCG Chair / Executive

http://images.myhomelifeessex.org.uk/Medication-Safety-in-Care-Homes-Newsletter-3-June-2012.pdf

http://images.myhomelifeessex.org.uk/Medication-Safety-in-Care-Homes-Newsletter-3-June-2012.pdf



Priority 6: Robust infrastructure to support medicines optimisation 6.1 CCG to assess its position against the National Prescribing Centre (NICE) Organisational competency framework to ensure the effective delivery of medicines management functions and responsibilities

September 2013 Senior Manager-Medicines Optimisation GP Prescribing Lead CCG Executive Lead

6.2 Review CCG arrangements for local decision making in relation to medicines to ensure good governance and compliance with the NHS Constitution whilst at the same time delivering efficient working practices and avoiding duplication of effort. Governance arrangements to be clarified through the development and adoption of a CCG policy.

July 2013 GP Prescribing Lead CCG Executive Lead

6.3 Establish a CCG Prescribing and Medicines Optimisation Forum through the formalisation and remit expansion of the current Practice Pharmacists’ Group.

July 2013 GP Prescribing Lead CCG Executive Lead

6.4 Review and evaluate GP Practice requirements for pharmacy support to assist in the delivery of the CCG strategy for prescribing and medicines optimisation and make recommendations for 2014 – 2015 requirements. Consider opportunities for efficiencies and skill mix.

December 2013 Senior Manager-Medicines Optimisation GP Prescribing Lead CCG Executive Lead

6.5 Agree a standard Practice Pharmacist job description for those functions associated with the delivery of CCG objectives. This to be done in consultation with Practice Pharmacists and GP Practices.

December 2013 Senior Manager-Medicines Optimisation Practice Pharmacists

6.6 Explore the potential role of an Interface Pharmacist with the University Hospitals of Morecambe Bay NHS FT to facilitate the optimisation of medicines across the primary-secondary care interface and assist in the resolution of problems relating to discharges, medication requests, etc.

December 2013 CCG Executive Lead GP Prescribing Lead Senior Manager-Medicines Optimisation

6.7 Consider benefits and potential investment requirements in bespoke service(s) provided to residents of care homes to optimise medicines use and reduce medicines waste

March 2014 CCG Executive Lead Senior Manager-Medicines Optimisation Practice Pharmacists

Priority 7: Partnership working with key stakeholders 7.1 Develop and agree a CCG policy for joint working with the pharmaceutical industry and other commercial organisations

September 2013 Senior Manager-Medicines Optimisation Chief Financial Officer

a - lead responsibility denoted in italics



NICE Key therapeutic topics: Medicines management options for local implementation (2013) (http://www.nice.org.uk/mpc/keytherapeutictopics/KeyTherapeuticTopics.jsp)

Laxatives Review and, if appropriate, revise prescribing of laxatives for adults to ensure that they are prescribed routinely only for the short-term treatment of constipation when dietary and lifestyle measures have proven unsuccessful or if there is an immediate clinical need.

Laxatives should be prescribed for treating children and young people with constipation in line with the NICE clinical guideline on constipation in children and young people.

Renin-angiotensin system drugs

Review and, if appropriate, revise prescribing to ensure it is in line with NICE guidance.

Lipid modifying drugs including ezetimibe

Review and, if appropriate, revise prescribing of ezetimibe and high-cost statins to ensure it is in line with NICE guidance.

Omega-3 fatty acid supplements

Review and, if appropriate, revise prescribing to ensure it is in line with NICE guidance.

High dose inhaled corticosteroids in asthma

Review the use of inhaled corticosteroids (ICS) routinely in people with asthma.

Step down the dose and use of ICS when clinically appropriate in people with asthma.

Hypnotics Review and, if appropriate, revise prescribing of hypnotics to ensure that it is in line with national guidance.

Low dose antipsychotics in people with dementia

Review and, if appropriate, revise prescribing of low-dose antipsychotics in people with dementia, in accordance with the NICE/Social Care Institute for Excellence (SCIE) clinical guideline and the NICE quality standard on dementia and the Alzheimer's Society best practice guide.

First-choice antidepressant use in adults with depression or generalised anxiety disorder

Review and, if appropriate, revise prescribing of antidepressants in adults to ensure that it is in line with NICE guidance.

Antibiotic prescribing - especially quinolones and cephalosporins

Review and, if appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.

Review the total volume of antibiotic prescribing against local and national data.

Review quinolone and cephalosporin prescribing against local and national data.

Three-day courses of trimethoprim for uncomplicated urinary tract infection

Review and, if appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing of 3-day courses of trimethoprim is in line with Health Protection Agency (HPA) guidance.

Minocycline Review and, if appropriate, revise prescribing of minocycline in light of its potential harms.

Type 2 diabetes mellitus Consider carefully the risks and benefits of both intensive glycaemic control and use of hypoglycaemic agents for type 2 diabetes mellitus. Review and, if appropriate, revise prescribing to ensure that it is in line with NICE guidance.

Review and, if appropriate, revise prescribing of long-acting insulin analogues for type 2 diabetes mellitus to ensure that it is in line with NICE guidance.

Review and, if appropriate, revise local use of self-monitoring of blood glucose for type 2 diabetes mellitus to ensure that it is in line with NICE guidance.

Appendix 2

http://www.nice.org.uk/mpc/keytherapeutictopics/KeyTherapeuticTopics.jsp

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12993

http://www.nice.org.uk/guidance/cg42

http://www.nice.org.uk/guidance/cg42

http://guidance.nice.org.uk/QS1

http://www.alzheimers.org.uk/site/scripts/download_info.php?downloadID=609

http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1197637041219





Non-steroidal anti-inflammatory drugs

Review the appropriateness of non-steroidal anti-inflammatory drug (NSAID) prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal and cardiovascular morbidity and mortality (for example, older people).

If an NSAID is needed, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, if appropriate, revise prescribing of etoricoxib to ensure it is in line with Medicines and Healthcare products Regulatory Agency (MHRA) advice and the NICE clinical guideline on osteoarthritis (currently being updated).

Co-prescribe a proton pump inhibitor with NSAIDs for people with osteoarthritis, rheumatoid arthritis or low back pain (for people over 45 years), in accordance with NICE clinical guidelines.

Wound care products Review and, if appropriate, revise prescribing of wound dressings to ensure that the least costly dressings that meet the required clinical performance characteristics are routinely chosen.

Prescribe the minimum quantity of dressings sufficient to meet people's needs.

Do not routinely choose antimicrobial (for example, silver, iodine or honey) dressings ahead of non-medicated dressings.

http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON1004250


http://www.nice.org.uk/CG59

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=13505








Primary Care Prescribing and Medicines Optimisation Workplan 2013/14

Specific elements of the CCG’s Prescribing and Medicines Optimisation Strategy that are particularly relevant to primary care and primary care clinicians are summarised in the 2013/14 workplan. GPs, Practice Pharmacists, Practice Nurses, Community Pharmacists and the wider primary care team have an important contribution to make to the delivery of the strategy and the achievement of the CCG’s challenging efficiency targets. The detail of the workplan as outlined seeks to support the achievement of the CCG’s overall aim to improve the health and experience of people of Lancashire North through the optimal use of medicines.

TOPIC INTERVENTION Impact on

Prescribing Budget

SUPPORTING INFORMATION

Priority 1: Reduce preventable deaths and minimise the burden of disease through the utilisation of medicines Review primary care prescribing in the following therapeutic areas, supported by Practice Pharmacists:

NICE Key Therapeutic Topics for Local Implementation, January 2013

• Asthma Review of therapy and step-down of treatment where appropriate in accordance with BTS Guidance

NICE Key Therapeutic Topic: High dose inhaled corticosteroids in asthma

• COPD Targetted review of patients prescribed inhaled triple therapy to assess for ongoing benefit

NICE guidance Chronic obstructive pulmonary disease CG101, June 2010

• Diabetes – implementation of NICE guidance with respect to treatment choices; rationalisation of blood glucose testing meters and strips

NICE guidance: Management of Type 2 diabetes CG66, May 2008 NICE guidance: management of Type 2 diabetes CG87 – newer agents (last modified March 2010)

Implement an integrated primary – secondary care prescribing formulary

Implementation of a CCG prescribing formulary integrated with secondary care to be supported via EMIS Web and loading of formulary recommendations onto the GP clinical system

UHMB Prescribing Formulary

Systematic identification of patients whose treatment may be optimised

Pilot of a software tool that interrogates GP clinical systems and identifies suitable patients for review to be undertaken in volunteer Practices and rolled to others, subject to evaluation

Medicines Management software tool further information

Priority 2: Minimise patient harm associated with medicines Implementation of patient safety alerts

CCG Prescribing and Medicines Optimisation Forum and Practice Pharmacists to provide guidance to practices on action required for individual alerts

MHRA Drug Safety Updates

Medication reviews Practice Pharmacists to provide support to GP Practices by prioritising medication reviews for patients taking “high risk” medicines, residents of care homes, and patients prescribed multiple medicines

Beers Criteria for potentially inappropriate medication use in older adults

Prescribing responsibility for specialist medicines

RAG list to be maintained and updated, and recommendations implemented in primary and secondary care.

Appendix 3



http://www.nice.org.uk/mpc/keytherapeutictopics/KTT5.jsp




http://guidance.nice.org.uk/CG66


http://publications.nice.org.uk/type-2-diabetes-cg87

http://publications.nice.org.uk/type-2-diabetes-cg87

http://www.uhmb.nhs.uk/files/6213/6879/5869/UHMB%20Medicines%20Formulary.pdf

http://www.fdbhealth.co.uk/solutions/medicines-management/

http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/index.htm

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf



Supporting safe transfer of care

Implement recommended data set for medicines when patients transfer between care providers e.g. hospital admission

Royal Pharmaceutical Society: keeping patients safe when they transfer between care providers, 2012

Review primary care prescribing in the following therapeutic areas, supported by Practice Pharmacists:

• Non-steroidal anti-inflammatory drugs

Review treatment and discontinue NSAID where possible, considering alternative therapeutic options as appropriate If an NSAID must be prescribed, choose a safer option e.g. naproxen or ibuprofen and consider gastro-protection

NICE key therapeutic topic: Non-steroidal anti-inflammatory drugs

• Antibiotics Review and discontinue minocycline Reduce unnecessary prescribing of antibiotics Minimise utilisation of cephalosporins and quinolones Restrict prescribing of trimethoprim to 3 day courses for uncomplicated UTIs

NICE key therapeutic topic: Antibiotic prescribing HPA Antibiotic Prescribing Guidance, February 2013

Priority 3: Improve the efficiency of prescribing and reduce medicines waste Generic prescribing Prescribing generically where clinically appropriate to do so and

avoid use of the more expensive stereoisomer preparations e.g. • escitalopram (citalopram preferred); • desloratadine (loratadine preferred);

Optimising treatment choices

Review and discontinue medicines considered of low priority by the CCG due to reasons of cost, safety or both. Substitute with alternative treatment where clinically appropriate.

• Doxazosin (follow NICE hypertension guidance);

NICE Hypertension CG127, August 2011

• Clopidogrel as an alternative to the combination of aspirin and / or dipyridamole for TIAs

Clopidogrel patient information leaflet (June 2013) Royal College of Physicians Clinical Guideline for Stroke 4th Edition, 2012

• Sildenafil first-line PDE5 inhibitor; prescribing audit of adherence to SLS criteria

HSC 1999/148 Department of Health Guidance

• Omacor® – to be prescribed on specialist recommendation only for the treatment of hypertriglyceridaemia. Do not prescribe for primary prevention of cardiovascular disease

NICE guidance: Management of Type 2 diabetes CG66, May 2008 NICE Key Therapeutic Topics Omega-3 supplements

• Co-Proxamol – discontinue and consider alternative pain management strategies if appropriate

MHRA safety advice on Co-Proxamol

• Eflornithine (Vaniqa®) – not to be prescribed for patients with purely cosmetic facial hirsutism

• Amorolfine – consider more effective alternative treatment if ongoing therapy required

http://www.rpharms.com/getting-the-medicines-right/keeping-patients-safe-report.asp

http://www.rpharms.com/getting-the-medicines-right/keeping-patients-safe-report.asp



http://publications.nice.org.uk/antibiotic-prescribing-especially-quinolones-and-cephalosporins-ktt9/options-for-local-implementation

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/


http://www.lancsmmg.nhs.uk/wp-content/uploads/sites/3/2013/04/Clopidogrel-Patient-Information-leaflet-June-2013.pdf

http://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf

http://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4012086.pdf







Oral nutritional supplements Malnourished patients to be risk assessed using the Malnutrition Universal Screening Tool (MUST). Consider food fortification first-line followed by Complan Shake® where clinically appropriate. Other forms of nutritional support to be prescribed on dietetic advice, or when food fortification and Complan Shake® are unsuitable.

BAPEN Malnutrition Universal Screening Tool (MUST)

Wound management Ongoing implementation and review of the dressings formulary

Dermatological Specials and Emollients

Implement the recommendations from the dermatological specials and emollients formulary

Infant formula milk Implement guidelines for prescribing infant formula in cows’ milk protein allergy and lactose intolerance

Guidelines for prescribing infant formula in cows’ milk protein allergy and lactose intolerance

Gluten free foods Review prescribing to ensure compliance with ACBS criteria, and control of quantities prescribed (Guidance on quantities is included within the reference source). It is inappropriate to prescribe cake mixes and sweet biscuits on the NHS.

Gluten free foods prescribing guideline, 2011

Repeat prescribing Review of repeat prescribing systems to ensure good governance arrangements and minimise medicines waste. Work with care homes specifically to identify opportunities to reduce medicines waste.

Sample Repeat Prescribing practice guide

Electronic prescriptions Increase the proportion of repeat prescriptions requested electronically by patients from GP practices, and increase the number of prescriptions produced electronically.

Electronic Prescription Service Improving patient on-line access enhanced service specification

Priority 4: Optimise the use of medicines by integrating medicines into care pathways and empowering patients Shared decision making Clinicians to empower patients in the management of their

medicines through engagement in shared decision making and utilisation of self-management plans

NHS/BMJ Shared Decision Making (SDM) resources

Support for medicines taking Identify those patients that may benefit from additional support for medicines taking and signpost to other services e.g. community pharmacist provided Medicines Use Review (MUR), Dispensing Review of the Use of Medicines (DRUM) provided by dispensing doctors, or referral to the Practice Pharmacist

NHS / MHRA Medicines Use Review Patient Information Leaflet NHS Employers Medicines Use Review (MUR) resources

Inhaler technique Optimise the use of inhaled medicines in respiratory disorders through improved inhaler technique

Greater Manchester Inhaler Technique demonstration videos

http://www.bapen.org.uk/pdfs/must/must_full.pdf

http://www.bapen.org.uk/pdfs/must/must_full.pdf

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/Infant-formula-milk-prescribing-guidelines.pdf

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/Infant-formula-milk-prescribing-guidelines.pdf

http://www.coeliac.org.uk/revisedprescribingguideline2011

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/RepeatPrescribing-Apracticeguide2011.pdf


http://www.gpcwm.org.uk/wp-content/uploads/NHS_England_ess-Improving_patient_online_access_2013_14_apr2013.pdf

http://www.gpcwm.org.uk/wp-content/uploads/NHS_England_ess-Improving_patient_online_access_2013_14_apr2013.pdf

http://sdm.rightcare.nhs.uk/

http://www.mhra.gov.uk/home/groups/pl-a/documents/websiteresources/con2023072.pdf

http://www.mhra.gov.uk/home/groups/pl-a/documents/websiteresources/con2023072.pdf

http://www.nhsemployers.org/PayAndContracts/CommunityPharmacyContract/CPCFservicedevelopments2011/MUR/Pages/TargetedMURs.aspx

http://www.nhsemployers.org/PayAndContracts/CommunityPharmacyContract/CPCFservicedevelopments2011/MUR/Pages/TargetedMURs.aspx

https://wessexhiecpartnership.org.uk/wires/video-series/inhaler-technique/

https://wessexhiecpartnership.org.uk/wires/video-series/inhaler-technique/



Priority 5: Structural enablers CCG Prescribing and Medicines Optimisation Forum

CCG Prescribing and Medicines Optimisation Forum to be established with links to each GP Practice via Practice Pharmacists and receipt of minutes by each GP Practice’s Prescribing Lead GP

Role clarification Template job description for CCG resourced functions of Practice Pharmacist role to be developed. Role outline for GP Practice Prescribing Leads to be proposed.

