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Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Subject Quality and safety



The CCE has the responsibility for scrutinising and gaining assurance in relation to the three domains of quality; safety, effectiveness and experience and the role of the Quality Group is to provide this assurance to the CCE. The group receives regular reports which collate information about quality, safety and experience from various sources.

Mitigating actions to address the areas of risk have been discussed for the following areas:Maternity services at DDH The action plan to address compliance with Outcome 4 was formally received at Executive Contract Board on 26 April 2012 and assurance will be given to ECB in June that all actions have been completed. NPSA Alerts Two alerts relating to minimising risks of mismatching spinal epidural and regional devices with incompatible connectors remain open. MYHT have accepted the risk of delaying implementation of the new equipment – a view also shared with the Association of Anaesthetics. Implementation timescale has been agreed as April 2013. Non compliance with the alerts has been added to the Trust‟s risk register and reported to ECB. HSMR Progress report on the actions being taken was presented to ECB in June 2012. Actions include weekly meetings to

The CCE Quality Group met on 14 June 2012 where information on the following key quality metrics was discussed. These were also reported to the CCE on 28 June 2012:Key Highlights No Eliminating Mixed Sex Accommodation breaches at MYHT since February 2012; VTE risk assessment at MYHT continues to be above the national average; MYHT Pinderfields (Maternity Unit and A&E) assessed as fully compliant with CQC outcomes at a follow-up visit in February 2012. MYHT Dewsbury (Maternity Unit) now compliant with CQC outcomes 13 (Staffing) - the warning notice issued has been lifted Rate of incident reporting at MYHT has increased to national average for large acute hospitals since the introduction of Datix. Significant improvement in 2011 survey of adult inpatients compared to 2010 – statistically significant for 22 questions. By the end of Q4, 75% of patients had undergone surgery following fracture neck of femur within 36 hours (the Best Practice tariff (BPT) standard) and 95% of patients had been assessed by a geriatrician within 72 hours of admission.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Area of risk Further compliance action for MYHT maternity services at DDH issued in relation to Outcome 4 (Care and welfare of people who use services) Two NPSA alerts remain open past the closure date of 2 April 2012. Although the current HSMR has fallen, concerns have been raised in respect of 2011/12 rebasing, work is ongoing to understand the full impact of the data which is due to be published in the Autumn. MRSA target above trajectory for NHS Wakefield District by the end of May 2012 (2 cases from a target of 10). Minor concern noted against Outcome 8 (Cleanliness and infection control) at a follow-up inspection of YAS in February 2012. Reduction in CQUIN achievement at Q4 for MYHT (acute), SWYPFT and YAS. The 2012/13 CQUIN schemes for independent sector, care homes and specialist commissioning group have been approved through contract negotiation processes. Commissioner commentary for MYHT Quality Accounts has been produced, and the CCG has contributed to commentary for SWYPFT and YAS accounts. Quality Accounts have to be published on the NHS Choices website by 30 June 2012. Continuing Care Evaluation Further to the update on the Continuing Care Evaluation report in the May Shadow Accountable Officer report. Preparatory work is continuing in anticipation of the evaluation taking place in Summer 2012 with a full report back to commissioners in Autumn 2012.

review all patient deaths; review of case notes in outlying diagnostic groups; and review adequacy of weekend medical cover. MRSA Two pre 48 hour bacteraemia cases – the first a patient in an intermediate care bed provided by MYHT which was deemed avoidable. An action plan is in place to prevent reoccurrence. Arrangements for MRSA suppression treatment postdischarge has been put in place through a LES with community pharmacists which began at the end of May 2012. MYHTâ€&#x;s MRSA Prevention Plan has been refreshed following a shared learning visit to South Tees NHS Trust. Stephen Eames has commissioned an external review of HCAI which will take place on 28 June 2012. The aim of the review is to provide assurance that all actions are being taken to reduce MRSA and C.diff. YAS The action plan from this inspection was formally received at the YAS Clinical Review Group on 29 May 2012.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Performance

Reporting mechanisms for Cluster board for 2012/13 has commenced through the use of a Dotty Matrix following the format of the SHA level reports. The matrix highlights the common high risk cluster areas. This month all indicators were reported for April 2012 and were green with the exception of NHS Health Checks and Health Visitors NHS Health Checks - March 2012 position Locally in 2011/12 the PMS contract was agreed and “offered NHS Checks”, was the only target for (PMS) GP practices. The PMS “offered” target for 2011/12 was 19,800, however 26,992 NHS Health Checks were offered, therefore exceeding the target set. However the number of Health checks received which remains an aspirational target but reportable to SHA under performed at 9.8% against the national target of 13.6%. This is a focus area in the June Finance and Performance Group and CCE.

