INTEGRATED
GOVERNANCE AND
PERFORMANCE REPORT
NHS Lambeth Clinical Commissioning
Governing Body
JANUARY 2014
Our Mission:
Our Mission is to improve the health and reduce
health inequalities of Lambeth people and to
commission the highest quality health services on
their behalf.
1
Contents
Table of Contents
SECTION 1
OVERVIEW
Introduction ................................................................................................................ 4
Corporate Risk Register, Heatmap and Board Assurance Framework ................. 6
1.0 Governance and Performance .......................................................................... 17
1.1 National CCG Assurance Framework 2013/14 ...................................................17
1.2 Financial Duties ..................................................................................................18
1.3 QiPP ...................................................................................................................21
1.4 Equalities ............................................................................................................30
1.5 Performance Dashboards ...................................................................................30
SECTION 2
OPERATIONAL DELIVERY
2.0 Planned Care Programme ................................................................................. 39
2.1 Long Term Conditions ........................................................................................39
2.2 Sexual Health .....................................................................................................41
2.3 South East London Community Based Care.......................................................44
3.0 Unplanned Care Programme............................................................................. 46
3.1 Urgent Care ........................................................................................................46
3.2 Lambeth & Southwark Integrated Care Programme ...........................................47
4.0 Mental Health Programme ................................................................................. 51
5.0 Staying Healthy Programme ............................................................................ 54
6.0 Children and Maternity
................................................................................... 56
7.0 Continuing Healthcare ..................................................................................... 58
8.0 Medicines Optimisation ................................................................................... 59
9.0 Cardiac and Stroke ........................................................................................... 63
10.0 Cancer ............................................................................................................... 63
11.0 Enabler Programmes ...................................................................................... 64
11.1 Primary Care Development ...................................................................... 64
2
12.0 Estates .............................................................................................................. 66
SECTION 3
ORGANISATIONAL DEVELOPMENT
12.0 Organisational Development .......................................................................... 67
12.1 Organisational Development Programme ............................................... 67
12.2 Engagement & Communications ............................................................. 70
12.3 Human Resources...................................................................................... 71
SECTION 4
QUALITY ASSURANCE
13.0 Governance and Assurance............................................................................ 74
13.1 Provider Quality Report ............................................................................. 74
13.2 Lambeth Quality Summit .......................................................................... 74
13.3 PALS and Complaints ............................................................................... 75
13.4 Information Governance ........................................................................... 79