Future developments Interface pharmacist Explore the potential role of an Interface Pharmacist with the

University Hospitals of Morecambe Bay NHS FT to facilitate the optimisation of medicines across the primary-secondary care interface and assist in the resolution of problems relating to discharges, medication requests, etc.

Practice Pharmacist resource

Review and evaluate GP Practice requirements for pharmacy support to assist in the delivery of the CCG strategy for prescribing and medicines optimisation and make recommendations for 2014 – 2015 requirements. Consider opportunities for efficiencies and skill mix

Care Homes Consider benefits and potential investment requirements in bespoke service(s) provided to residents of care homes to optimise medicines use and reduce medicines waste

Key:

high impact potential on the prescribing budget

medium impact on the prescribing budget

lower impact on the prescribing budget and/or relevant to other strategic priorities e.g. patient safety, reducing hospital admissions, improving outcomes

Note: It is the responsibility of the clinician, in consultation with the patient, to determine the most appropriate treatment for individual patients. The suitability of recommendations made in the workplan need to be assessed on an individual basis, and relevant prescribing information consulted.





Appendix 4 – Relationship map for CCG medicines optimisation governance and leadership arrangements

1 | P a g e


Meeting Title /Date: Governing Body Meeting - 10th of September 2013

Report Title: 2014/15 Contracting Timetable

Paper Prepared By: Gary O’Neill Date of Paper:

02/09/2013

Executive Sponsor: Hilary Fordham Responsible Manager:

Gary O’Neill

Background Paper(s): None

Summary of Report:

The attached flow diagram provides an overview of the draft commissioning and contracting process for 2014-15 along with a summary of the key actions and timescales.

Recommendation(s): The Governing Body are asked to note the contents of the report.

Please Select Y/N

Identified Risks:

No

Impact Assessment: (including health, equality, diversity & human rights)

No

Strategic Objective(s) Supported by this Paper:

Please Select x

To Improve the health of our population and reduce inequalities in health To reduce premature deaths from a range of long term conditions To develop care closer to home X To commission safe, sustainable and high quality Hospital Health Care X To commission safe, sustainable and high quality Mental Health Care X To improve capacity and capability of primary care services to respond to the changing health needs of our population

Please contact:

Gary O’Neill Senior Manager – Performance and Business Intelligence 01524 519325

2 | P a g e

2014-15 Contract Round Action Plan The diagram below provides an overview of the commissioning and contracting process for 2014-15 along with a summary of the key actions and timescales.

Please note that the above timeline is subject to change throughout the process in response to guidance from NHS England and the publication dates of key documents such as the 2014-15 PBR Guidance and the NHS Operating Framework. Other factors such as allocations changes and the impact of Specialist Commissioning may also have an impact.

September 2013

•Development and agreement of a contract round action plan

•Review current commissioning intentions and issue revised intentions to providers for 2014-15

•Notify providers whose contracts we do not plan to extend

•Complete the initial review of LES agreements

October 2013

•Gather and review feedback on commissioning intentions, assess financial impact

•Review and respond to draft guidance on 2014-15 NHS Contract (due for issue in late September)

•Review any Code of Conduct (charging) changes requested by the providers

•Commence the development of CQUIN schemes for 2014-15

•Initiate the review of current service specifications / drafting of any new specifictation as required

November 2013

•Develop and agree the CCG contract negotation strategy (tolerances, key outputs etc.)

•Develop detailed contract level plans for contract leads

•Initiate the review of other contract schedules with providers (Quality, Information etc.)

December 2013

•NHS Operating Framework for 2014-15 and updated PBR guidance to be issued by NHS England

•Review and refresh of contract round plans and CCG negotiation strategy

•Indicative contract activity and financial plans to have been developed (based on forecast outturn)

January 2014

•Commence weekly contract negotiations and progress reporting to the CCG exectutive

•Formal update to the smaller providers on block values for 2014-15

February 2014

•All key contract schedules (inc CQUIN) to have been agreed with providers (early February)

•Contract Finance and activity plans to have been agreed with providers (mid February)

•All contracts / collaborative agreements to be issued for signature (end of February)

March 2014

•All contracts to be signed by Mid March 2014 and side letters issued

•Oustanding issues / provider queries to be addressed (end of March)

•Contract review meetings to be booked for 2014-15

•Contract governance arrangements agreed by the CCG exec


Meeting Title/Date: Governing Body - 10th September 2013

Report Title: Local Enhanced Services - review 2013

Paper Prepared By: Hilary Fordham Date of Paper: September 2013

Executive Sponsor: Kevin Parkinson Responsible Manager:

Hilary Fordham


Since April 2013, NHS England has delegated responsibility to Clinical Commissioning Groups (CCGs) for the management of Local Enhanced Service agreements (LES) with Primary Care Providers. From April 2014 these will be the sole responsibility of CCGs therefore, as under the new governance arrangements CCGs are not permitted to hold LES agreements, all of these arrangements need to be reviewed and the services re-commissioned under new arrangements if they are to be continued.

Summary of Report:

This paper sets out for the Governing Body the process the CCG will be following in undertaking the review of these services and meeting the guidance that has been set out by NHS England.

Recommendation(s):

The Governing Body is asked to: Note the paper and process Agree the working principles to be used

Please Select Y/N

Identified Risks: Y


Y


Please Select (X)

To Improve the health of our population and reduce inequalities in health x

To reduce premature deaths from a range of long term conditions x

To develop care closer to home x

To commission safe, sustainable and high quality Hospital Health Care x

To commission safe, sustainable and high quality Mental Health Care x

To improve capacity and capability of primary care services to respond to the changing health needs of our population x

Please contact: Hilary Fordham, Chief Commissioning Officer, LN CCG

Local Enhanced Services - Review 2013 Background Since April 2013, NHS England has delegated responsibility to Clinical Commissioning Groups (CCGs) for the management of Local Enhanced Service Agreements (LES) with Primary Care Providers (General Practitioners, Pharmacists, Optometrists and Dental Providers). However, this is an interim arrangement; from April 2014 these will be the sole responsibility of CCGs and will not be delegated and therefore, as under the new governance arrangements CCGs are not permitted to hold LES agreements, all of these arrangements need to be reviewed and the services re-commissioned under new arrangements if they are to be continued. This paper set out for the Governing Body the process the CCG will be following in undertaking the review of these services and meeting the guidance that has been set out by NHS England. Working Principles In order to ensure that the process is undertaken in line with the CCGs overall vision for service commissioning as set out in the Strategic Plan and Commissioning Intentions documents and that the process is fair a set of working principles have been developed for this work to be undertaken against:- 1. The CCG must be able to demonstrate that it has conducted a fair, open and

transparent process and has effectively managed any identified conflicts of interests in line with current national procurement guidance and the CCG constitution.

2. The CCG should commission a range of out of hospital services which meet the

needs of its patients. These should be delivered by sustainable providers who are best able to meet the standards specified for each service required.

3. It may be necessary to commission services from list-based primary care providers

but this may not apply to all cases. 4. It is incumbent on the CCG to decommission services which are no longer required

or do not meet the needs of the local population. 5. The re-commissioning process to be used by the CCG in 2013/14 will ensure existing

and new providers are assisted in responding effectively to the required contract models and contracting processes.

6. In making judgements about the services the CCG agrees are required to meet the

health needs of the population, the organisation will not be constrained by historic patterns of service provision or maintaining payment levels to individual providers.

7. The re-commissioning process does not set out to make providers unsustainable. The process will incorporate the CCGs standards of Business Conduct and Managing Conflict of Interest policies.

Process The following process will be used for reviewing and decision making regarding these services:-

Review of each LES and summary of findings – this will cover the elements that would be undertaken as part of any service review relating to re / de-commissioning of services.

Decision of future commissioning – to include future commission, scope and method.

Action based on the above to re/decommissioning as required by April 2014

Recommendation The Governing Body is asked to:-

Note the paper and process.

Agree the working principles to be used. Hilary Fordham Chief Commissioning Officer September 2013


Meeting/Date:

Governing Body - 10th September 2013

Report Title:

Dementia Site Option Appraisal Process

Paper Prepared By:

Andrew Bennett

Date of Paper:

3rd September 2013

Executive Sponsor:

Andrew Bennett

Responsible Manager:

Kevin Parkinson



Please Select (x)

To commission services that meet the needs of the population X

To develop care closer to home To commission high quality health care X To improve the health of our population and reduce

inequalities in health

To reduce premature deaths from a range of long term conditions

To commission sustainable Mental Health Services X To improve the quality of Primary Care Summary of Report:

Recommendation(s): The Governing Body is asked to receive the recommendations of the Lancashire CCG Network and agree to: Proceed with the use of the site at The Harbour near

Blackpool as the location for the inpatient 30 place unit for people suffering from specialist dementia in Lancashire.

Welcome the comprehensive range of community service proposals presented by Lancashire Care Foundation Trust to support people and families.

The CCG Network separately considering the responsibilities of NHS commissioners when approving service reconfigurations in relation to patient and relatives’ transport and aim to create a Lancashire policy that can be applied

irrespective of the reconfiguration. In Case of Query Please Contact:

Kevin Parkinson

3

NHS Lancashire North CCG

Governing Body

10th September 2013

Dementia Site Option Appraisal Process

Introduction

At its meeting in July 2013, the Governing Body received an update on the option appraisal process which had commenced to review the location of specialist In-patient Dementia Services in Lancashire. The Governing Body noted the creation of a Joint CCG Specialist Dementia Committee and received information on the criteria to be used to undertake the option appraisal. The Committee invited representatives from Healthwatch, Age UK and the Alzheimer’s Society to assist them in their deliberations. The Governing Body is now asked to note that the Joint CCG Specialist Dementia Committee has completed the option appraisal process and has made a number of proposals to the Lancashire CCG Network. Having considered the results of the JSDC’s work, the Lancashire CCG Network has asked each CCG’s Governing Body to consider the recommendations below. Context Members of the Governing Body will recall that a formal public consultation about Dementia Services took place in 2012-13 which was led by NHS Lancashire. NHS Lancashire considered the outcomes of the consultation at its final meeting in March 2013 and accepted a recommendation that there should be a single location for a specialist inpatient Dementia Unit in Lancashire. Given that a number of concerns and comments had been raised during the consultation about the proposed location of The Harbour site in Blackpool, NHS Lancashire agreed that CCG and Local Authority commissioners should work in partnership with LCFT to undertake a technical appraisal of the options for the specialist dementia unit location. This led to the creation of the JSDC in May 2013.

The JSDC has now completed the option appraisal process using the criteria which were set out in the paper to the Governing Body in July 2013. The full report on the option appraisal is attached as Annex 1. Whilst a number of alternative locations have been considered, the option which has attracted the most support continues to be The Harbour in Blackpool. This recommendation is now to be considered by each CCG Governing Body in Lancashire.

In receiving this outcome from the JSDC, the CCG Network was reminded that a single location for an inpatient dementia service would also facilitate the development of a comprehensive range of community services for people and families living with dementia. As there are variations currently in the range and scope of community services across the county, further discussions will now be necessary between Lancashire North CCG and Lancashire Care Foundation Trust to understand the priorities for development in this locality.

4

In considering the outcomes of the public consultation on Dementia services, the board of NHS Lancashire also noted the concerns expressed about the potential impact on patients, carers and families for transport and travel to a relocated inpatient service. A recommendation was accepted that further work should be undertaken by the CCGs to consider how best to respond to these concerns.

The CCG Network has noted that transport and travel concerns are frequently raised in the context of major service reconfigurations. The Network is therefore making a recommendation to CCG Governing Bodies that consideration is now given to the development of a common policy on the issue of patient and family transport raised in the context of major service change. This policy will need to take account of any national guidance on the issue and be realistic in the context of the financial challenges facing the NHS.

Decision Required

Following discussion at the Network of the recommendations of the Joint Specialist Dementia Committee a decision was taken to recommend to each CCG in Lancashire that they individually agree to:

1. Proceed with the use of the site at the Harbour near Blackpool as the site for the in-patient

30 place unit for people suffering from specialist dementia in Lancashire. 2. Welcome the comprehensive range of community service proposals presented by

Lancashire Care Foundation Trust to support people and families. 3. That the network will separately consider the responsibilities of NHS Commissioners when

approving service reconfigurations in relation to patient and relatives’ transport and aim to create a Lancashire Policy that can be applied irrespective of the reconfiguration.

Andrew Bennett

Chief Officer

5

ANNEX 1

Joint CCG Specialist Dementia Committee

Produced by Staffordshire and Lancashire CSU 20th August 2013

6

CONTENTS

Item Description Page

1

Introduction

3

2

Methodology

3

3

Long List Generation and Agreement

4

4

Short List Generation and Agreement

5

5

Options Appraisal of the Short List

6

6

The Scoring Criteria

7

7

Scoring Guidance

8

8

Scoring Weighting

8

9

Appraisal Scoring Results

9 - 11

Appendix 1

LCFT Presentation of Short List Options

12 - 15

7

1 Introduction This report has been produced as a record of the process and outcome of the Options Appraisal carried out by the Joint CCG Specialist Dementia Committee (JCSDC) in the period May 2013 to August 2013. The appraisal took place to deliver the action required following the decision made by NHS Lancashire in response to the consultation carried out early in 2013 – for further consideration of the location for the single specialist dementia inpatient facility.

The Joint CCG Specialist Dementia Committee was established to provide the mechanism necessary for CCGs to work in collaboration with each other and with the local authorities and key stakeholder representatives to carry out this appraisal.

The Methodology for the appraisal was designed by the Staffordshire and Lancashire CSU (SLCSU) and was presented and ratified by the Committee at their inaugural meeting in May 2013.