Health Visitors – April 2012 position Mid Yorkshire Hospitals NHS Trust are committed to this indicator, in 2011/12 they made progress in all areas to increase the workforce and achieve the trajectory set. The trust continues to have robust plans in place for this indicator with additional members of the work force expected to complete training in the autumn and further successful candidates expected by year end 2012/13. Because Health Visitor training necessitates prolonged study, this indicator remains difficult to monitor in year, but the commissioners are confident that the trust‟s plans are justified and robust to achieve a good year end position.

A second Health Equity Audit to understand the delivery of the programme in more detail is being undertaken; the results will demonstrate where we need to improve our efforts in continuing to achieve the numbers offered and received A patient satisfaction questionnaire to identify any areas that patients feel requires improving is also being undertaken.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Performance at Mid Yorkshire remains a key focus for NHS Wakefield CCG and the following items were highlighted at the Finance & Performance Board sub group: Referral to treatment times Validated April 2013 MYHT position achieved 90.5% for admitted, 96.5% for non admitted but as the recovery plan agreed within the 18 week recovery board continues the unvalidated position has reduced as expected. However the signs are promising that the recovery is on track, the current figures as at 14 June show projected improving admitted performance 84.26% and non admitted projected 96.3% at month end. There continues to be a reduction in the admitted waiters > 18 weeks to 643 and there has been a reduction in the number of trip overs from 197 in May to 162 as at 14 June crucial to the management of the 18 week pathways. Concerns for admitted pathway underperformance remains with Gynaecology, Oral Surgery, Plastics and Orthopaedics. The PAS upgrade which incorporates 18 weeks as standard user templates has been upgraded and should provide improved 18 week data quality A&E In the financial year 12/13 to date (June 17th) A&E performance at MYHT has been as per the table below. 2012/13 as at June 17th MYHT PGH DDH PGI

4 hr performance 2012/13 96.9% 96.0% 97.5% 98.0%

18 week recovery plan continues to be actioned with frequent 18 week control towers which facilitates escalation of issues and risks

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer The period above includes both the Easter, May and Jubilee Bank holiday periods which are traditionally a busy time for A&E Departments and therefore it is encouraging that performance has been maintained across all three MYHT hospital sites in the financial year to date. The strong indications are that MYHT will achieve the required A&E performance standard for Q1. Cancer Report 62 days – slight improvement on year end; April validated position is 88.06% against a target of 85%. The consultant upgrade remains below target at 33% against a target of 90%, but there were only 3 patients within this category.

Finance and QIPP

All budgets are monitored against plan to ensure cost pressures and expenditure variation does not compromise the delivery of our objectives and achievement of value for money. At the end of May we were showing a small underspend of £202K with a forecast yearend position of breakeven A number of reports were discussed at the June Finance and Performance group; these included the budget setting process for member practices. There has been no new allocation formula released for 2012/13 therefore all commissioning budgets have been allocated on a fair shares basis supported by the current DOH toolkit. The total of budgets will be reported to member practices on a monthly basis. Forecast outturn will be estimated on the latest activity information plus any know additional factors relating to contracts, other expenditure will be based on trend analysis and best

The cancer waiting time targets have been subject to a similar “Deep Dive” performance analysis to that undertaken for A&E and Referral to Treatment Time. This has been considered at both the Finance and Performance Group and CCE. This paper is appended to this report for information. All budgets are monitored on a monthly basis and variances identified with appropriate actions. A commissioning intention budget is available for use following submission of bids in the business planning process

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer information available. All practice reports will be developed to ensure that practices are able to monitor their contribution to the overall success of QIPP targets. A comprehensive budget review has commenced and will be completed by the 30th September 2012. The review will be split into three stages and at each stage of the process a robust analysis will take place to ensure that the budget reflects the organisations objectives and future objectives of the Wakefield CCG in line with the planning round for 2013/14 Primary Care Prescribing Based on month 1 PPA data the prescribing budget is reporting ÂŁ78k underspend with a year end forecast of breakeven. Preliminary progress has been made against QIPP plan in terms of ImPP engagement from practices, and peer review of plans is to take place on 5th July. QIPP The CCG has established a new internal QIPP tracker. Progress against planned savings is monitored monthly at the Finance and Performance Group. A first quarter 2012/13 report is planned to be presented at the July meeting of the CCE.