13.5 Incidents .................................................................................................... 79
13.6 Serious Incidents ...................................................................................... 79
13.7 Never Events ............................................................................................. 84
13.8 Quality Alerts ............................................................................................. 84
Appendices (available on the website as detailed below)
Appendix 1 Q2 Provider Quality Report
http://www.lambethccg.nhs.uk/NewsPublications/Publications/Pages/default.aspx
3
SECTION 1 OVERVIEW
1
Introduction
NHS Lambeth CCG comprises of 48 member Practices across three localities.
The NHS Lambeth CCG Governing Body is responsible for ensuring that the CCG has
appropriate arrangements in place to exercise its functions effectively, efficiently and
economically and in accordance with the CCG Constitution and our principles of good
governance. Membership of the Governing Body is drawn from our Member Practices,
appointed individuals with statutory roles and nominees from our key Lambeth partners.
The Governing Body is overseen by the NHS Lambeth CCG Collaborative Forum made
up of all Lambeth member practices. The Collaborative Forum held its second meeting on
Tuesday the 15th October 2013. This builds upon a range of events with Member
Practices over the past two years. Under the CCG’s agreed Constitution the Collaborative
Forum has a number of specified responsibilities, including changes to the NHS Lambeth
CCG Constitution and oversight of the CCG Commissioning vision and strategic direction.
The Governing Body is supported by the Clinical Network of clinical leads for each area of
work being taken forward. The purpose of the Clinical Network is to provide the CCG
Board members with sound clinical advice on commissioning care services, clinical
pathways and best practice. The Clinical network consists of care and clinical “subject
matter experts” from within Lambeth including GPs, practice managers, nurses,
pharmacists, opticians and social care colleagues.
This report sets out how NHS Lambeth CCG is performing against its agreed objectives
under the leadership of the NHS Lambeth Clinical Commissioning Governing Body. It is a
tool for providing assurance to the Governing Body that objectives are being delivered or,
where performance is behind plan, that mitigating actions are in place to address
performance improvement.
The 2013-14 Business Plan sets out our key objectives as detailed below. This report
provides an update against each of these business areas and strategic objectives.
Area of Business
(i)
(ii)
Strategic Objective
Operational
Delivery To deliver our agreed priority health
(SECTION 2) through our programmes and effective high quality and safe
health programmes
care with robust operational risk and financial
management.
Organisational
To manage the transition of commissioning
Development (SECTION
responsibility
to
the
Lambeth
Clinical
3)
Commissioning Group and the establishment of
new Health and Wellbeing arrangements,
engaging the public and patients and addressing
4
equalities.
(iii)
Governance & Assurance
(SECTION 4)
To ensure systems and processes are in place
to support individual, team and corporate
accountability for delivering patient centred,
safe, high quality care, within our resource
limits.
Performance against corporate objectives are detailed within this report to provide a
consolidated performance report.
Performance is also reviewed at quarterly Lambeth Assurance meetings with the NHS
England. The next meeting is on the 24th of January 2013. A new Assurance Framework
for CCGs across London has been developed by NHS England and the key elements are
incorporated within this report. (Section 1.1 page 17). Lambeth CCG is currently rated as
follows under the latest Assurance Framework;
5
Corporate Risk Register, Heatmap and Board Assurance Framework
The NHS Lambeth CCG Board Assurance Framework (BAF) is included along with a Heat Map showing key risks. The BAF and supporting
Risk Register are living documents, updated monthly.
Lambeth Clinical Commissioning Group Corporate Risk Register Heat Map of current residual risks