The Committee membership made up the membership of the appraisal panel. It was agreed as part of the methodology that there would be two categories of membership:

- Statutory Commissioners – 8 CCGs and 3 Local Authorities - Advisory parties – voluntary and community sector/ patient representatives - In addition, Lancashire Care Foundation Trust (LCFT) were invited to attend to provide

evidence as advisory partners. 2 Methodology A separate detailed paper was produced for the May meeting of the Committee which contains the full description of the methodology and rationale for the process used. This option appraisal was a stakeholder based exercise – this is a specific form of appraisal that enables inclusive and equitable participation and generates an evidence base for and improved ownership of the decision making process. Each commissioning organisation has one ‘vote’ – ie. has their own individual scoring. In addition, there are advisory scores from organisations providing the third sector/ patient and carer perspective. The process was developed to be consistent with the original Technical Appraisal for the overarching Adult Mental Health Reconfiguration and in line with ‘industry standard’ public sector approaches1. In summary, the key steps in this process consisted of:

- Consideration Long List of options – submitted to the Committee by LCFT in May 2013 with detailed account of the site selection criteria. Unanimously accepted as complete and accurate long list with no amendments or additions.

1 HM Treasury (Updated 2011) The Green Book; NICE Guide to the Method of Technology Appraisal; OGC Gateway

Guidance; DCLG (2009) Multi Criteria Analysis Manual; ESSU (2007) Options Appraisal Criteria and Matrix; Desk review of comparator public sector site based appraisals (Carried out by Lancashire CSU)

8

- Selection of the Short List to form the basis of the Appraisal – proposal submitted to the Committee in May 2013 by LCFT and unanimously agreed.

- Methodology for the Appraisal of the short list presented to the Committee May 2013 including criteria for and relative weighting. Considered and agreed with minor amendments to ensure categories prioritised taking into account consultation findings and consequent agreement to build in ‘acid test’ thresholds.

- Options Appraisal of the Short List – Workshop session held June 2013 to consider evidence / allocate scoring, facilitated by SLCSU with evidence submitted by LCFT. Further scoring session held using the same format July 2013 for those members of the Committee unable to attend the first session.

- Analysis of the scoring results identifying the commissioner scoring totals and the advisory scoring separately, to identify the emergent option – presented to the Committee July 2013.

- Implementation Assurance Check on emergent – initial consideration carried out by the Committee July 2013

- Submission of further detailed evidence on the emergent option submitted to the Committee August 2013 and considered in more detail. Recommendations made by the Committee at the conclusion of the session to be taken to CCG Network and individual commissioning organisations as appropriate.

- Recommendations to be taken to CCG Network September 2013 (this report) and individual CCGs/Local Authorities to take the recommendations onto individual bodes.

Communications and engagement planning and activity took place throughout the course of the exercise, with the final updated Communications Plan considered and agreed by the Committee in August 2013 to assist with the process of communicating the recommendations in a coherent and co-ordinated way. 3 Long List Generation and Agreement The sites under the long list were generated following a search by commercial agents Eckersleys. The criteria for assessment of all sites follow typical site procurement processes and the selection process used following the 2006 public consultation for mental health services in Lancashire. These generally fall into two categories, Technical criteria supported by specialist advisors and Service criteria following workshops comprising service users, carers and clinical staff:

Technical Criteria Service Criteria

o Potential for the Trust to secure control of the site

o Potential for the Trust to manage abnormals on the site

o Potential to gain planning permission o Affordability and value for money o Potential for the site to meet size criteria

o Accessibility to other NHS services o Accessibility to local services (shops etc.) o Good public transport o Travel distance to other LCFT / health

services o Site with enough outdoor space o Not in a high crime area o Future expansion space

This generated a long list of sites as below:

9

1 The Harbour, Blackpool

2 Ribbleton Hospital

3 Royal Blackburn Hospital

4 Ormskirk DGH site

5 Guild Park, Whittingham

6 Site in Leyland (Not detailed in this report for commercial reasons)

7 Site in Bamber Bridge (Not detailed in this report for commercial reasons)

8 Site in Leyland (Not detailed in this report for commercial reasons) The Committee were given the names for the last three sites however they are not named here as they are all commercial sites. These three sites represented the option of introducing a ‘new’ site location option and therefore can be combined as representing a single Proxy Site. The Committee agreed to use the single “Proxy site” description in the Options Appraisal.

4 Short List Generation and Agreement

The proposal to reach the short list involved a detailed account of each site in the long list, provided by LCFT in the form of a presentation and question & answer session at the May meeting.

This concluded with the exclusion of options 4 and 5 as these did not demonstrate adequate deliverability or risk control to go forward.

As noted above, it was also agreed to combine 6,7 and 8 as noted above into one proxy site. Therefore the Short List was unanimously agreed as:

1 The Harbour, Blackpool

2 Ribbleton Hospital

3 Royal Blackburn Hospital

4 Proxy ‘New’ Site Following this agreement, further detailed evidence was prepared for presentation by LCFT on these four options for the Appraisal workshop session.

10

5 Options Appraisal of the Short List The Appraisal was carried out at a Workshop session of the Committee held in June 2013, with facilitation and guidance provided by SLCSU.

A presentation at the start of the workshop provided the background to the methodology, the expectations and guidance on the criteria and scoring:

Further technical guidance was provided at each step and on request. The Scoring Sheets also provided decision-aiding guidance.

11

6 The Scoring Criteria The Appraisal criteria were introduced and described at length:

- Timing and Deliverability - Integration - Access - Clinical Quality

Patient Experience & Safety

The Scoring Sheets were designed as visual aids in themselves – with one criteria per scoring sheet presented in tabular format with the criteria definition and key components and evidence checkpoints. These were collated into a workbook for each scorer for each of use and to minimise any risk of loss of paperwork and ensure only one copy of a score sheet existed so that scores could not be duplicated or missed. Example of Scoring Sheet:

12

7 Scoring Guidance

Guidance was provided at the start, during the process and on the scoring sheets:

Assessment was based upon a 0-10 scale and guidance provided as below:

8 Scoring Weighting

Weighting was applied during the analysis stage – as agreed by the Committee using standard weighting points below:

Criteria Weighting Range % Midpoint Access 10 – 20% 15% Integration 10 – 20% 15% Clinical Quality 20 – 30% 25% Patient Experience & Safety 20 – 30% 25% Timing 15 – 25% 20%

13

9 Appraisal Scoring Results The analysis of the scoring results are shown below, as presented to the Committee July 2013. Voters1 are the statutory commissioner scores. Voter2 are the advisory scores. The boxes highlighted in yellow show acid test flags – scores less than 5. 9.1 Option 1 The Harbour

9.2 Option 2 Ribbleton DGH

9.3 Option 3 Proxy Site – Central Lancashire

14

9.4 Option 4 Blackburn DGH

9.5 Acid Tests The presentation to the Committee also highlighted the Acid Tests – scores of less than 5 – across all voters, criteria and options. This demonstrated that all options had at least one result of less than 5 in Access and two options had negative acid tests in deliverability.

Option 1 – The Harbour, Blackpool Option 2 – Ribbleton DGH Option 3 - Proxy site – Central Lancs Option 4 – Blackburn DGH

15

9.6 Final Totals – Weighted and Ranked Scores

Option 1 – The Harbour, Blackpool Option 2 – Ribbleton DGH Option 3 - Proxy site – Central Lancs Option 4 – Blackburn DGH

10. Outcome and Recommendation Option 1 – The Harbour – ranked the highest as per the above table. It ranked highest for both commissioning scorers and advisory scorers. It ranked highest when both scores where combined. Therefore the emergent option was identifiable as an outcome of the appraisal as Option 1. This is therefore recommended as the option to be progress subject to the implementation assurance check and monitoring.

Unweighted WeightedTiming & Deliverability Integration Access Clinical Quality Patient Experience Ranked Voters1

n=11

Option1 100 89 69 95 96 91.45Option2 79 71 73 69 86 76.15Option4 58 80 65 81 90 76.1Option3 49 68 68 68 87 68.95

Ranked Voters2n=6


Ranked 1 & 2N=17


16

Appendix 1 LCFT Presentation of Short List Options to the Appraisal Committee Option 1 – The Harbour – the “do nothing” option

Co-located with

• Advanced Care 2 x 18 male and female single gender wards all single bed en suite

• Functional adult mental health – 4 x 18 male and female single gender wards all single bed en suite

• 2 x 8 bed PICU male and female single gender wards all single bed en suite

External space – Good

All wards have their own secure gardens Dementia ward gardens designed specifically for dementia

patients Tenure

Owned by LCFT

Strategic Expansion Space

No unless purchasing adjacent land

Delivery

Opens February 2015

Costs

All costs known and planned for

Has planning permission

Yes

17

Options 2 - Ribbleton – Central Lancs

Co-located with

18 beds functional male/female, all single bed en suite


All wards will have their own secure gardens Dementia ward gardens will be designed specifically for dementia patients

Tenure

Owned by LCFT


Yes, site is larger than current mental health plans

Delivery

Mid to late 2016 (subject to decision date)

Costs

Unknown (more details by economic appraisal)


Existing use consent

18

Option 3 - Proxy site – Central Lancs

Location – No isochronal map – comparable with Ribbleton

Co-located with

18 beds functional male/female, all single bed en suite


All wards will have their own secure

gardens Dementia ward gardens will be designed

specifically for dementia patients

Tenure

Owned by LCFT


Yes, site would be planned to be larger than current mental health plans (circa 1 acre +)

Delivery

Late 2016 / early 2017 (subject to decision date)

Costs



unknown

19

Option 4 – Blackburn

Co-located with

Advanced Care 2 x 18 male and female single gender wards all single bed en suite Functional adult mental health – 2 x 18 male and female single gender wards all single bed en suite


All wards will have their own secure gardens

Dementia ward gardens will be designed specifically for dementia patients

Tenure

Owned by East Lancashire NHS Trust


Uncertain at this time (dependant on ELHT site and development plans)

Delivery

2017 + (depends on ELHT development plans)

Costs



Existing use consent

20

Page 1 of 3 MW/NLCCG/3rd September 2013


MEETING / DATE:

Clinical Commissioning Governing Body

Report Title:

Quality Improvement Update

Paper prepared by:

Margaret Williams

Date of Paper:

3rd September 2013

Executive Sponsor: Kevin Parkinson Responsible Manager:

Margaret Williams

Background paper(s):

NCB publications outlining CCG responsibilities and Lessons Learned

Everyone Counts Planning for Patients 2012/13 Securing Excellence in Commissioning Primary Care Quality in the New Health System NHS Constitution Duty of Candour A promise to Learn- a commitment to act

Summary of Report: This paper updates the Governing Body:

of CCG governance processes of progress against the Quality Improvement Framework and reaffirms CCG commitment to build on what we do well. Using clinical

expertise, resources and intelligence to promptly respond to warning signals that services we commission may be failing.

Recommendation(s): The Governing Body is asked to: Note progress and continue to support the approach to Quality

Improvement being undertaken

Please select (Y/N)

Risk Identified: Have any risks been assessed? Y Equality Impact Assessment:

Has an EIA been completed in respect of this report/issue requiring decision?

No

Strategic objective(s) supported by this paper:

Please Select (√)

To improve the health of our population and reduce inequalities in health √ To reduce premature deaths from a range of long term conditions √ To develop care closer to home √ To commission safe, sustainable and high quality Hospital Health Care √ To commission safe, sustainable and high quality Mental Health Care √ To improve capacity and capability of primary care services to respond to the changing health needs of our population √


1.0 Introduction 1.1 This paper updates the Governing Body:

of CCG governance processes of progress against the Quality Improvement Framework and reaffirms CCG commitment to build on what we do well. Using clinical

expertise, resources and intelligence to promptly respond to warning signals that services we commission may be failing.

2.0 Background

2.1 The CCG continues to endorse a commitment to encouraging a culture of continuous improvement and accountability, seeking to scrutinize and strengthen assurance sources on behalf of the community it serves. The CCG as recently reviewed ‘Improving the Safety of Patients in England’ A promise to learn – a commitment to act. August 2013. The CCG welcomes the 10 recommendations particularly the need for the health care system to be transparent and seek out the patient and carer voice to ensure a culture that is firmly rooted in continual improvement.

3.0 CCG Governance 3.1 We describe governance as being the ‘systems, processes and behaviours by

which the CCG lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations’. Department of Health - Integrated Governance Handbook, 2006. “Good governance leads to good management, good performance, good stewardship of public money, good public engagement and, ultimately, good outcomes” (Sir Alan Langlands, Good Governance Standard for Public Services, 2004). In our first 6 month the CCG has embedded systems and processes and run a number of checks to ensure rigour. Notably, Safeguarding, management of Serious untoward Incidents, Complaints, Risk management and Quality improvement have been the priority focus.

Safeguarding 3.2 On the 8th August 2013 the Quality Improvement Committee reviewed and agreed

the CCG self-assessment of current safeguarding arrangements against the requirements detailed in Working Together to Safeguard Children and the NHS Accountability and Assurance framework: Safeguarding Vulnerable People in the Reformed NHS. The CCG has not identified any outstanding actions but is working with partners to clarify required financial contributions, requirements for GP lead for safeguarding and in the review of the designated Doctor work programme. The CCG continues to work with partners and CCG’ s Lancashire wide to deliver the Safeguarding agenda. The recently appointed Designated nurse will support the delivery of the CCG action plan and further strengthen working relationships with Local Safeguarding Children Board and Local Safeguarding Adult Board and the Safeguarding Network. It is important to recognise that the commissioning responsibilities for CCG’s is not just about managing contracts and employing expert practitioners, it is about working with others to ensure that critical services are in place to respond to children and adults who are at risk or who have been harmed, and it is about delivering improved outcomes and life chances for the most vulnerable. This requires strong leadership, working as a committed partner and investing in effective co-ordination and robust quality assurance of safeguarding arrangements.


Compliments, Concerns and Complaints 3.3 The CCG welcomes any comments patients, carers and their families may have

on the services we commission, whether that is a complaint, a suggestion or a compliment. Our aim is to provide the best possible care and treatment for service users and understand that although we strive for excellence, occasionally things may go wrong or may not be how you would like. We have a number of processes that support the CCG to be timely, transparent and consistent in our response to issues these include enrolling Commissioning Support Unit expertise, liaison with Area Team, General Practice, and Members Council. Monitoring Provider response and learning via contract quality meetings and weekly review of the CCG engagement and reputation tracker that capture multimedia reviews and comments, patient opinion postings and requests from local members of parliament.

4.0 Progress against the Quality Framework 4.1 Delivery against activity continues in line with timeframes, the next period will

focus on implementing the electronic risk management system, complimenting the model of leadership walk rounds and reviews, collaborating with Care Home Managers in order to advance delivery of the safety thermometer and harm free care relating to pressure ulcer care, falls with harm and inappropriate use of indwelling urinary catheters. Working with University of Cumbria to enhance student nurse placements in Providers including Primary Care, gaining insight into student placement feedback.

Assurance System 4.2 The CCG assurance system strengthens the CCG governance systems and

processes. In June 2013 the CCG’s early warning system triggered escalation of issues predominantly gathered from across the CCG member’s council relating to specific services at the local acute hospital. The process that followed involved the CCG Executive receiving a briefing paper outlining recurring care delivery and patient experience themes and the CCG Chief Officer meeting with the Trust Chief Executive and Cumbria CCG to agree a collaborative approach to gain clarity and further insight of issues triggered by the early warning system. The CCG the Trust and Cumbria CCG are committed to promptly responding to and acting on what patients have to say about their care and experience and as a consequence agreed four areas of collective focus. This is aimed at establishing a deeper understanding of what the quality of care issues are for patients and that we collaboratively ensure that quality of care and patient safety care via our Providers.