Governance and risk

All high-level transformational milestones as reported through the Strategic Health Authority tracker have been met as planned for April and May. The CCE Audit and Governance Group met on 14 June 2012 where the following information was discussed:The 2011/12 Risk Management Annual Report which describes achievements against the cluster Risk Management Policy was

The CCG holds a contingency reserve available to mitigate risk areas

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer received; The High Level corporate Risk Log was reviewed prior to presentation at the cluster Governance Committee. There are 64 risks identified in the corporate risk register for NHDWD. This is an increase as we are now capturing all risks within this register. There were no critical risks identified, but there are 8 serious risks with a score above 15 – the majority relate to MYHT:– Failure to deliver 2012/13 QIPP objectives; – Performance and access targets (MYHT) – Reputation risk (MYHT) – Contracting and financial risks (MYHT) – Ophthalmology - service access and impact of decommissioning services for glaucoma patients; – Meeting TIA target. The 2011/12 Annual Report on Complaints was received. There has been no change in the number of complaints received compared to 2010/11 for categories that are the responsibility of the PCT. There has been a 9% increase in complaints related to primary care contractors and a 6% decrease in complaints regarding other NHS providers. Two complaints have been referred to the Parliamentary and Health Service Ombudsman (PHSO) – the PHSO have confirmed that they will not be investigating one of these, and the outcome or the other case has not yet been received. The group supported the revised terms of reference for the IFR Panel to consider cases from Kirklees. This was ratified at the cluster Governance Committee on 20 June 2012. A number of routine items were discussed – internal audit and counter fraud progress reports, standards of business conduct, losses and special payments and the use of the seal.

Further analysis and review of all corporate risks will be undertaken with members of the Audit and Governance Group prior to the next meeting.

There has been an issue in receiving responses back from provider organisations, where complaints related to other providers. Staff continue to meet with MYHT to discuss the reasons for delays and improve the timeliness of responses. This will also be raised through Quality Board arrangements.

There will be a CCG informal board session specifically focusing on the role of external audit.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Managing the transition and workforce

An authorisation project plan is in place to support application in firstwave by 2 July. This is supported by a project manager with access to a cross-organisational team. Application-focused informal board sessions took place on 7 and 12 June. Uploading of documentary evidence via the national portal commenced from 18 June. This is expected to continue through to close of application period on 2 July. Draft constitution and local clinical network models will be discussed with member practices on 26 June. Documents requiring approval prior to submission in application will be presented at the next CCE on 28 June. The indication from our 360 degree stakeholder survey is that we have had a 78% response rate. The NHS Wakefield CCG Board to Board meeting took place on 23 May 2012. The CCG is confirmed as proceeding within the first wave of authorisation. At the Board to Board the CCG presented an analysis of its position on progress towards authorisation. This was based directly upon the six domains of authorisation and their 32 sub-domains. We identified ten areas of focus for improvement: • • • • • • •

Engagement with patients, public and population Engaging with communities The case for change Structure and culture of change Financial management capacity/ capability Business intelligence and reporting The role of leadership in governance, including appropriate delegation

Throughout last year, the CCG has used a range of diagnostic tools and activity to support the Board and other leaders to understand the organisational development needs of the CCG and to prioritise the OD activity and interventions, these include semi-structured interviews with member practices, diagnostic interviews with Board members, use of electronic polling in Board and member practice meetings and regular stocktakes and refreshing of the OD plan.

Accordingly there has been three iterations of the OD plan, all underpinned by an ongoing process of reflection and diagnostic activity. The latest document builds on these. IT describes the CCG‟s progress so far, and sets out an outline OD plan for the next stage of our development journey towards authorisation and beyond, which captures all the feedback from our recent self assessment and board to board development session. These include recognition of the need to invest in external and internal relationships

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer The following were identified by the Cluster Board as our areas of strength: Good leadership demonstrated in resolving the configuration issues; Looking across other systems for evidence based good practice and adopting it locally; Aspiration for a „team without walls‟; The way you positively view the use of the WYCSS as a critical friend and future resource; Strong and detailed examples of positive actions you have taken and the outcomes achieved around QIPP; Real evidence of rolling up of your sleeves and sorting out issues; The development of relationships with Wakefield Council and MYHT and bringing focus through the Strategic Commissioning Board; and Practices vision for the future, the development of the Practice Support Unit and practice engagement. The following areas for further development were suggested by the Cluster Board: The need to be able to describe our lead commissioning role across the system in more detail; Clarifying and rationalising work streams and different sets of priorities – including greater clarity on their governance; Need to practice describing the stories in simpler terms and ensuring participation of all team members on the eCCG panel; Further development of the locality model with the Local Authority; A clearer understanding of our Organisational Development plans;