Risk Matrix
Impact
Likelihood
Negligible
1
Minor
2
Moderate
3
Major
4
Catastrophic
5
Risk Description
Rare
1
1
2
3
4
5
SO7CB
SO7EA
SO7DA
Unlikely
2
2
4
6
8
SO2LB
SO7AA
SO3BB
SO3AA
SO6AB
Possible 3
SO6AD
SO6AF
3
6
SO2PA
Performance Levels for RTT
SO1QA
SO1QA
Planned Care QIPP
SO2CA
SO2CA
A&E Performance
SO2LB
SO2LB
111 Service and risk to OOH provision
SO2PA
SO2PA
Unplanned Care QIPP
SO3AA
SO3AA
Implementation of AMH Prgramme
SO3BA
SO3BA
Community Services Forensic Service Changes
SO3BB
SO3BB
MH Forensic Services
SO4AA
SO4AA
TSA Process Impact
SO6AA
SO6AA
Statutory Financial Targets Delivery
SO6AB
SO6AB
Disaggregation of PCT Baselines
SO6AC
SO6AC
Financial Planning and Strategic Approach
SO6AD
SO6AD
QIPP and Acute Over-performance
SO6AE
SO6AE
Internal Financial Controls
SO6AF
SO6AF
Risk associated with the disaggregation of PCT Legacy balances
SO7AA
SO7AA
Delivery of CCG Strategy [Zero Tolerance Risk]
SO7CA
SO7CA
Safeguarding Adults [Zero Tolerance Risk]
SO7CB
SO7CB
Safeguarding Children [Zero Tolerance Risk]
SO7DA
SO7DA
Emergency Planning [Zero Tolerance Risk]
SO7EA
SO7EA
Equality Act
SO6AC
SO6AE
SO7CA
12
SO1AA
SO1AA
SO4AA
9
SO3BA
10
SO1AA
15
SO1QA
SO6AA
Likely
4
4
8
12
16
20
Updated 30/12/2013
SO2CA
No risks removed this month
Three new risks added this month
Almost Certain
5
5
10
15
20
6
25
SO1QA
SO1QA
Planned Care QIPP
SO2PA
SO2PA
Unplanned Care QIPP
SO6AF
SO6AF
Risk associated with the disaggregation of PCT Legacy balances
There are currently 15 risks rated 12 or above as of December 2013. This number has
increased from 12 in October 2013 as three new risks have been added to the Risk
Register.
These are as follows:
 SO1QA - ‘Risk of non-delivery of Planned Care Programme project milestones
(financial risks covered under risk reference SO6AD)’. This risk has been
identified via the Planned Care Programme Board and a detailed action and
recovery plan is in place. The score for this risk is 4 x 4 (Major/Likely) = 16
 SO2PA – ‘Risk of non-delivery of proposed A&E Admission Avoidance QIPP
target’. This risk has been identified via the Unplanned Care Programme Board
and a detailed action and recovery plan is in place. The score for this risk is 4 x
3 (Major/Possible) = 12
 SO6AF – ‘Risk associated with the disaggregation of PCT Legacy balance’.
This risk has been added by the Chief Financial Officer and actions identified to
mitigate the risk. The score for this risk is 4 x 3 (Major/Possible) = 12
The existing Mental Health Programme risk SO3AA has been reviewed and reworded
to incorporate QIPP. The score for this risk is 4 x 3 (Major/Possible) = 12
Actions to address SO1AA, Performance Levels for RTT, which is graded 16 are led by
the NHS SLCSU Acute Contracts Team.
All risks over 12 have been reviewed and updated where required.
All risks have robust action plans in place to address any gaps in assurance. A
summary of key risks rated 12 and above over the following pages set out NHS
Lambeth CCG’s Board Assurance Framework. Areas that have been updated are
noted in bold.
One risk has an increased risk score – Risk reference CO2CA, ‘A&E Performance
Level Risk’. The risk was discussed at the Integrated Governance Committee on 18
December 2013 and the increased risk score agreed (from 12 to 15) as the likelihood of
KCH not achieving A&E targets has increased.
7
Risks graded 12 or above:
Code
Risk Summary
SO1AA
Performance Levels for
RTT Risk
SO1QA
SO2CA
Risk Score Direction
Risk Owner
Key Actions
16
Harriet Agyepong
KCH outsourcing some elective activity to private
providers to assist with the reduction of the
backlog. Additionally more capacity will be made
available on the Denmark Hill site and the
Orpington site, which will further assist in
admitted backlog reduction.
KCH are transferring some orthopaedic patients to
GST for treatment – due to start August 2013
RTT Recovery Plan (March 2014)
Risk of non-delivery of
proposed Planned Care
QIPP savings
16
Claire Hornick
Development of Recovery Plan as detailed in the
Planned Care QIPP Performance Report (updated
monthly)
A&E Performance
Level Risk
15
Therese Fletcher
Delivery KCH action plan completed (March 2013)
Delivery GSTT action plan completed (March 2013)