5.0 Recommendation

5.1 The Governing Body is asked to: Note progress and continue to support the approach to Quality Improvement

being undertaken

Margaret Williams Senior Manager, Integrated Governance and Quality Improvements 3rd September 2013

1 | Page


Meeting Title /Date: Governing Body Meeting - 10th of September 2013

Report Title: CCG Performance Report

Paper Prepared By: Gary O’Neill Date of Paper: 15th of August 2013

Executive Sponsor: Hilary Fordham Kevin Parkinson

Responsible Manager: Gary O’Neill

Background Paper(s): Appendix 1: Financial Position - Month 4 Appendix 2: CCG Assurance - Exception Report Appendix 3: CQUIN Focus Report

Summary of Report:

The purpose of this report is to outline the CCGs current performance and to provide an exception report on any areas of under achievement. Appendices are provided with further detail on the CCGs financial position, performance against the Assurance Framework and provider delivery against CQUIN quality improvement schemes.

Recommendation(s): The Governing Body are asked to note the CCGs performance against the key financial and assurance measures.

Please Select Y/N

Identified Risks: Y

Impact Assessment: (including health, equality, diversity & human rights)

No


Please Select

X To Improve the health of our population and reduce inequalities in health X To reduce premature deaths from a range of long term conditions X To develop care closer to home X To commission safe, sustainable and high quality Hospital Health Care X To commission safe, sustainable and high quality Mental Health Care X To improve capacity and capability of primary care services to respond to the changing health needs of our population X

Please contact:

Gary O’Neill Senior Manager – Performance and Business Intelligence 01524 519325

2 | Page

CCG Performance Report 1. Introduction

1.1. The following report provides an overview on the CCG’s performance at the end of July 2013 taking into account the CCGs position on finance, activity, quality, constitutional commitments and clinical outcomes.

1.2. As highlighted in previous reports, there remains a significant difficulty in accessing information that was readily available to PCTs. The CCG is able to assess its performance at a high level for many of its key objectives but lacks the detailed information needed to investigate variation or underperformance.

1.3. NHS England has established an information governance task force, which will be

overseen by a programme board with representation from the Department of Health, HSCIC (Health and Social Care Information Centre), and other stakeholders. The task force has been established to address the concerns around information provision and to help newly formed organisations deliver whilst working within information governance rules. However, the creation of the task force and the lead times associated with their work indicate that this issue will not be resolved quickly.

1.4. The Lancashire CSU are working towards gaining Accredited Safe Haven (ASH)

status so that they can process and handle SUS (Secondary user Service) information required for monitoring contract activity. They anticipate that this will be in place for the 30th September 2013. Until this is achieved the CCG is having to establish its performance based on alternate data sources which increases the risk of data quality issues. This risk has been flagged on the CCG risk register.

1.5. The CCG senior managers met with representatives from the Local Area Team (LAT)

on the 5th of August to review the performance position and to ensure that our estimates on performance match those of NHS England. Reassuringly the CCG and the LAT have similar assessments of our position and agreement on the areas of priority. This provides much needed assurance on the robustness of our performance management and position in lieu of being access the level of data we would like.

2. Financial Performance

2.1. A supporting report on the CCG’s Financial Position for month 4 has been provided under appendix 1 along with annexes showing expenditure and QIPP performance in more detail.

3. Activity Levels

3.1. At the end of quarter 1 there are a number of key themes emerging in relation to contract activity. Referral activity from GPs and other sources remains below our projected plans

for 2013-14. As a result, first outpatient appointments are also lower than plan.

3 | Page

Elective admissions and day case activity are below plan; however outpatient procedures are above our forecasts for 13-14.

Some of the this trend can be explained by commissioning intentions put in place by the CCG such as the requirement for the University Hospitals of Morecambe Bay (UHMB) to deliver skin procedures in outpatients rather than as a day case.

Accident and emergency activity and non-elective activity are below plan. Excess bed day numbers are now below plan as well by 3%.

3.2. However within this positive downward trend in activity there are a number of issues

for the CCG to consider: Firstly, although activity numbers are reducing the cost of this activity is

increasing. Some of this trend may be due to the impact of commissioning intentions such as

the REACT scheme. Lower value and less complex activity is being diverted to other more appropriate providers or is being managed in primary care, this however leaves the more complex and expensive activity with the acute provider.

Changes to clinical coding practice may also be having an impact, resulting in the same activity costing more in 13-14 than it did in 12-13.

Changes to clinical practice may also be altering the activity and financial profiles of the contracts.

3.3. Based on the available activity data a number of lines of enquiry are being pursued

with our providers. They key themes being:

An over performance in outpatient procedures, particularly in lower GI procedures, electrocardiogram monitoring and stress testing, respiratory sleep studies and major knee procedures for non-trauma cases

An over performance in Trauma and Orthopaedics at both UHMB and BMI. Most likely due to the increased capacity UHMB have put in place to support delivery of the 18 week target and the onward referral to BMI Lancaster of activity they cannot manage.

Data Quality: Both Lancashire Teaching Hospitals (LTH) and UHMB have activity which has not been coded and is therefore unclassified; this is a particular issue at LTH who have £174,281 of activity that is not correctly coded.

All of these issues are being taken forward via the contract meetings with the providers and actions agreed in response.

4. Constitutional Commitments

4.1. A detailed report on CCG performance against the national draft CCG assurance framework is provided along with appendices which show performance against the key constitutional commitments, quality and outcomes and finance measures. The CCG has scored itself as “Amber / Green” against all of the domains. The key areas to note are:

The Accident and Emergency 4 hour target has improved and we are on track to

achieve the target in quarter 2. Performance against the 62 day cancer target has deteriorated due to a number

of complex patients breaching the target time and delays in patients be seen and treated at tertiary providers.

4 | Page

Blackpool Teaching Hospitals (BTH) have reported a Mixed Sex Accommodation breach.

4.2. The CCG, in line with national guidance, will publish a position statement on its

website for quarter 1 of 2013-14 in September which will show performance against all of the key metrics in the first three months of this year.

5. Quality

5.1. The CCG has a number of concerns with respect to quality. Firstly, UHMB currently have a MONITOR compliance risk rating of RED. This

rating was put in place in response to the major Incident in 2011. BTH are an outlier on HSMI (Hospital Standardised Mortality Index) and have

recently had a Keogh review. The provider have not been given any special measures as part of their registration, however significant work is required to ensure they do not remain an outlier.

UHMB have performed poorly on the Friends and Family Test, this was due to the provider not meeting the 15% response rate for patients or asking an adequate number of patients.

6. Clinical Outcomes

6.1. Clinical outcome monitoring is still at a relatively early stage. The CCG has been provided with a range of national reports which show trends for long term conditions, mortality and potential years of life lost, however the measurement of these outcomes is in some cases a number of years behind, e.g. the 2011 position is the latest data for some measures.

6.2. The CCG has initiated work with Public Health staff from Lancashire County Council (LCC) and are developing a Long Term Conditions strategy which will be implemented through the CCGs strategic groups. The plan will consider access to screening, care closer to home; survivorship and other agendas that will help ensure patients receive quality care and intervention in line with best practice guidance.

6.3. A main area of focus in quarter 1 is the implementation of Health Checks in GP practices and alcohol liaison nurses in Accident and Emergency. The Health Check is being commissioned by LCC and the CCG will support in ensuring that at least 20% of the eligible population is offered a check.

7. Recommendations

The Governing Body is asked to note the contents of this report.

Hilary Fordham Chief Commissioning Officer Kevin Parkinson Chief Finance Officer and Director of Governance Gary O’Neill Senior Manager - Performance and Business Intelligence

5 | Page

Appendix 1: Financial position for the period ended 31st July 2013

1. Purpose

1.1. The purpose of this report is to outline the CCG’s financial position for the period ended 31 July 2013.

2. Actions

2.1. The Governing Body is requested to:

Note the CCG’s financial position for the period ended 31 July 2013. Note the position in relation to QIPP schemes and the immediate requirement to

identify schemes to achieve the outstanding balance.

3. Introduction

3.1. The CCG is reporting a position of £1,290k surplus to date, which is comprised of a planned surplus of £1,277k on commissioned (programme) services and an underspend on CCG running costs of £13k. Activity information is now starting to flow and therefore this position is based, to a large extent, on actual information received from providers as at month 03. However, there remain a number of areas where further work is required to verify expenditure, particularly in respect of Continuing Health Care, Local Enhanced Services and non-contract activity (NCAs). It is anticipated that the CCG will achieve its overall required surplus of £1,933k by the end of the financial year.

4. Allocations Summary

4.1. The overall CCG allocation has been revised upwards to £198,563k, as a result of the reinstatement of the anticipated allocation adjustment for the errors in the baseline relating to public health. It has now been agreed that the CCG will receive an allocation of £700k to cover this item. The overall allocation is as follows:

Item £’000 Programme: Anticipated allocation at month 03 194,133 Removal of anticipated adjustment re public health baseline 700 Total anticipated Programme allocation 194,833 Running costs: Anticipated allocation at month 03 3,730 Total running costs allocation 3,730 Total anticipated CCG allocation 198,563

6 | Page

5. Month 04 Financial Position – Programme Expenditure

5.1. As stated above, the CCG is reporting a £1,277k surplus to date for programme expenditure, which is in line with the financial plans submitted to NHS England at the start of the year. Within this position there are a number of areas of variance, as detailed in Annex 1, but principally:

a) University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBFT): the UHMBFT contract is over-performing by approximately £275k to month 04, mainly due to increased costs of non-elective inpatient activity (£200k) and outpatient procedures (£223k). There are a number of other overspending lines but these are offset by underspends in a number of other areas. Work is on-going with the Trust to identify causes of variances and to derive a robust year end forecast.

b) Independent sector acute contracts: independent sector acute contracts are over-performing by approximately £216k to month 04, mainly due to activity undertaken by BMI Healthcare. It is understood that this relates to patients deflected from UHMBFT, but the activity and costs require further verification.

c) GP prescribing: the GP prescribing overspend of £367k is based on prescribing

expenditure information received from NHS Prescription Services as at May 2013. It is anticipated that the work being undertaken within the CCG to manage prescribing expenditure will result in a breakeven position by year end.

5.2. In terms of other contract expenditure, the CCG is reporting variances against each

contract (both favourable and unfavourable), as per the information received to month 03 extrapolated for four months. At this stage these variances are not significant, but all of these contracts will continue to be monitored throughout the financial year.

5.3. Work continues with the Lancashire Commissioning Support Unit to enable receipt and use of patient identifiable data, which is required to verify payments and to facilitate forecasting. As the flow of information improves, the accuracy of financial reporting will be enhanced.

6. Month 04 Financial Position – CCG Running Costs

6.1. The CCG is reporting a £13k surplus to date for running costs, mainly as a result of holding a small number of vacancies. A number of assumptions have been made about spend for non-pay items and, as the year progresses, forecasting will become more accurate in relation to these areas. At this stage, therefore, caution needs to be exercised in order to ensure budgets remain in a breakeven position by year end.

7. Progress on QIPP Schemes

7.1. Annex 2 highlights the QIPP schemes identified to date and details progress. Of the schemes already identified, which comprise £3,019k of the £4,680k total, progress to date is as per plans. However, no new QIPP schemes have started in month 04 and it remains a priority for schemes to cover the full outstanding QIPP requirement of £1,661k to be identified. The CCG is currently reporting a “red” rating on QIPP in its financial returns to NHS England and therefore this is an area which will require immediate action.

7 | Page

8. Summary

8.1. The CCG’s financial position continues to be satisfactory, although it is acknowledged that there remain a number of areas where activity information flow needs to improve. Further work will be undertaken to investigate levels of expenditure for all commissioned services as the year progresses.

Kevin Parkinson Chief Finance Officer and Director of Governance

8 | Page

Annex 1: NHS Lancashire North CCG Expenditure Comparison Statement as at 31 July 2013

Annual Budget YTD Budget YTD Actuals Variance

Acute Commissioning

University Hospitals of Morecambe Bay 77,534,000 25,844,664 26,120,063 275,399

Lancashire Teaching Hospitals NHS Foundation Trust 8,044,686 2,681,561 2,693,300 11,739

Blackpool Fylde & Wyre Hospital NHS Foundation Trust 2,672,328 890,776 874,517 (16,259)

East Lancashire NHS Trust 457,234 152,412 105,179 (47,233)

Wigan Wrightington & Leigh NHS Foundation Trust 967,064 322,350 325,138 2,788

Central Manchester University Hospital NHS Trust 835,758 278,585 311,225 32,640

Other Acute Providers 2,877,241 960,458 911,478 (48,980)

Independent Sector 1,558,043 519,343 734,851 215,508

North West Ambulance Services 5,441,268 1,813,756 1,813,756 0

NCAS/OATS 160,136 53,377 94,357 40,980

Sub-Total 100,547,758 33,517,282 33,983,864 466,582

Mental Health

Child & Adolescent Mental Health 275,670 91,888 91,888 0

Learning Difficulties 1,788,323 596,104 504,761 (91,343)

Lancashire Care Foundation Trust 14,943,084 4,981,028 4,981,028 0

Calderstones NHS Foundation Trust 1,371,210 457,069 457,068 (1)

Mental Health - Not Contracted 0 (13) 0 13

Mental Health - Other 6,840,560 2,280,165 2,280,166 1

Sub-total Mental Health 25,218,847 8,406,241 8,314,911 (91,330)

Continuing Care

CHC Adult Fully Funded 10,735,401 3,578,464 3,779,741 201,277

Funded Nursing Care 2,158,012 719,336 518,059 (201,277)

Sub-total Continuing Care 12,893,413 4,297,800 4,297,800 0

Primary Care

Central Drugs 603,186 201,060 201,060 0

Commissioning Schemes 1,978,750 432,240 432,240 0

Local Enhanced Services 2,402,877 800,822 800,822 0

Out of Hours 1,340,487 446,824 446,824 0

Oxygen 249,152 83,048 83,048 0

Prescribing 23,947,066 7,982,355 8,348,994 366,639

Sub-total Primary Care 30,521,518 9,946,349 10,312,988 366,639

Community Health

Community Services 1,383,658 461,188 475,589 14,401

Lancashire Care NHS Foundation Trust 755,353 251,784 251,784 0

Blackpool Fylde & Wyre Hospital NHS Foundation Trust 12,104,278 4,034,757 4,034,757 0

Hospices 1,294,134 424,812 424,812 0

Sub-total Community Health 15,537,423 5,172,541 5,186,942 14,401

Other

Recharges NHS Property Services 449,951 149,982 149,982 0

Commissioning Non Acute 750,471 271,736 250,489 (21,247)

Sub-total Other 1,200,422 421,718 400,471 (21,247)

9 | Page

Corporate

CEO/Board Office 710,634 236,869 219,492 (17,377)

Chair & Non Exec's 61,283 20,423 21,053 630

Clinical Support 244,980 81,656 70,432 (11,224)

Commissioning 456,134 152,036 142,147 (9,889)

Finance 144,328 48,108 62,142 14,034

Performance 105,711 35,232 34,495 (737)

Quality Assurance 140,738 46,912 46,389 (523)

Corporate Costs & Services 1,703,259 567,729 579,379 11,650

Pay Reserve 162,933 0 0 0

Sub-total Corporate 3,730,000 1,188,965 1,175,529 (13,436)

Other Corporate

Reserves 8,642,619 735,047 0 (735,047)

I & E 1,933,000 1,277,000 0 (1,277,000)

QIPP (1,662,000) 0 0 0

Sub-total 8,913,619 2,012,047 0 (2,012,047)

Total 198,563,000 64,962,943 63,672,505 (1,290,438)

Allocation

Anticipated (1,518,000) 0 0 0

Confirmed (197,045,000) (64,962,943) 0 64,962,943

Potential 0 0 0 0

Total Allocation (198,563,000) (64,962,943) 0 64,962,943

Annex 2: Summary of QIPP schemes 2013/2014

Current CCG QIPP target: 4,680

Heading Description

FYE of 2012/2013 schemes

£'000

New schemes 2013/2014

£'000Total £'000

Target to month 04

£'000

Achievement to date

£'000

Variance to month 04 £'000 Comments

MSK Re-design clinical pathway for MSK patients

305 0 305 102 102 0

Falls Falls assessment service 363 0 363 121 121 0

OPPROC/day case

Correct recording/payment 0 81 81 27 27 0

Mental Health Lancashire Acute bed reconfiguration

0 270 270 90 90 0

Primary care prescribing

Underspend achieved in 2012/13

0 1,600 1,600 533 533 0

Primary care prescribing

Other schemes 0 400 400 133 133 0 schemes to be advised

Total all schemes 668 2,351 3,019 1,006 1,006 0

Shortfall 1,661 0

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Appendix 2: CCG Assurance Framework – Exception Report 1. Introduction

The purpose of this report is to outline the current position against the CCG Assurance Framework1 for the period ending 31st July 2013 and to provide an exception report on any areas of underperformance. Annex 3 provides a detailed summary of the performance to date on each of the key domains.