The need to develop a more integrated governance arrangements, combining the value of the existing arrangements with a more joined up approach to governance CCG‟s ability to translate strategic ambitions to meaningful change for patients The need to build a strong membership model.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer


Further development of local third sector engagement; and Strategic/operational plans need to more adequately reflect the work and risks around MYHT and the assurances around these risks. Mid Yorkshire Health and Social Care Partnership Programme Board The governance arrangements and structures for the Mid Yorkshire Partnership Programme have been revised to better meet the requirements for both recovery and transformation across the Mid Yorkshire health and social care economy. The key change is the clearer distinction between the recovery and transformation elements and development of new work streams, each of which will be closely monitored within new programme management arrangements. Work is progressing on the suite of programmes that sit underneath the Transformation Programme: Out of Hospital Care; Urgent Care and Maternity, Children and Young People. A joint workshop took place on the 29th May 2012 with GPâ€&#x;s from across Wakefield and Kirklees to raise awareness of the work that has taken place to date related to the three transformation programmes set in the context of the emerging clinical services strategy. It was agreed all programmes must focus on delivering the required transformation at scale and at pace. Key actions related to each of the above programmes are detailed below. Out of Hospital Care Transformation Programme There are a number of key work streams aligned to this programme. Progress is as follows:

From a risk perspective there is recognition that all transformation programmes must focus on delivering the required transformation at scale and at pace throughout 12/13. In order to achieve this it is essential that throughout the transition period there is sufficient workforce capacity and skills to take forward the agreed actions within the milestones set. Further work (aligned to the Primary Care Transformation Scheme) is underway to gain an improved understanding of the factors which may be contributing towards the A&E attendance and emergency admissions activity profile in April and May (Appendix B attached to this report refers.)

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer Discharge to access and re-admission prevention scheme ‘5 a day, 10 a day’ – The Project Manager commenced work (13 June), the Project Initiation Document and Project Governance arrangements are in development. Meetings with key stakeholders in MYHT, the Local Authority and Primary Care have commenced; Care Home and Liaison Support (C.L.A.S.S) – Approval given by the Joint Strategic Commissioning Board Meeting (15 June) for final Business Case to be submitted to CCE in July 2012. This work is aligned to the „5 a day 10 a day work stream‟. Improved access to hospice care across 24/7 spectrum and development of specialist palliative care community crisis intervention - This builds on the End of Life Commissioning Strategy agreed in November 2010. A key objective of which is to support people better in achieving their preferred place of death. Avoidable admissions of terminally ill people to secondary care, particularly out of hours is a key action to enable this. A Project manager is appointed, the Project Initiation Document (PID) is developed and Stakeholder meetings have commenced. The aim is for the services to launch in October 2012; Predictive risk tool- This tool is currently being piloted by three Wakefield practices. Evaluation of implementation and recommendations are due by July 2012. Integrated networks are in place across the District, with weekly MDTs and input of Health and Wellbeing team. Care planning in general practice being widely implemented via Primary Care Transformation Scheme. Clinical templates, three training/Care planning workshops held and further planned throughout the year; Virtual Ward – The Evaluation Report has been completed by White Rose Surgery and will be considered by the Urgent Care Clinical Commissioning Unit in July 2012. The Evaluation report will inform the Discharge to Access „5 a day 10 a day‟ work

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer stream‟. Re-ablement – An evaluation report of all schemes associated with re-ablement funding has been completed and will be considered by the Joint Commissioning Board in July 2012. This work will also inform the Discharge to Access „5 a day 10 a day work stream‟. Urgent Care Transformation Programme Third draft PID developed which will be refined once urgent care workshops have been held (scheduled to take place 19th July 2012); Nominations for Urgent Care Programme Board received and draft Terms or Reference developed; Primary Care Transformation Scheme (PCTS) - April saw the creation of an additional 6,643 appointments. Further capacity has also been created through the implementation of Doctor First and similar schemes. The PCTS will result in the appointment of additional staff equating to 528 nursing hours per week nurse time, 403 GP hours per week time and 194 hours per week of other health care professionals. April A&E attendances are 2.1% lower than the same period in the previous year. PCTS benefits realisation tracker in place awaiting populating with the Secondary User Service data (the secondary care activity profile) when it becomes available; PCTS implementation reports ratified to trigger second 30% payment to practices; Maternity, Children and Young People‟s Transformation programme Draft Programme Brief produced; Draft Terms of Reference for a Programme Board produced; Organisational/patch representatives being identified and Proposed date for visioning workshop mid to late August.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Shadow Accountable Officer


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