Achievement of Target Risk Score (March 2013)
Recovery and Improvement Plan submitted to NHS
England (July 2013)
Further assurances due September 2013 - to be
updated on action plan 2 October 2013
Winter Capacity and Recovery Plan completed (Sept
2013)
Refresh of winter surge arrangements
Divert policy in place
Intelligence Conveyencing
Appointment of SEL Urgent Care Project Manager,
leading to more effective streamlining of processes.
Risk discussed at Integrated Governance
Committee 18/12/13 and increased risk score
agreed (from 12 to 15) as likelihood of KCH not
achieving A&E targets has increased
8
Code
Risk Summary
SO2LB
Implementation of 111
Service Risk
SO2PA
Risk Score Direction
Risk Owner
Key Actions
12
Therese Fletcher
PMO to negotiate new contract with SELDOC until
March 2014 (extended from April 2013)
Exit Strategy being discussed and agreed for NHS
Direct and appropriate step in arrangements being
discussed with relevant providers (August/September
2013)
Risk of non-delivery of
proposed A&E
Admission Avoidance
QIPP target
12
Therese Fletcher
Development of Recovery Plan as detailed in the
Unplanned Care QIPP Performance Report
(updated monthly)
SO3AA
Transforming Adult
Mental Health Services
via the Lambeth Living
Well Collaborative
Programme Risk / Risk
of non-delivery of
proposed Mental
Health QIPP savings
12
Denis O'Rourke
Launch of Living Well Network (Sept. 2013) (new
front end to MH support system)
Agree provider alliance contracting framework
(December 2013)
Support SLaM AMH redesign – implementation from
Jan 2014.
Primary care engagement strategy developed
including a community incentive scheme from April
2014
Work is ongoing on 2014/15 Commissioning
Intentions, building on 2013/14 development
+ QIPP - Recovery Plan actions
Terms of reference and reporting arrangements
being reviewed and revised - December 2013
SO3BA
Community Services
Forensic Service
Changes Risk
12
Denis O'Rourke
Sean Rigg action plan - ongoing delivery (relates to
community forensic service delivery actions)
Service specifications to be updated for 2014/15
contact period to include multiagency response
(December 2013)
Continue to deliver 'step down and move on' actions.
(December 2013)
Review of CJS MH police custody service – currently
being considered by LA, SLaM and CCG
9
Code
Risk Summary
SO4AA
TSA Process Impact
Risk
SO6AA
Statutory Financial
Targets Delivery Risk
Risk Score Direction
Risk Owner
Key Actions
12
Christine Caton
Implementation through the Community Based
Care strategy (ongoing)
Agree business cases for provider service
transformation due early 2014.
Impact of service transformation to be built into
Commissioning Strategy Plan and Trusts
contracts.
Confirmation of treatment of Market Forces
Factor (MFF) for new Trust configurations.
Finalise detail of non-recurrent funding package
for 2014/15 onwards.
12
Christine Caton
Deliver effective systems and financial management
controls (ongoing)
Develop and implement recovery plan with emphasis
on achievement of underlying financial balance.
(ongoing)
Ensure that use of 2% non recurrent investment fund
is maximised (ongoing)
Monthly budget review process.
Work with London CFOs/CSU and NHSE through
Technical Group to agree specialised
commissioning transfer value. To be concluded
by Dec 2013.
10
Code
Risk Summary
SO6AB
Disaggregation of PCT
Baselines Risk
SO6AC
Financial Planning and
Strategic Approach
Risk
Risk Score Direction
Risk Owner
Key Actions
12
Christine Caton
Timely monthly reporting arrangements to identify
potential areas of risk and facilitate monthly reporting
and forecasting.
Clear process for transferring funds to mitigated risk
across London CCGs/NHSE.
Agree methodology for 2014/15 to ensure smooth
implementation of baseline changes and clear
resource position
Work with London CFOs/CSU and NHSE through
Technical Group to agree specialised
commissioning transfer value. To be concluded
by Dec 2013.Use of Non Recurrent Investment
Fund to manage impact of Specialised Services
not cost neutral – non recurrent solution only
12
Christine Caton
Produce new 5-year Plan (including SE London wide
plan), Confirm CCG priorities going forward in the
context of resource assumptions. Update plans