Lancashire North CCG Assurance Dashboard

CCG Assurance Domains Performance

Are CCGs commissioning services within their Financial allocations? Amber / Green

Are local people getting good Quality care? Amber / Green

Are patient’s rights under the NHS Constitution being promoted? Amber / Green

Are Health Outcomes improving for local people? Amber / Green

2. Are CCGs commissioning services within their financial allocations?

QIPP

The QIPP full year forecast indicator is being reported as “Amber Green” due to the current plans in place only being equivalent to an achievement of 65% of the required target (£3,019k of £4,680k). Senior Managers are working with the Executive Team and Lead GPs on developing QIPP schemes to recurrently cover the full annual target. These are currently in the planning stage but full proposals will be presented to the Finance and Performance meeting as and when the schemes are fully worked up.

Activity Levels

The table below shows a summary of the CCGs performance at the end of month 3 against the Everyone Counts activity trajectories submitted in March 2013. These activity plans are used to monitor CCG delivery and were based on contract activity plans as of March 2013.

Activity Plan Actual Variance Comments

GP Referrals 8370 7724 -646 (-8%) Referral levels are steady over the first quarter of the year and numbers are lower than the most recent financial years. Other Referrals 6236 5220 -1016 (-16%)

First Outpatient Appointments 13754 11516 -2238 (-16%)

This reduction is in part due to lower referrals but also due to other factors such as some outpatient activity being re-coded as outpatient procedures.

1 CCG Assurance Framework: http://www.england.nhs.uk/wp-content/uploads/2013/05/ccg-af.pdf

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Elective Episodes 5547 5683 136 (2%) Our contract activity shows that day cases and elective admissions are below plan. However, outpatient procedures are above plan.

Non Elective Episodes 4833 4345 -488 (-10%)

Non elective episodes are below plan; however the cost of NEL contract activity is slightly above plan due to case mix.

Currently the CCG practices are referring fewer patients to the acute providers and as a result the number of outpatient appointments has reduced. In addition the numbers of other referrals are also below plan, e.g. Consultant to Consultant referrals.

Total elective procedures are over plan by 2%; however the contract activity data shows that this is being driven by an increase in outpatient procedures alone, most notably at the University Hospitals of Morecambe Bay (UHMB). Some of this growth can be accounted for, such as the movement of certain skin procedures (JC15Z) from day case to outpatient treatment which was not factored into the activity plan. There remains however significant growth in a number of areas such as:

FZ50Z - Intermediate Large Intestine Procedures for Adults EA47Z - Electrocardiogram Monitoring and stress testing DZ50Z - Respiratory Sleep Study HB22C - Major Knee Procedures for non-trauma cases

Growth is also being recorded in a number of specialities, most notably Trauma and Orthopaedics. The increase in this speciality alone accounts for a £552,220 over performance against plan at month 3. This over performance is in part likely to be driven the by UHMBs work in 2012-13 to reduce waiting times in line with the 18 week targets, additional capacity was created at the trust and at BMI Lancaster to allow more patients to be treated on a monthly basis. This activity allowed the long waiting list at the trust to be reduced, however the service is now routinely operating with more capacity and thus the costs have increased as well.

Accident and emergency activity and non-elective admissions remain below plan. The over performance on excess bed days has reduced and is now 3% below the activity and financial plan. Although overall activity levels are reducing, the cost of the activity is increasing due to a number of factors. These include the acute trusts treating a more complex case mix of patients, changes to coding that result in activity costing more than planned, changes to provider capacity and changes to clinical pathways. There is also a significant amount of activity that needs further investigation due to concerns over the completeness and quality of the coding. Based on the activity data to hand, a list of specific lines of enquiry have been developed which the CCG is reviewing with providers to establish the cause of the variation and the joint response. This is being addressed via the provider contract meetings.

3. Are local people getting good Quality care?

Regulators MONITOR currently rates UHMBs governance as RED, this rating has been in place since the Major Incident called in October 2011. Recovery plans and actions have been put in place and communicated to MONITOR by the Trust however the rating has not been changed since the initial concerns were raised in 2011. Concerns around quality issues are being discussed regularly by the CCG governing body at Exec to Exec

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meetings with UHMB, these also include Cumbria CCG. At the last meeting it was agreed to focus on the following four main areas of safety:-

Outpatient Management Discharge A&E Harm Free Care (this includes pressure ulcers, falls, and deteriorating patient

conditions)

The four areas of priority have been identified through the Quality Surveillance Group and via the DATIX monitoring system.

Clinical Incidents The CCG is currently involved in the performance management of 22 serious incidents open to STEIS. Of the 22 incidents:

4 have been reported by Lancashire Care Foundation Trust (LCFT) 1 has been reported by Lancashire Teaching Hospitals (LTH) 1 has been reported by Blackpool Teaching Hospital ( related to the incident at

LCFT) 11 have been reported by the University Hospitals of Morecambe Bay (UHMB) 5 have been reported by the CCG/PCT on behalf of providers who cannot access

the STEIS

All of the incidents are being investigated and lessons learnt identified and enacted in response. All incidents should be investigated and closed within 45 days of being registered on STEIS. However, a number have been extended due to their complexity, e.g. due to multi-agency involvement such as the inclusion of the Coroner, Police etc. Currently the CCG is reviewing the reporting and investigation timelines with providers to ensure that all incidents are being managed effectively and as a high priority. The CCG is also clarifying the roles of the lead and co-commissioner within each investigation to ensure that the newly formed commissioning organisations engage effectively.

Incidence of Healthcare Associated Infection (HCAI) Clostridium Difficile Lancashire North CCG has recorded 19 cases of Clostridium Difficile for its patients in the first quarter of 2013; this is against an annual trajectory of 49 cases. In the main this is due to high numbers at UHMB and LTH. The CCG is working with Acting Director of Nursing and the Infections Control nurses to monitor the provider’s infection control plans. UHMB have rolled out a cross divisional action plan and have put in place weekly surveillance meetings which include the Director of Nursing, Microbiology, Pharmacy and medical input.

Pharmacists are supporting improvements in antimicrobial prescribing by reviewing drug charts daily and reporting any noncompliance with the Trust formulary. Thematic reviews are being carried out in each case. Multi-disciplinary walk rounds have been implemented covering the patient environment, which include Infection Prevention and the Matrons. UHMB are also developing a communications plan to promote awareness and to highlight the necessary actions it is progressing. The CCG anticipate being back on trajectory within the next 1-2 months.

13 | Page

Friends and Family Test On the 30th of July NHS England published the Friends and Family test data for Quarter 1 of 2013-14 which included our two main acute hospital providers UHMB and BTH. Friends and Family test performance is measured using two standards:

The response rate from patients (indicating the degree of implementation), this should be a minimum of 15% for Quarter 1.

The ‘Net Promoter’ score which is calculated based on the number of positive and negative responses.

The test should be implemented in Accident and Emergency departments and inpatient wards. For Quarter 1 both BTH and UHMB failed to achieve the 15% response rate with UHMB achieving 9.5% and BTH 10.1% for both A&E and Inpatient responses combined. The response rate nationally for both A&E and Inpatients combined was only 13.1% so although performance is low it mirrors a national trend. At UHMB the majority of the responses collected were via A&E with only a limited amount from the inpatient wards. The trust collected this data electronically using text or smartphone / tablet technology. BTH collected significantly more responses from inpatients and less from A&E and did this using a paper process. The result of the poor performance is that both providers will fail to achieve their CQUIN quality payments for Friends and Family in the first quarter of 2013-14.

With regards to achievement, or the ‘Net Promoter Score’, BTH achieved a good performance of 74 from 398 responses, UHMB were however one of the poorest performers nationally with 44 from 87 responses. The score is calculated by analysing responses and categorising them into promoters, detractors and neutral (passive) responses.

The proportion of responses that are promoters and the proportion that are detractors are calculated and the proportion of detractors is then subtracted from the proportion of promoters to provide an overall ‘net promoter’ score. More detail can be found on NHS choices2 regarding the methodology and performance. The Friends and Family Test forms part of the CCG Quality premium and achievement of this will be based on the providers net promoter score increasing between Quarter 1 and the end of the financial year.

2 NHS Choices: http://www.nhs.uk/nhsengland/aboutnhsservices/pages/nhs-friends-and-family-test.aspx

1

2

3

4

5

6

7

8

9

10

11

Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14

Inci

denc

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f C. D

iffic

ile

Months

Chart to show Incidence of C.DifficileData Source: Health Protection Agency

Plan

Actual

http://www.nhs.uk/nhsengland/aboutnhsservices/pages/nhs-friends-and-family-test.aspx

14 | Page

MSA Breaches A single breach has been reported for CCG patient at Blackpool Teaching Hospitals. This will incur a financial penalty for the trust. The provider is completing a root cause analysis on this incident to establish the cause.

4. Are patient’s rights under the NHS Constitution being promoted?

Referral to Treatment pathways Lancashire North CCG has achieved all of the 18 week targets in May 2013 at an aggregate level (all specialities combined). Neurology is the only specialty failing the 18 week target for all pathways (Admitted 50%, Non-Admitted 89%, Incomplete 82%). The underperformance is primarily at Lancashire Teaching Hospitals (LTH) and these issues will be escalated to the contract meetings with the provider.

The following specialties are underachieving (within 5% of target) for LN CCG patients and will be monitored over the coming months.

Specialty Patient Pathway

Cardiothoracic Surgery Admitted Gastroenterology Non-Admitted General Surgery Admitted Neurology Incomplete Ophthalmology Admitted Plastic Surgery Admitted, Incomplete Thoracic Medicine Non-Admitted

Urology Admitted

A&E 4 hour waiting time - Total time in the A&E department

A&E Waits Period Target Performance

A&E waiting time - total time in the A&E department Quarter 1 95% 94.5%

Quarter 2 95% Forecast 96.6%

The average weekly performance against the A&E target has remained above target across May and June. The main reasons for breaching on the Lancaster site have been due to available bed capacity, difficulties in discharging patients and delays in the patient being seen by a Doctor in A&E.

The health economy, via the Urgent Care Network, has developed an A&E recovery plan which addresses the issues underpinning poor performance. These include improving the discharge process, better integration and support from social services to enable discharge and improving community capacity. Performance for quarter 2 is on track to deliver the target.

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Cancer Waiting Time Performance

Cancer Target Period Target Performance

62 Day GP Referral Quarter 1 85% 80.9%

The CCG has under-performed on the 62 day cancer target in Quarter 1 due to particularly poor performance in May 2013. June performance increased to back above the target level at 87.9% but the underperformance in April and May has kept the overall figure below target for the quarter. Four breaches occurred during the month but these were all due to complex patient pathways or patients being unwell for treatment.

5. Are Health Outcomes improving for local people?

Data Availability

Currently the CCG is unable to access key data with respect to the delivery of outcomes targets. This is due to three key issues:

In some cases, there is a lack of clarity nationally as to how these measures will be assessed, for example, Potential Years of Life Lost (PYLL) performance needs to improve by 3.2% for the CCG to achieve its quality premium. Currently we are only able to view the data for 2011 and do not have any nationally agreed methodology for monitoring this more frequently.

For another group of measures the data is not yet accessible due to the national restrictions and issues relating to Patient Confidential Data (PCD). As an example, the CCG needs to reduce the number of Emergency Readmissions within 30 days, however the SUS data required to calculate this will not be available until the CSU have been given the appropriate accreditation by the HSCIC (Health and Social Care Information Centre).

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

07/0

4

21/0

4

05/0

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19/0

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02/0

6

16/0

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30/0

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14/0

7

28/0

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11/0

8

25/0

8

08/0

9

22/0

9

06/1

0

20/1

0

03/1

1

17/1

1

01/1

2

15/1

2

29/1

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12/0

1

26/0

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09/0

2

23/0

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09/0

3

23/0

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% o

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ient

s w

ithin

4 h

ours

Week (2013-14)

Chart to show A&E 4 hour target performanceData Source: Weekly Sitrep Data

UHMB

RLI

Target

National

16 | Page

Finally, the remaining data should be accessible but is not yet being provided by the CSU, this includes the number of asthma admissions for patients under 19 and the number of patients offered a Health Check.

The CCG has met with the CSU to try to address these issues and will be sending a schedule of data requirements that will need to be delivered by the following month. The CCG is also working with LCC to ensure that the Health Checks data is shared once it becomes available.

6. Recommendations

The Governing Body is asked to note the contents of this report.

Hilary Fordham Chief Commissioning Officer Kevin Parkinson Chief Finance Officer and Director of Governance Gary O’Neill Senior Manager - Performance and Business Intelligence

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Annex 3: Lancashire North CCG Assurance Dashboard

Version 0.1

Commentary

Amber / Green

One or more areas of concern, action plans in place.

1. UHMB currently have a MONITOR compliance risk rating of RED.

2. BTH are an outlier on HSMI (Hospital Standardised Mortality Index) and are part of the Keogh review.

3. UHMB and LCFT have unclosed SUIs (Serious Untoward Incidents).

4. Concerns around quality issues being discussed regularly by the CCG governing body.

5. UHMB have performed poorly on the Friends and Family Test - Providers are not meeting the 15% response rate.

6. UHMB have reported a Never Event in July 2013.

Amber / Green

Three Indicators rated as Amber.

1. CCG achieved 80.9% on the Cancer 62 day waits (Ref to Treatment) target against a threshold of 85%.

2. UHMB have achieved 94.5% against the A&E 4 hour target in Quarter 1 but are on track to achieve Quarter 2.

3. BTH have reported one MSA breach for a LNCCG Patient.

Amber / Green

Not all indicators are on track for achievement of the Quality Premium.

1. 19 cases of C. Difficile reported in YTD 2013 which is 39% of the CCG target..2. CCG unable to access key information to monitor local prioities and outcomes.

Amber / Green

One indicator is rated as Amber / Red

1. QIPP full year forecast, plans currently in place only achieve 65% of required target

Domain RAG Rating

GreenAmber GreenAmber RedRed

The RAG rating for each assurance domain is provided in the following sections

Are CCGs commissioning services within their

Financial allocations?

23 August 2013

Are local people getting good Quality care?

Are patients rights under the NHS Constitution being

promoted?

Are Health Outcomes improving for local people?

CCG Assurance Domains

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Lancashire North CCG: Quality

Version 0.1

UHMB LCFT BTH Period Comments

Providers

No No No Jul-13

Yes No No Jul-13 UHMB are classed as RED by Monitor (national Quality Dashboard)

No No No Jul-13 No record of enforcement action on the TDA website.

Yes N/A No Jul-13RLI: Among the worst (score: 44 from 87 responses)BTH In the normal range (score: 74 from 698 responses)

No No Yes Jul-13 Keogh investigation at BTH

No No No Jun-13

Yes No No Jun-13 19 cases have been reported for LN CCG patients.

No No Yes Jul-13 1 case reported at BTH

Yes Yes Yes Aug-13 11 for UHMB, 4 for LCFT, 1 for BTH and 1 for LTH

Yes No No Jul-13 UHMB has reported a Never Event for a Surgical Incident.

No N/A No QTR 1UHMB had a combined response rate of 9.5% and BTH 10.1% against the national standard of 15%

No Jul-13 No conditions on authorisation

Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk?

Formal Monitoring

Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern?

Has local provider been subject to enforcement action by the CQC?

Indicator Description

Has the provider been identified as a 'negative outlier' on SHMI or HSMR?

- MRSA cases are above zero

- the provider has reported more C Difficile cases than trajectory

- MSA breaches are above zero

Does the provider currently have any unclosed Serious Untoward Incidents (SUIs)?

Has the provider experienced any 'Never Events' during the last quarter?

Does the CCG have any outstanding conditions of authorisation in place on clinical governance?

Is the provider meeting the 15% response rate on the Friends and Family Test

Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions?

23 August 2013

Providers with over 5% of CCG spend

Do provider level indicators from the National Quality Dashboard show that:

CCG

19 | Page

Yes Jul-13

Discussed at Exec to Exec including Cumbria CCG. Agreed to focus on four main areas of safety. Outpatient Management, Discharge, A&E, and Harm Free Care (this includes pressure ulcers, falls, and deteriorating patient conditions).

No Jul-13 None

No Jul-13 None

No Jul-13 None

No Jul-13 No emergency events in the last quarter

No Jul-13 To be confirmed

Domain RAG Rating

Green All 'No' ResponsesAmber Green One or more 'YES' responses but action plan in place that successfully mitigates patient riskAmber Red One or more 'YES' responses and no action plan in place / plan does not successfully mitigate patient riskRed Enforcement action is being undertaken by the CQC, Monitor or TDA and the CCG is not engaged in proportionate action planning to address patient risk

Has the CCG self-assessed and identified any risk to progress against its Winterbourne View action plan?

- Concerns around the arrangements in place to proactively identify early warnings of a failing service

- Concerns around quality issues being discussed regularly by the CCG governing body

Has the CCG self-assessed and identified any risks associated with the following:

EPRR (Emergency Preparedness, Resilience and Response)

Winterbourne View

If there was an emergency event in the last quarter, has the CCG self-assessed and identified any areas of concern on the arrangements in place for dealing with such an event?

- Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events

- Concerns around being an active participant in its Quality Surveillance Group

20 | Page

Lancashire North CCG: Constitutional Commitments

Version 0.1

ID Indicator Description Frequency Basis Standard Lower Threshold Performance Data

Available Period Performance Comments

CB_B1 Referral to Treatment pathways - Admitted Pathway Monthly CCG 90% 85% Green CCG Jun-13 91%CB_B2 Referral to Treatment pathways - Non Admitted Pathway Monthly CCG 95% 90% Green CCG Jun-13 98%CB_B3 Referral to Treatment pathways - Incomplete Patients Monthly CCG 92% 87% Green CCG Jun-13 96%CB_S6 Number of 52 week Referral to Treatment Pathways Monthly CCG 0 10 Green CCG Jun-13 0

CB_B4 Diagnostic test waiting times Monthly CCG 99% 94% Green CCG Jul-13 99.4%

CB_B5 A&E waiting time - total time in the A&E department Weekly Provider 95% 90% Amber UHMB QTR 1 94.5%Quarterly position based on UHMB A&E weekly sitrep data. Quarter 2 is on track to achieve 96.06%.

CB_B6 Cancer 2 week waits Quarterly CCG 93% 88% Green CCG QTR 1 93.8%CB_B7 Cancer 2 week waits (Breast Symptoms) Quarterly CCG 93% 88% Green CCG QTR 1 94.8%CB_B8 Cancer day 31 waits (DTT to Treatment) Quarterly CCG 96% 91% Green CCG QTR 1 97.6%CB_B9 Cancer day 31 waits (Subsequent Surgery) Quarterly CCG 94% 89% Green CCG QTR 1 97.4%CB_B10 Cancer day 31 waits (Subsequent anti Cancer Drug) Quarterly CCG 98% 93% Green CCG QTR 1 100.0%CB_B11 Cancer day 31 waits (Subsequent Radiotherapy) Quarterly CCG 94% 89% Green CCG QTR 1 96.9%CB_B12 Cancer 62 day waits (Ref to Treatment) Quarterly CCG 85% 80% Amber CCG QTR 1 80.9%CB_B13 Cancer 62 day waits (Cancer Screening Service) Quarterly CCG 90% 85% Green CCG QTR 1 100.0%CB_B14 Cancer 62 day waits (Consultant Upgrade) Quarterly CCG 85% 85% Green CCG QTR 1 90.5%

CB_B15_01 Ambulance clinical quality - Category A (Red 1) 8 minute response time

Monthly Provider 75% 70% Green NWAS Jul-13 75.5%

CB_B15_02 Ambulance clinical quality - Category A (Red 2) 8 minute response time Monthly Provider 75% 70% Green NWAS Jul-13 77.9%

CB_B16 Ambulance clinical quality - Category A 19 minute transportation time Monthly Provider 95% 90% Green NWAS Jul-13 95.5%

Category A Ambulance Calls

Cancer 62 day waits (Referral to Treatment) is the only standard currently not meeting the target for quarter 1.

Performance for June 2013 is 87.9% which is above the standard of 85%. 4 breaches occured at UHMB due to complex patient pathways.

All of the indicators have been achieved for July 2013, with the NWAS cumulative YTD on all indicators above target. Lancashire North CCG Ambulance Call performance is as follows :

July 2013 Only:R1 Calls = 79.5%, R2 Calls = 71.0% and All Red

Calls = 95.2%

Apr-Jul 2013 YTD :R1 Calls = 67.8%, R2 Calls = 71.4% and All Red

Calls = 94.4%

23 August 2013

Local Monitoring and SurveillanceFormal Monitoring

18 Weeks

Diagnostic Waiting Times

A&E Waits

Cancer Waits

21 | Page

CB_B17 Mixed Sex Accommodation (MSA) Breaches Monthly CCG 0 >10 Amber CCG Jul-13 1 1 breach at Blackpool Teaching Hospitals

CB_B18 Cancelled Operations N/A CCG N/A N/A N/A UHMB Jul-13 0

Unable to monitor this data at a CCG level at present. There were none at UHMB for July, however there were 3 cancellations in the first week of August.

CB_B19 Mental Health Measure - Care Programme Approach (CPA)

Quarterly CCG 95% 90% Green CCG Qtr. 1 100% Lancashire CSU are now able to provide this data on a monthly basis for the CCG footprint.

Indicator RAG rating

Green Performance at or above the standardAmber Performance between the standard and the lower thresholdRed Performance below the lower threshold OR same indicator has amber performance for two consecutive quarters

Domain RAG Rating

Green No indicators rated redAmber Green No indicator rated red but future concernsAmber Red One indicator rated redRed Two or more indicators rated red

Mental Health

Mixed Sex Accommodation

Cancelled Operations

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Lancashire North CCG: Outcomes

Version 0.1

Indicator Description Frequency Basis ThresholdQuality

PremiumPerformance

Data Available

Period Performance Comments

Potential years of life lost (PYLL) from causes considered amendable to healthcare

Annual CCG <3.2% on 2012/13 12.5% TBC CCG 2011 6388.2 Total PYLL for men and women.

- Under 75 mortality rate from cardiovascular disease Annual CCG >= 2012/13 - TBC CCG 2011 85.7 - Under 75 mortality rate from respiratory disease Annual CCG >= 2012/13 - TBC CCG 2011 37.9 - Under 75 mortality rate from liver disease Annual CCG >= 2012/13 - TBC CCG 2011/12 28.5

- Under 75 mortality rate from cancer Annual CCG >= 2012/13 - TBC CCG 2011 139.6

Avoidable Emergency Admissions Bi-Annual CCG >= 2012/13 25.0% TBC ? ? ? - Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

Annual CCG >= 2012/13 - TBC ? ? ?

- Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Annual CCG >= 2012/13 - TBC ? ? ?

- Emergency admissions for acute conditions that should not usually require hospital admission

Annual CCG >= 2012/13 - TBC ? ? ?

- Emergency admissions for children with Lower Respiratory Tract Infections (LRTI)

CCG >= 2012/13 - TBC ? ? ?

Friends and Family test Quarterly CCG

Assurance that all relevant local providers

of services commissioned by a

CCG have delivered the nationally agreed roll-out plan to the national

timetable

6.25% Amber Provider Q1 <15%

For Quarter 1 both BTH and UHMB failed to achieve the 15% response rate with UHMB achieving 9.5% and BTH 10.1% for both A&E and Inpatient responses combined. The response rate nationally for both A&E and Inpatients combined was only 13.1%.

Patient experience for acute inpatient care and A&E services, as measured by the Friends and Family Test.

Quarterly CCG

An improvement in average FFT scores for

acuteinpatient care and A&E services between Q1

2013/14and Q1 2014/15 for acute hospitals that

serve aCCG’s population.

6.25% TBC Provider Q1 N/AThis measure will be updated when quarter 2 data becomes available.

Incidence of healthcare associated infection (HCAI) i) MRSA

Monthly CCG 0 6.25% Green CCG Jun-13 0

Incidence of healthcare associated infection (HCAI) ii) C.difficile

Monthly CCG 49 6.25% Amber CCG Jun-13 19

Local Priority 1: The number of under 19 asthma related admissions.

Monthly CCG 100 TBC ? ? ? Awaiting monitoring data from the CSU.

Local Priority 2: Emergency readmissions within 30 days of discharge from hospital for UHMB

Monthly CCG 11% 12.5% TBC ? ? ? Awaiting monitoring data from the CSU.

Local Priority 3: Percentage of eligible people offered a health check.

Monthly CCG 20% 12.5% TBC ? ? ? Awaiting monitoring data from the CSU.

Monitoring data not yet available nationally. We are in discussion with Lancashire CSU to establish a monthly monitoring process based on SUS data.

Only 2011 data available for mortality data. PYLL data is available for 3 years, currently showing an upward trend. Awaiting guidance on how these should be regularly measured.

23 August 2013

Formal Monitoring Local Monitoring and Surveillance

Quality Premium Measures (and supporting measures)

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- Referral to Treatment pathways - Incomplete Patients Annual CCG 92% -25% Green CCG Jun 13 96% 0

- A&E waiting time - total time in the A&E department Annual CCG 95% -25% Amber UHMB QTR 1 94%Quarterly position based on UHMB A&E weekly sitrep data. Quarter 2 is on track to achieve 96.06%.

- Cancer 62 day waits (Ref to Treatment) Annual CCG 85% -25% Amber CCG QTR 1 81%

Cancer 62 day waits (Referral to Treatment) is the only standard currently not meeting the target. Performance has increased to above the standard at 87.9% and has just cleared the threshold for the YTD. 4 breaches occured at UHMB due to complex patient pathways.

- Ambulance clinical quality - Category A (Red 1) 8 minute response time

Annual CCG 75% -25% Green NWAS Jul-13 76%

All of the indicators have been achieved for July 2013, with the NWAS cumulative YTD on all indicators above target. Lancashire North CCG Ambulance Call performance is as follows :

July 2013 Only:R1 Calls = 79.5%, R2 Calls = 71.0% and All Red Calls = 95.2%Apr-Jul 2013 YTD :

Health-related quality of life for people with long-term conditions

Bi-Annual CCG >= 2012/13 - TBC ? ? ? ?

Proportion of people feeling supported to manage their condition

Bi-Annual CCG >= 2012/13 - TBC PCTJan - Sep 2012

12% 12% of respondents said no, 40% said yes.

Estimated diagnosis rate for people with dementia Annual CCG 56% TBC ? ? ? Awaiting monitoring data from the CSU.

Emergency readmissions within 30 days of discharge from hospital

Monthly CCG >= 2012/13 Yes TBC CCG Feb-13 7.70% Awaiting monitoring data from the CSU.

Total health gain assessed by patients (PROMS) Quarterly CCG >= 2012/13 - Green CCG 2012-13 0.28 - Groin Hernia Quarterly CCG >= 2012/13 - Green CCG 2012-13 0.066 - Hip Replacement Quarterly CCG >= 2012/13 - Green CCG 2012-13 0.417 - Knee Replacement Quarterly CCG >= 2012/13 - Green CCG 2012-13 0.3561 - Varicose Veins Quarterly CCG >= 2012/13 No Green CCG 2012-13 None

IAPT Coverage - performance against plan Quarterly CCG 14% - TBC PCT Q4 2%

PCT was green on IAPT measures for patient accessing IAPT service and moving on to recovery. Awaiting CCG level data to assess position from April 2013 onwards.

Domain RAG Rating

Green All relevant indicators on track for achievement of Quality PremiumAmber Green Not all indicators on track for achievement of the Quality PremiumAmber Red At least one indicator statistically significantly off track for achievement of the Quality PremiumRed All indicators statistically significantly off track for achievement of the Quality Premium

National data is currently 6 months behind, we will have an indicative position for April 2013 in October 2013. There is an upward trend for the last two years.

Other Key Outcome Measures

Potential Deduction from Quality Premium (Failure to deliver Constitution rights and pledges)

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Lancashire North CCG: Financial Management

Version 0.1

ID Green Amber Green Amber Red Red Performance Period Comments

1 >= 2% 1% - 1.99% 0% - 0.99% < 0% Green May-132 >= 1% >= 0.8% >=0.5% < 0.1% Green May-133 >= 1% >= 0.8% >=0.5% < 0.1% Green May-134 Yes No Green May-13

5 >= 95% of plan

>= 80% of plan >= 50% of plan < 50% of plan

Green May-13

6>= 95% of

plan >= 80% of plan >= 50% of plan< 50% of

plan Amber Red May-13

7 < 101% of plan

< 102% of plan <103% of plan < 104% of plan

Green Apr-13

8< 101% of

plan < 102% of plan <103% of plan< 104% of

plan Green Apr-13

9 <= RCA >RCA Green May-13

10Indicator met

in full

Indicator partially met -

limited uncovered risk

Indicator partially met -

material uncovered risk

Indicator not met Green May-13 93.80%

11 TBC TBC TBC TBC Green May-13 97.60%

12 TBC TBC TBC TBC Green May-13 97.40%

Domain RAG Rating

Over-riding ruleQualified audit opinon would lead to an overall RED rating

To be defined. However, an overall green rating can only be achieved if all primary indicators are individually rated green. 2 or more red primary indicators would lead to a overall red rating.