once 2 year allocations and planning
assumptions are issued mid Dec 2013.
Work with LA partners to determine impact/risk
associated with implementation of Integration
Transformation Fund from 2014/15 onwards.
Use benchmarking, other data to provide
evidence base for decision making and support
implementation of robust KPIs and contractual
levers.
Focus on reporting to include recurrent
underlying position. This is included as part of
CCG assurance framework (ongoing)
Commissioning Intentions being developed into
costed QIPP proposals and review with
Governing Body, Finance and QIPP Working
Group and Programme Boards December 2013
Negotiation meetings with providers underway.
11
Code
Risk Summary
SO6AD
QIPP and Acute Overperformance Risk
SO6AE
Risk Score Direction
Risk Owner
Key Actions
12
Christine Caton
CCG working through detailed risk management
strategies/recovery plan to address projected
financial risk and strategies leading into 2014/15 for
recurring impact of under delivery of QIPP and
activity over performance
Internal Financial
Controls and Audit
Health Risk
12
Christine Caton
Induction/Training Programme for Governing Body
and staff
Internal Audit Plan 2013/13 is being delivered
according to plan.
Regular review meetings and progress report to
each Audit Committee – ongoing
Regular monitoring to ensure that audit
recommendations for CCG and CSU are being
implemented
SO6AF
Risk associated with
the disaggregation of
PCT Legacy balances
12
Christine Caton
NEW RISK DECEMBER 2013
Legacy and CCG Teams undertaking detailed
review of legacy transactions to ensure
robustness of return submitted.
Regular communication with NHSE (London)
Legacy Team.
Additional resourcing put in place by NHSE to
ensure Legacy Project delivered. Receivers to
agree Legacy balances by Month 9 Agreement of
Balances exercise
SO7CA
Safeguarding Adults
Risk [Zero Tolerance
Risk]
12
Alex McTeare
Implement the accountability and assurance
framework for safeguarding vulnerable people
Recruit designated doctor and designated nurse for
adult safeguarding
Influence NHSE contracts to include safeguarding
training requirements
Practices to nominate staff to attend 'Alerters'
safeguarding training
12
Zero Tolerance Risks: There are a number of areas where the Board has suggested a zero tolerance for reporting. There are currently four such
risks as per the table below. Within Lambeth CCG no ‘zero tolerance’ risk is rated as greater than 12. One risk (S07CA) is duplicated from the
previous table.
Code
Risk Summary
SO7AA
Risk re insufficient
capacity and capability in
commissioning system to
fulfil requirements as a
statutory body and
membership organisation
to deliver the CCG
strategy. [Zero Tolerance
Risk]
SO7CA
Risk Score Direction
Risk Owner
Key Actions
9
Janie Conlin; Lucy Day;
Catherine Flynn
OD plan delivery (March 2014)
Communications and Engagement action plan (March
2014)
Implementation of CCG Assurance Framework (March
2014)
Safeguarding Adults Risk
[Zero Tolerance Risk]
12
Alex McTeare
Implement the accountability and assurance framework
for safeguarding vulnerable people
Recruit designated doctor and designated nurse for adult
safeguarding
Influence NHSE contracts to include safeguarding training
requirements
Practices to nominate staff to attend 'Alerters'
safeguarding training
SO7CB
Safeguarding Children
Risk [Zero Tolerance
Risk]
8
Avis Williams-McKoy
Implement the accountability and assurance framework
for safeguarding vulnerable people
SO7DA
Emergency Planning Risk
[Zero Tolerance Risk]
8
Marion Shipman
Internal operational guidance updated.
LCCG Business Continuity Policy drafted October 2013
- to be ratified at December Integrated Governance
Committee
LCCG EPRR Risk Assessment and EPRR plan to fully
meet assessment criteria drafted October 2013 - to be
ratified at December Integrated Governance
Committee
New surge management arrangements confirmed
October 2013 - PMO managing surge arrangements
Emergency Plan to be tested February 2014
13
Board Assurance Framework
Chief Officer
Lambeth CCG
Strategic Objective 3: To deliver good
quality mental health care services and
improve patient outcomes
Responsible
Executive:
Director of
Integrated
Commissioning
16
16
16
16
16