N/A

N/A

GreenAmber GreenAmber RedRed

QIPP ** - full year forecast

Activity trends - year to date

Activity trends - full year forecast

Running costs

Clear identification of risks against financialdelivery and mitigations

This covers internal and external audit opinions, and an assessment of the timeliness and quality of returns.

Balance sheet indicators including cash management and BPCC

Underlying recurrent surplus

23 August 2013

Local Monitoring and Surveillance

18 Weeks

Formal Monitoring / ThresholdsIndicator Description

Unable to confirm at present due to patient identifiable data issues.

Surplus - year to date performanceSurplus - full year forecastManagement of 2% NR funds within agreed processes

QIPP ** - year to date delivery

25 | Page

Appendix 3: Focus Report – CQUIN Q1 (2013-14) Progress Update 1. Introduction

1.1. Updates the Quality Improvement Committee on progress to date against the Commissioning for Quality and Innovation (CQUIN) scheme in Q1 making reference to the activity of the 2 main Providers, UHMB and the Community Contract of Blackpool Teaching NHS FT.

1.2. Outlines progress against national, regional, and local CQUIN for 2013-14 and notes plans in the preparation for CQUIN 2014-15.

2. Background

2.1. The CQUIN payment framework enables Commissioners to reward excellence to compliment the delivery of improved outcomes and experience for patients. It links a proportion of Health Care Providers’ (in England) income against agreed, clinically determined improvement goals with indicators being set at national, regional and local levels. Detail and specific measurement of the nationally set CQUINs are discussed locally to ensure improvement targets reflect local need. The regional CQUIN is supported via the Advancing Quality Alliance (AQuA), a membership body aiming to improve the quality of healthcare, while the CCG works direct with clinicians across Commissioning and Provider settings to shape, develop and set local CQUIN targets, each evidencing strong rationale for inclusion.

3. Monitoring and Assurance Process

3.1. This year specific attention has been paid to the importance of establishing baseline measurement, developing specific improvement measures (indicators) that serve to demonstrate the effect we are aiming to achieve. This then supports to provide a focus and clarity when monitoring progress for improved outcomes which, in turn, strengthens our ability to interrogate performance data and so be assured of successful impact.

3.2. The ‘sign off’ process involves nominated leads, clinicians from Providers, Commissioners and Associate Commissioners coming together to review, scrutinize and spot check specific elements as considered necessary. The CCG has involved GP leads in the review of evidence and ‘sign off’ for Q1. The CCG GP lead for Quality also chairs the UHMB Contract Quality Meeting, leading the ‘sign off’ process with CCG Cumbria and the Trust. Blackpool Teaching Hospitals’ CQUIN ‘sign off’ process is held by the Corporate Team with discussion and specific evidence being presented to the LN CCG Contract meeting chaired jointly by the GP Community Workstream Lead and the CCG Chief Commissioning Officer.

26 | Page

3.3. The GP Lead for Quality and the Senior Manager for Governance and Quality have undertaken numerous site visits to see CQUIN indicators in action. Examples include attending the Blackpool Teaching Families’ Division Management meeting, engaging in the quality aspects of the agenda including patient narrative; Harm Free Care and Intentional Rounding launch event; visiting the Pharmacist and Customer Care Team; engaging with and working alongside GP Leads and other CCG Managers to understand progress being made in line with pathway or work stream activity, including attendance at UHMB ‘grand rounds’ end of life clinical session.

3.4. The final ‘sign off’ in terms of activity achievement is confirmed by the Senior Manager for Governance and Quality either via by email or by completion of the CQUIN ‘sign off’ form into the Provider. This is discussed and recorded via respective Contract Quality Meetings. It should be noted that any specific issues are brought to the attention of the lead clinician, appropriate Senior Manager and Executive as appropriate.

4. Areas Not Achieved (Annex 4 and 5)

4.1. National Dementia CQUIN- Acute Provider UHMB have been unsuccessful in delivering FAIR achievement thresholds in Q1. The Trust reports these will be met by the end of September.

4.2. National Friends and Family Test CQUIN- Acute Provider UHMB has been unsuccessful in achieving the baseline response rate of 15% to the survey (achieved 9.5%), a single response rate from the A & E and acute inpatients area. The Trust has subsequently recognised that a major limiting factor to performance was their decision to use just one method of data capture, one which also proved to be inappropriate to a significant percentage of patient profile. The Trust now aims to use multiple methods of data capture to promote engagement with the survey and, will carefully monitor their position while being confident of achieving target as at Q4. NB: this non achievement impacts 12.5 % of the CCGs quality premium

4.3. Regional Advancing Quality CQUIN- Acute Provider UHMB data set not yet published as delivery reporting will be retrospective to coincide with Advancing Quality submissions.

4.4. ‘You’re Welcome’ Children and Young People’s Standards - Local CQUIN Acute Provider To date UHMB have not commenced delivery of this CQUIN due to failure to recruit (appointed but back word given). The Trust expects to fill the post in Q2, stating that targets will be caught up in year. Following discussion LN CCG has agreed to review Q2 and Q3 performance as a whole at the end of Q3 but present lack of activity does not bode well. While baseline data will still need to be collected to ensure the development of appropriate engagement activity to progress the indicator over the remaining quarters (and so achieve future 2013-14 CQUIN incentive), the Trust has failed to meet, and now cannot meet, agreed Q1 targets which raises uncertainty around future performance.

4.5. End of Life – Local CQUIN Acute Provider Although UHMB has fallen slightly below agreed performance for 2 of the cohort 1 thresholds (staff training), agreement has been given for the release of payment as per profile based on the significant progress made towards this indicator, together

27 | Page

with achievement of the other 4 milestones within the quarter. Payment is subject to performance being back on track by the end of Q2.

4.6. Pressure Ulcer Reduction – Local CQUIN Community Provider Part of the Blackpool Teaching Community Contract Q1 CQUIN was to identify reporting rates, trends, lessons learnt and improvement as a result of rapid reviews for stage 2 pressure ulcers together with RCAs for stage 3 and 4 pressure ulcers. Evidence presented shows that while pressure ulcers are being reported and managed appropriately, there is no escalation of grade 3 and 4 cases onto StEIS as per reporting criteria. The Trust has been asked to confirm the position, the CCG having requested an audit of clinical records. Subject to assurances being received Q1 CQUIN will be met. Failure to do so will result in the Provider failing to meet Q1 requirements. Such will form part of contract discussion.

5. Future CQUIN Development

5.1. The “Review of incentives, rewards and sanctions: Discussion paper for stakeholders” (published 2 July 2013, NHS England) invites feedback from stakeholders on possible changes to the regime of incentives, rewards and sanctions in the NHS business rules for 2014/15 and beyond by 2 August 2013. With specific regard to CQUIN, comment is sought on the following proposals: The value of the CQUIN scheme 2014/15 remains at the current level of 2.5%. A national policy position is agreed for 14/15 on the applicability of CQUIN to

pass through payments; small contracts; and non-contracted activity. A more rigorous approach is adopted to the indicators that are used for CQUIN

schemes. Options for achieving this include fewer or no local indicators; clearer rules around indicator development; or a pick-list for local indicators.

The current pre-qualification gateway for CQUINs is removed on the basis that where this prohibits entry into CQUIN schemes Providers may lose motivation to improve quality.

Document accessed via http://www.england.nhs.uk/wp-content/uploads/2013/07/incent-rew-sanct.pdf

5.2. While we await the outcome of the DH CQUIN discussion paper, LN CCG has proposed to the Medical Director UHMB and Director of Nursing Blackpool a coming together to focus on the value and importance of ‘measurement for improvement’. The CCG are proposing to facilitate an event that brings clinicians and health care professional together to jointly learn and share improvement methodology and innovations for improved outcomes. The event will take place in the autumn.

6. Recommendation

6.1. The Quality Improvement Committee is asked to: Note progress made Note areas that are not met Note current CQUIN consultation document

Margaret Williams

http://www.england.nhs.uk/wp-content/uploads/2013/07/incent-rew-sanct.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/07/incent-rew-sanct.pdf

28 | Page

Senior Manager, Integrated Governance and Quality Improvements Gillian Kinloch Quality & performance Manager, Clinical Commissioning Support Unit

Annex 4: CQUIN Delivery - UHMB

29 | Page

Annex 5: CQUIN Delivery – Blackpool Teaching Hospitals Community Contract

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Quality Improvement Committee Tuesday 4th June 2013

1.30pm Room 2A Moor Lane Mills

Lancaster

Present: Sue McGraw (Chair) Lay Member Andrew Bennett Chief Officer Margaret Williams Senior Manager – Integrated Governance & Quality Improvement Dr David Knapper GP Clinical Quality Lead Dr Robin Jackson GP Executive Lead – Quality Jillian McCarthy Registered Governing Body Lay Nurse Dr David Wrigley GP Executive Lead – Public Engagement Lynn Jones Executive Lead – Practice Management Susan Hornshaw (Minutes) Administrator - Lancashire North CCG In Attendance: Diane Smith (Presenter) Dementia Matron, UHMB Jane Pattinson Commissioning Support Manager CCG Helen McConville Commissioning Manager CCG Julie Dockerty Commissioning Manager LCC – A&CS Item Description Action

8.1 Post Agenda – A Presentation on Dementia

Margaret Williams (MW) introduced Diane Smith (DS) who proceeded to give a comprehensive presentation on the Trust Dementia Improvement Work.

CCG presenation for dementia by D Smith.pptx Diane has also developed a ‘Forget me not Passport’ that should be completed for each patient so that their medical & mental history can be tracked throughout their journey within the system wherever they may be treated, be it at hospital or in a Care Home.

When asked what one specific activity would collectively support the programme, Diane agreed it would be the use of the ‘forget me not’ passport throughout the organisation. It was also agreed that one other action which would accelerate the programme would be to increase visibility of clinical leadership.

Minutes Approved on 20th August 2013

Agenda Item 14.0.

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The QIC members agreed unanimously that the dedication and attention to detail Diane had put into developing this scheme was praise-worthy. The QIC members agreed that this project should be integrated and owned across the patient journey where ever a patient may access health care. Robin Jackson (RJ) proposed that DS should be put forward as a recipient for the NHS Innovation Challenge award. http://www.nhschallengeprizes.org/ Points made following on from the presentation: Action

� need for a joined up approach between Doctors, other

dementia groups and this scheme so as to provide a united front. JP to inform relevant groups

� present this to the Practice Managers at their next meeting � present this to the District Nurses � present this to Care Home Managers � try and arrange for the QIC to visit to RLI to see the scheme

in action � improved clarity was needed on discharge letters. It was

acknowledged this would form part of broader improvement work

JP LJ DS/MW DS/MW DS/MW MW

1.0

Apologies for Absence Kevin Parkinson; Jacqui Thompson

2.0 Declaration of Interest None declared.

3.0 Minutes of the meeting held on 30 April 2013 1st paragraph, top page 3 amendment to structure of paragraph. Page 3 spelling correction of ‘Surveillance’. Page 4 para (7) 1st line – change ‘that’ for ‘the’. The Minutes where then declared a true and accurate account of the meeting.

4.0 Matters Arising 5.2 – Post Winterbourne – on agenda for discussion. 6.1 – Meeting between Colin Potter and Jacqui Thompson had taken place and a review would be given at the next meeting.

5.0 Action Sheet 4.1 & 4.1 – complete 5.1 – complete 5.2 – on agenda 6.1 – complete 6.2 – on agenda 4. Safety – QA System: All complete except: 4.2 – Dashboard process – will be placed on the next Agenda.

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6.0 6.1 6.2

Governance Risk Register (RR) MW gave an overview of the RR. MW described the development of the RR including the summary dashboard. The Committee approved the method and report format. MW stated she had shared with Internal Audit. Points raised:

! Point no. 1: this constantly changes. This is to be addressed at the GP Leads meeting on 5th June 2013.

! The majority of risks fall in the areas of Governance and Compliance. ! Delivery of Learning Disability self-assessment and Winterbourne to be

added as a risk. ! The Committee reinforced the importance of completing the ‘change

log’ for audit purposes Discussion ensued regarding the Risk Registers of our Providers there was a general concern about the lack of any visible RR’s in other Trusts. The Committee agreed it would be a positive move to share the CCG RR with our providers requesting that they reciprocate. MW suggested the CCG receive input from internal audit before sharing, the Committee members approved. Sue McGraw (SM) to contact Providers (Lancashire Care, Blackpool and UHMBT) for their Risk Registers. It was agreed that the following should be added to the register:

! Implications of cost improvement Plans ! Implications of delay or failure to deliver the Clinical Strategy

ACTION Assurance Framework (AF) MW gave an overview of the AF Summary document explaining the rationale, the format and reporting framework. She then reminded members of the CCGs 6 strategic objectives and that the function of the AF is to capture what risks may prevent the CCG achieving these. Points raised:

! It was confirmed that the AF will be presented quarterly to the Audit Committee, Governing Body and QIC.

! Audit and tracking changes will continue to improve with internal auditors.

! MW explained that each AF risk as a target at which it is controlled, it was agreed that these risk were to remain on the AF as a point of reference.

MW stated that in the near future both the RR and AF will be managed on the Datix risk management system and therefore accessible to all from their desktops. MW was thanked for all her work on developing this Plan.

SM

7.0 7.1

Safety – Quality Assurance System Quality Dashboard Development MW explained that there were two prongs to this work: � Corporate (internal) linked to the CCG Assurance Framework 2013/14

NHS England (members are to note this is DH guidance and not the AF as stated in 6.2)

� Externally linked to the Providers and role of the CSU to deliver

These two parts needed to be aligned but to date this had not progressed. Gary O’Neill (GON) has been working with CSU to progress and will report at the next meeting. It was thought that this was too long a time to wait as this needed to be addressed immediately (within the next 2-3 weeks) so that a

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7.2 7.3

fuller report could be given at the next meeting. Andrew Bennett (AB) agreed to discuss the blocks of this with GON escalate with CSU as required. . ACTION SU/StEIS Report Overview of report given by MW in Margaret Hey’s (MH) absence who explained that this was a summary of serious incidents reportable to StEIS. Points made: Amend point 4.1 East Lancs data

! Look at patterns/similarities of frequently seen incidents – will be addressed once more data is available.

! The report should show a robustness in the reporting of incidents ! Outcomes should be noted. ! The report should be in such a format that the Governing Body can get

an overall picture of the type of incidents being reported. ! Duty of Candour – this should be explained more fully in writing so that

a true measure can be gauged. MW reiterated that this work was in its early stages of development and all the above points would be taken into consideration. MW requested paper copies of the report to be handed back in to Chair to safeguard information governance. ACTION Safeguarding Update MW gave an overview of the key points within the report. A more detailed report will be given at the next meeting by the Safeguarding Manager Fiona O’Donohue. ACTION Quality Surveillance Assurance Group – Thematic review David Knapper (DK) gave an overview of Groups’ objectives.