9

12
12
12
12
12
12
12
12
16
8

12
12
12
12
12
12
12
12
12
8

SO3AA
Risk the Adult Mental Health (AMH)
change programme won't be fully
implemented as planned impacting
negatively on patient outcomes
and financial savings targets.
9

15
15
15
15
12
12
12
12
SO3BA
Risk that the pathways between
secure services and community are
fragmented and under-developed
due to the changes in the
commissioning arrangements for
forensic secure services from 1
April 2013 from CCG to NHS
England
6

12
12
12
12
12
12
12
12
Therese
Fletcher
SO2LB
Therese
Fletcher
SO2PA
14
16
12
Apr
Dec
16
Mar
Nov
16
Feb
Oct
16
Jan
Sep
16
8
SO2CA
Denis
O'Rourke
Monthly Progress

Therese
Fletcher
Denis
O'Rourke
There is a risk of not achieving the
agreed access initiative
performance levels for RTT due to
i.e. backlog of admitted patients
waiting more than 18 weeks (at
KCH) and a number of patient
waiting more than 52 weeks at
different providers
Risk of non-delivery of Unplanned
Care Programme project
milestones (financial risks covered
under risk reference SO6AD
There is a risk of not achieving the
agreed access performance levels
fo A&E
Risk that pilot implementation of a
111 service for SEL may negatively
affect out of hours service
provision
Risk of non-delivery of Planned
Care Programme project
milestones (financial risks covered
under risk reference SO6AD)
Target Risk
Score and
Direction of
Travel
12
SO1AA
Claire Hornick SO1QA
Strategic Objective 2: To improve the
integration and quality of care for
older people and reduce the number
of avoidable hospital admissions and
readmissions
Principal Risk (Obstacle to achievement
of Strategic Aim)
Aug
Harriet
Director of Care
Agyepong
Pathway
Commissioning /
Chief Officer
Southwark CCG
Risk Register
Ref
Jul
Operational
Lead
Jun
Strategic Objective 1: To develop and
deliver planned care which reduces
premature mortality and improves
quality of life, reducing reliance on
hospital services and improving the
quality of primary care
Executive Lead
May
Strategic Aim
UPDATED DECEMBER 2013
Apr
ASSURANCE FRAMEWORK 2013/14 – PROGRESS SUMMARY
SO4AA
Risk of the TSA process and
outcomes negatively impacting on
provider landscape and delivery of
CCGs strategic plans to 2017-18
12

12
12
12
12
12
12
12
12
12
Responsible
Executive: Head
of Finance
Christine
Caton
SO6AA
Failure to deliver statutory financial
targets. Financial risk management
and reputational risk.
4

9
12
12
12
12
12
12
12
12
Responsible
Executive: Head
of Finance
Christine
Caton
SO6AB
Risk associated with the
disaggregation of PCT baselines
across new commissioning
organisations
8

12
12
12
12
12
12
12
12
12
8

12
12
12
12
12
12
12
12
12
12

12
12
12
12
12
12
12
12
12
4

12
12
12
12
12
12
12
12
Responsible
Executive: Head
of Finance
Christine
Caton
SO6AC
Risk that current planning and
strategic approach is not
sufficiently robust to manage
pressures and deliver sustainable
position in the context of potential
reduction in growth resulting from
the implementation of the CCG
allocation formula.
Responsible
Executive: Head
of Finance
Christine
Caton
SO6AD
There is a risk that failure to
deliver QIPP and acute
overperformance leading to CCG's
risk on financial sustainability
Responsible
Executive: Head
of Finance
Christine
Caton
SO6AE
Failure to embed and maintain
strong internal financial controls
and achieve a clean bill of audit
health
15
Apr
Dec
Christine
Caton
Mar
Nov
Responsible
Executive:
Director of Care
Pathway
Commissioning
Feb
Oct
Monthly Progress
Sep
Target Risk
Score and
Direction of
Travel
Aug
Principal Risk (Obstacle to achievement
of Strategic Aim)
Jul
Risk Register
Ref
Jun
Strategic Objective 6: To deliver our
annual operating and medium term
financial plans to ensure an ongoing
sustainable financial position that
delivers our strategic health goals for
the Lambeth population.
Operational
Lead
May
Strategic Objective 4: To implement
the Secretary of State's (SoS) TSA
recommendations
Executive Lead
Apr
Strategic Aim
UPDATED DECEMBER 2013
Jan
ASSURANCE FRAMEWORK 2013/14 – PROGRESS SUMMARY
Strategic Objective 6: To deliver our
annual operating and medium term
financial plans to ensure an ongoing
sustainable financial position that
delivers our strategic health goals for
the Lambeth population.
Responsible
Executive: Head
of Finance
Christine
Caton
Strategic Objective 7: To ensure
systems and processes are in place to
support individual, team and corporate
accountability for delivering patient
centred, safe and high quality care
Responsible
Executive:
Director of
Governance and
Development
Janie Conlin;
Lucy Day;
Catherine
Flynn
Responsible
Executive:
Director of
Strategic Objective 7: To ensure
Governance and
systems and processes are in place to
Development
support individual, team and corporate
Responsible
accountability for delivering patient
Executive:
centred, safe and high quality care
Director of
Governance and
Development
Responsible
Executive:
Director of
Governance and
Development
Strategic Objective 7: To ensure
systems and processes are in place to
support individual, team and corporate
accountability for delivering patient
Responsible
centred, safe and high quality care
Executive:
Director of
Governance and
Development
SO6AF
Risk associated with the
disaggregation of PCT Legacy
balances
8

SO7AA
Ze ro T o le rance Risk - There is a
risk that there will not be capacity
and capability in the
commissioning system to fulfill
requirements as a statutory body
and membership organisation to
deliver the CCG strategy.
6

Alex McTeare SO7CA
Ze ro T o le rance Risk - Risk of
failure to safeguard adults and
identify and respond appropriately
to abuse.
4

Avis WilliamsSO7CB
McKoy
Ze ro T o le rance Risk - Risk of
failure to safeguard children and
identify and respond appropriately
to abuse
4
Marion
Shipman
SO7DA
(TA9.7AP)
Andrew
Parker
SO7EA
(Q7.3AP)
Ze ro T o le rance Risk - There is a
risk of inadequate response to
emergencies owing to the CCG
responsibilities changing as
category 2 responder and NHS
England as category 1 responder.
Lambeth CCG fails to comply with
the Equality Act (2010) and does
not achieve its equality objectives,
leading to negative impact on
population health and equity.
Requirements of the Equality Act
(2010) are not integrated into core
business
16
12
9
9
9
9
9
9
9
9
12
12
12
12
12
12
12
12
12

8
8
8
8
8
8
8
8
8
6

12
8
8
8
8
8
8
8
8
4

6
6
6
6
6
6
6
6
6
Apr
Mar
Feb
Jan
Dec
Nov
Monthly Progress
Oct
Target Risk
Score and
Direction of
Travel
Sep
Principal Risk (Obstacle to achievement
of Strategic Aim)
Aug
Risk Register
Ref
Jul
Operational
Lead
Jun
Executive Lead
May
Strategic Aim
UPDATED DECEMBER 2013
Apr
ASSURANCE FRAMEWORK 2013/14 – PROGRESS SUMMARY
1.0 Governance and Performance Summary
1.1 National CCG Assurance Framework 2013/14
The CCG Assurance Framework is designed to give assurance that CCGs are
delivering quality and outcomes for patients, as well as being the basis for
assessing they are continuously improving from the start point of
authorisation.
The NHS England London region uses a CCG Assurance Balanced
Scorecard approach to monitor its performance against the framework. Q1
findings were published at the end of October and Q2 was published in
November.
Lambeth’s Q2 position was assessed as follows:
Domain 1: Quality of care
CCGs have a duty under the Health and Social Care Act to secure continuous
improvement in the quality of services and the outcomes from the provision of
services. This includes assuring themselves of the quality of services they
commission. This Domain covers 7 standards relating to CCG internal
governance and risk processes which are all compliant. There are 10
provider standards of which 9 inform the assurance rating. We are
underperforming on two standards, one relating to MSA (mixed sex
accommodation) breaches and the other for Serious Incidents. Action plans
are in place to address these areas.
17
Domain 2: Performance Standards
The NHS Constitution contains a number of core standards which both NHS
England and CCGs have a legal duty to have regard and to promote. There
are 20 core standards within this domain. Lambeth CCG is meeting 15 of
these standards (Rated Green). We are under performing on 5 standards (4
Amber and 1 Red). Three of these standards relate to waiting times and
access. One relates to LAS response times and the fifth relates to breaches in
mixed sex accommodation. Action plans are in place to address each of these
areas with improved performance by the end of 2013/14.
Domain 3: Are we improving health outcomes for local people?
The CCG is fully compliant against the standards required to be met for this
Domain, moving from an Amber-Red status in Q1 to Green in Q2. This is due
to the removal of the 1 case of MRSA which had been incorrectly attributed to
Lambeth CCG. The target of zero tolerance for MRSA cases will remain
challenging for the rest of the year.
Domain 4: Are we delivering services within our financial plans?
The financial requirements for CCGs are set out in Everyone Counts. This
domain requires an assessment that CCGs are planning to meet their own
financial targets as agreed with NHS England as well as deliver sound
financial management.
The CCG has an Amber-Green rating based on two issues; at Q2 the year to
date QIPP was 93% of plan, although this moves to 96% annual forecast