! Aspects that the group was in the process of accessing further information assurance from the Trust related to a Communication process between middle and senior management at the Trust

! Outcomes of patient incident rapid reviews that had been undertaken 1 managed under StEIS

! Agree and collaborate with Cumbria CCG and the Trust key areas of improvement focus

AB had positive response when discussed with the Trust and Cumbria CCG MW to take next steps forward and feedback next meeting ACTION

AB MW FOD

MW

8.0 8.1 8.2

Experience – System Feedback Service Insight – Dementia Care UHMB – this was presented at the beginning of the meeting. Winterbourne Review MW introduced Julie Dockerty (JD) who gave a brief update on how progress was being made in fulfilling the requirements outlined in the Winterbourne Report. Points noted:

! A register was in place ! Review of the packages was complete. ! CCG was working with LA and key stakeholders to ensure these

actions were delivered on behalf of patients affected ! Links would be made to the broader CCG Learning Disability self-

assessment responsibilities.

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8.3

8.4

MH was working closely with JD to ensure CCGS delivered its Objectives. MW summarised the on-going work with CSU / LAT / CCG.

! A Steering Group had been set up in light of the Learning Disability Self-Assessment, need to review of current commissioned services and the Winterbourne Review.

! The LD self-assessment framework must be completed by September 2013.

! The LN CCG response s and actions are on target ! JD and MH will track and record Risks and the mitigation of these if

they arise ACTION CCG Response to Francis Report and Action Plan MW explained that we were at the next stage of the response to the Francis report. She introduced the draft Plan on a Page which was very well received. Points raised:

! CCG to receive responses from Providers. ! Senior Managers to review the actions and the sources of evidence. ! Need support from this meeting and colleagues’ input. ! Need to make the wording on the Plan on a Page more our own (this

plan was adapted from one set up by another CCG). ACTION MW to work with Senior Managers and present plan on a page for publication Discharge Summaries Robin Jackson (RJ) stated that this had not moved forward and was, in his opinion, a major clinical risk. Lynn Jones (LJ) gave her opinion on discharge summaries and said that they could be sent through the MIG (Medical Interoperability Gateway) system. A discussion ensued on the problems regarding these summaries and it was agreed that Consultants were a major factor when it came to making sure that these notes were sent out correctly and to the correct GP. Alex Gaw (Chair CCG) to meet with the Chair of the Trust. There was a need for the problem surrounding Discharge Summaries to be escalated. MW referred to the earlier agreement of commissioners and the Trust to focus on key areas for improvement of which Discharge Summaries was a suggested.

MH MW

9.0 9.1

Any Other Business CCG Business Continuity Plans MW informed members that the CCG was currently developing its CCG Business Continuity plans and that JT would present at the next meeting ACTION

JT

Date & Time of next Meeting This is scheduled for : Tuesday 20th August 2013. 1:30 – 4:30pm Room 2A, Moor Lane Mills, Lancaster

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MINUTES OF A MEETING OF THE EXECUTIVE TEAM

Tuesday, 9 July 2013 at 1.30pm Heritage Room, Moor Lane Mills, Lancaster

PRESENT: Dr Alex Gaw Clinical Chair Andrew Bennett Chief Officer Dr Cliff Elley GP Executive Lead - Commissioning Hilary Fordham Chief Commissioning Officer Dr Robin Jackson GP Executive Lead - Finance Lynn Jones Executive Lead – Practice Engagement Dr Mike Kingston GP Executive Lead – Practice Engagement Kevin Parkinson Chief Finance Officer/Director of Governance David Wrigley GP Executive Lead – Public Engagement In attendance: Sue Cole PA (minutes)

Action 206/13 207/13 208/13 209/13

APOLOGIES FOR ABSENCE There were no apologies for absence. DECLARATONS OF INTEREST Declarations of interest relating to item 10 (Commissioning LES/Risk Profiling DES update) were made by GP Executives. MINUTES OF THE LAST MEETING HELD ON 25 JUNE 2013 The minutes of the previous meeting held on 25 June 2013 were agreed as a correct record with the following amendment - Item 201/13 – Presentation of the draft Prescribing Strategy. Add ‘annually’ after ‘£0.3m’ in the second paragraph. MATTERS ARISING INCLUDING REVIEW OF THE ACTION SHEET There were no matters arising The action sheet was reviewed and updated:

Minutes Ratified - 23.7.13

Agenda Item 15.0.

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210/13 211/13

Item – 166/13 – Informatics Update It was agreed the Informatics update paper would be taken to

the Membership Council in September. The Clinical Informatics Project report and the Infrastructure report would come to an Executive meeting in September.

Item – 167/13 – Discussion paper on the Commissioning ES This item would be discussed under Item 215/13 on today’s

agenda Item – 186/16 – Briefing on NHS 111 This item would be discussed under AOB on today’s agenda Item – 190/13 – Health and Safety Andrew Bennett confirmed an action sheet would be presented

at the Executive meeting on 13 August 2013. Item – 200/13 – Prioritisation Paper Cliff Elley confirmed he had spoken to David Manion in Gary

O’Neill’s absence. Figures from 2011/12 and 2012/13 were compared and it would take a reduction of 3.4% of the 12/13 levels to take it back to the 11/12 figure.

URGENT CARE Hilary Fordham introduced Sarah Eccles and forwarded Jeremy Marriott’s apologies for not being able to attend. Hilary summarised the tabled report on Urgent Care Improvement and reminded the Executives that there was still further work to be done around resilience for winter. Robin Jackson raised a query regarding staffing levels with the Emergency Department of UHMBFT. Hilary explained that the Urgent Care Network was already looking at how to use resources available to them and commented that this was also a national problem. WORKSTREAM/QIPP REPORT (FIRST VERSION) Hilary Fordham introduced the report which Sarah Eccles and Vicki Lockwood had prepared. Sarah explained the report in further detail and asked for comments on the format. Executives were happy with the overall design, but suggested some minor amendments to the format.

AB

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212/13 213/13 214/13 215/13

PUBLIC HEALTH WORK PROGRAMME TO SUPPORT LNCCG Hilary Fordham introduced Dr Karen Slade who presented an outline of her paper. Karen continued that although the specialist work programme towards health care commissioning had been developed, there was still further work to be done and would welcome Executive’s views. Karen commented that public health’s role was to look at prevention and changes were slow to happen, however predictive modelling can help with looking at the impact. Discussions followed on the various aspect of the work programme. It was felt that public health colleagues should be part of more CCG meetings. The Executive Team agreed with the proposed work programme, to receive reports on a quarterly basis and for Karen Slade to link these with the Workstream/QIPP reports. UPDATE ON THE HEALTH AND WELLBEING BOARD David Wrigley gave a brief update on the Lancashire Health and Well Being (H&WB) Board and of the key people who attend. He explained there was an opportunity to increase collaboration between the Lancashire H&WB Board and Lancaster District H&WB Partnership of which he had recently become Chair. A question was raised by the new Lancashire H&WB Board Chair regarding priorities and David agreed to circulate these via email to Executives. It was noted that there was currently a review of the Lancashire H&WB Board underway and Lancashire CCG’s had been asked to take an active role. IMPLICATIONS OF SPENDING REVIEW Andrew Bennett explained he had circulated the letters from NHS England for information. Kevin Parkinson added that further information was required to fully work through the implications of the statement, not least the use of CCG funds to support integration plans with social care. These would be discussed further at a future meeting. A brief discussion ensued. COMMISSIONING LES/RISK PROFILING DES UPDATE

(a) Commissioning LES - Mike Kingston requested that LNCCG run the Commissioning LES until the end of March 2014 until a National Contract is produced covering Vulnerable Families, Scheduled Care and Urgent Care. Discussion followed on the various LESs. The Executives were reminded that if the CCG continued to use the LES as it did now it would be extremely difficult to measure outcomes. A debate ensued and Andrew

DW

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216/13 217/13 218/13 219/13 220/13

Bennett confirmed that clearer measures were needed to obtain figures to allow the CCG to commission services over the next 3 years. It was felt that the process needed to be formally reviewed and Mike Kingston, Lynn Jones and Sarah Eccles agreed to discuss this further. Alex Gaw commented that everyone within the Executive Team should be party to discussions on what, as Commissioners, we support, but Executive GPs should not vote on the decision.

(b) Risk Profiling DES Update - Mike Kingston gave an update

and stated that Dr Pete Nightingale was doing work around the ePIG risk profiling tool (as presented by Dr Peter Nightingale at the GP Development Day) to try to help actively/proactively reduce urgent care. After discussion Hilary Fordham agreed to prepare a paper which would clarify the strategy. It was confirmed, after a question was raised, that Lancashire North CCG are piloting this scheme and that the work would also be benchmarked. The outcome would come back to a future Executive meeting when complete.

SESSION WITH AREA TEAM – 23 JULY 2013 Andrew Bennett explained that Lancashire Area Team Executives were coming to meet on 23 July 2013 and for colleagues to consider any issues they would like raising on the agenda. VASCULAR UPDATE Andrew Bennett gave a brief update. It is now understood that a decision on vascular services from the Secretary of State is imminent. PLANNED CARE – REDUCING DEMAND It was agreed that this item would be deferred to the next meeting. OPHTHALMOLOGY OUT OF HOURS UPDATE Cliff Elley explained that although we had given our preferred option as Option 3, since then, an alternative option had been proposed which had been accepted by colleagues in Cumbria CCG. This is that the weekend service would be based in Lancaster as Cumbria CCG felt that Lancaster was more accessible than Kendal by public transport. GOVERNING BODY – FINAL ARRANGEMENTS Andrew Bennett explained to Executives there would be a brief Part 2 Agenda after the main Governing Body meeting.

MK/LJ/SE

HF

ALL

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221/13 222/13 223/13 224/13 225/13

RESPONSE TO STEVE FAIRCLOUGH PRESENTATION This item was covered under ‘Review of the action sheet’ CSU UPDATE It was agreed that this item would be deferred to the next meeting. TEAM TO TEAM WITH CUMBRIA CCG It was agreed that this item would be deferred to the next meeting. ANY OTHER BUSINESS

a) NHS 111 – Hilary explained that Dr Amanda Doyle was leading a group to look at the options regarding NHS111 and LNCCG had responded.

b) Membership Council – it was agreed due to the limited items for the agenda and annual leave that the August Membership Council be cancelled.

c) Freedom of Information (FOI) request – Kevin Parkinson

explained the Department of Health Legacy team had taken over a previous North Lancashire PCT FOI. The case is still on-going.

d) Alex Gaw confirmed he had met with the Chair of UHMBFT

DATE AND TIME OF NEXT MEETING Tuesday, 23 July 2013 at 4.00pm, Heritage Room, Moor Lane Mills

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MINUTES OF A MEETING OF THE EXECUTIVE TEAM

Tuesday, 25 June 2013 at 1.30pm Heritage Room, Moor Lane Mills, Lancaster

PRESENT: Dr Alex Gaw Clinical Chair Andrew Bennett Chief Officer Dr Cliff Elley GP Executive Lead - Commissioning Hilary Fordham Chief Commissioning Officer Dr Robin Jackson GP Executive Lead - Finance Lynn Jones Executive Lead – Practice Engagement Dr Mike Kingston GP Executive Lead – Practice Engagement Kevin Parkinson Chief Finance Officer/Director of Governance In attendance: Sue Cole PA (minutes)

Action 195/13 196/13 197/13 198/13

APOLOGIES FOR ABSENCE Apologies for absence were received from David Wrigley DECLARATONS OF INTEREST There were no declarations of interest relating to the items on the agenda. MINUTES OF THE LAST MEETING HELD ON 11 June 2013 The minutes of the previous meeting held on 11 June 2013 were agreed as a correct record with the following amendment - Item 183.13 (170/13) – Clinical Leads Update. Add ‘regarding LD’ at the end of the paragraph. MATTERS ARISING INCLUDING REVIEW OF THE ACTION SHEET There were no matters arising The action sheet was reviewed and updated: Item – 134/13 & 188/13 – EMPLOYMENT STATUS OF GPs Action complete

Minutes Ratified - 9.7.13

Agenda Item 15.0.

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199/13 200/13

Item – 154/13 – UHMBFT CIP QUALITY IMPACT ASSESSMENTS

Action complete

Item – 183/13 (168/13) – REMOTE CARE MONITORING DES After discussion it was decided that Lynn Jones and Mike Kingston would discuss with Practices directly and that a paper wasn’t therefore required for Membership Council. Item – 184/13(c) – BETTER CARE TOGETHER PRIMARY CARE WORKSTREAM Andrew Bennett listed who had been invited to the event on 26 June 2013 and those who had confirmed were attending. Item – 185/13 – FUNDING PRIORITISATION PAPER Hilary Fordham provided further information to the Executive Team on questions raised within the main agenda. Item – 189/13 – UHMBFT OPHTHALMOLOGY OUT OF HOURS WEEKEND ARRANGEMENTS Cliff Elley confirmed he had spoken to UHMBFT regarding LNCCG’s preferred option 3.

GOVERNING BODY DRAFT AGENDA Andrew Bennett outlined the items on the draft agenda and asked for any comments. A query was raised on how often the Audit Committee met and Kevin Parkinson explained that the Committee met when necessary and the next meeting was in September 2013. PRIORITISATION PAPER Hilary Fordham explained the first part of her paper covered previous questions raised. The paper then suggests how the CCG might allocate funding i.e. recurrent or non-recurrent and Hilary explained this in further detail. Alex Gaw stated that the CCG should review its approach to referral management as this was an area of demand which GPs could influence. After a discussion it was felt that the CCG should aim for a 5% reduction in referrals as this would create savings to enable future investments. Cliff Elley agreed to speak to Gary O’Neill to request statistics from 2011-12 to enable further discussion on how this would happen. After further deliberations on the various schemes Alex Gaw confirmed that the Executive Team was happy with the priority list and that the

CE

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201/13 202/13 203/13 204/13 205/13

only issue was the affordability of the Community Stroke service. PRESENTATION OF THE DRAFT PRESCRIBING STRATEGY (VERSION 0.2) Robin Jackson presented the draft Prescribing Strategy. He continued that the CCG’s Prescribing Strategy should align with Community Pharmacists and the Pharmacy Network. Robin Jackson also stated that he had reached agreement with 3 Practices (Ashtrees, Rosebank and Landscape) to run a prescribing Pilot and if accepted in the future could save the CCG £0.3m annually going forward. The Exec approved the strategy for presentation at the Membership Council. EXEC TO EXEC AGENDA Andrew Bennett outlined the agenda items for the meeting with executive colleagues from UHMBFT. DEMENTIA UPDATE (ALTHAM MEADOWS) Kevin Parkinson gave a brief update and explained that there is public concern over the future of dementia services in Altham Meadows. He reminded Execs that the decision to close Altham Meadows was a part of a wider Lancashire strategy. ANY OTHER BUSINESS

a) Alex Gaw stated he was meeting John Cowdall the Chair of University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust and also Phil Halsall, Chief Executive of Lancashire County Council and asked if there were any questions colleagues would like him to raise.

b) Andrew Bennett gave a brief presentation on the current position

of Better Care Together. DATE AND TIME OF NEXT MEETING Tuesday, 9 July 2013 at 1.30pm, Heritage Room, Moor Lane Mills

RGJ

P age GOVERNING BODY AGENDA Tuesday 10 September ...

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