delivery, and the CCG’s underlying position reflects the use of the 1% non
recurrent investment fund to manage the impact of the specialised services
transfer.
Domain 5: CCG Authorisation
This domain does not form part of the assessment process. Lambeth CCG
was fully authorised in April 2013 without any conditions.
1.2 Financial Duties
To deliver financial control totals for resource and cash and support the
delivery of statutory financial duties 2013/14
The CCG is reporting a year to date surplus of £3.118m at month 8 (November 2013)
and that it will meet its 1% control target surplus of £4.682m at year end.
On cash limit, the CCG is currently forecasting a breakeven position against its
forecast cash limit. The final cash limit has not been notified yet.
18
Revenue Resource Limit
Forecast Year
Mth 8 Year to End
Date
Expenditure
£'000
£'000
280,399
420,093
277,121
415,366
3,278
4,727
1%
1%
3,118
4,682
Total Income
Total Expenditure - CCG
Total Surplus/(Deficit)
Planned Surplus
Variance Against Planned Surplus
160
Previous
Months Year to
Date
£'000
243,962
241,094
2,868
1%
2,730
45
138
Cash Limit
Cash Drawings - Plan
Cash Drawings - Actual and Forecast
Forecast Underspend against Cash Limit
Cash Limit
Actual Year Cash Limit Full
to Date
Year
£'000
£'000
248,190
407,129
248,189
407,129
0
0
% Drawn down
Year to Date
£'000
61%
61%
0
Key Financial Performance Duties
Performance Area
Commissioning
Performance
Commentary
Lambeth CCG is reporting a surplus of £3,279k for the period ending
November 2013. This is slightly ahead of the year to date plan by £161k.
The forecast outturn surplus is £4.722m which is in line with our target of
delivering a 1% surplus (£4.682m) for the year.
Cash balances are planned to be maintained at low levels. (less than 5%
of cash drawn) Lambeth CCG's cash balance as at the end of November
was £139k. The CCG expects to meet its cash limit target by the end of
the year.
QIPP year to date is an over delivery of £96.86k as at the end of
November. The forecast for the year is expected to be an underdelivery
QIPP of £268k (3%)
Performance on commissioned services as at the end of November is a
total overspend of £4.093m of which £6.154m relates to acute services.
Non Acute services are underspent £1.4m. Forecast outturn variance is
£6.928m against plan. The main issues relate to acute services (£8.9m),
learning disability and mental health.
Public Sector Payment
Policy
Public sector payment target is 95%. Lambeth CCG is not achieving its
target for Non NHS invoices (90.59%) however the target for non nhs
numbers was met for the first time during October. The CCG is currently
performing at 92.01% overall on numbers and at 98.69% by value.
Revenue Surplus
Cash Limit
QIPP
Capital Resource
Running Cost
Ensure that capital resources use does not exceed the limit set for capital
Ensure that revenue resources use on prescribed matters relating to
admin costs (i.e. not relating to healthcare services) does not exceed the
running cost allowance set by NHS England.
19
Year to Forecast
Date Outturn
The CCG’s financial year to date and forecast position is detailed below:
SUMMARY OF YEAR TO DATE & FORECAST OUTTURN 2013/14
Year to Date
Acute
Non Acute
Primary Care
Other
Reserves
Total Programme
Total Corporate
Total Expenditure - CCG
Budget
£'000
148,670
86,608
27,853
720
11,031
274,881
5,518
280,400
Actual
£'000
154,824
85,176
27,290
654
3,713
271,657
5,464
277,121
Planned Surplus
Variance Against Plan
Forecast Outturn
Variance
(over)/under
spend
£'000
(6,154)
1,432
563
66
7,317
3,224
55
3,279
Budget
£'000
223,005
129,912
41,270
1,080
16,546
411,813
8,280
420,093
Actual
£'000
231,568
127,892
40,631
1,465
5,570
407,126
8,240
415,366
Variance
(over)/under
spend
£'000
(8,563)
2,019
639
(384)
10,976
4,687
40
4,727
3,118
4,682
161
45
Actions being taken to ensure delivery of financial targets and mitigate
financial risk include:
 Use of 0.5% contingency and other reserves
 Release of population and incidence reserves in year
 Manage expenditure in overspending areas back in line with budget
 Maximise use of 2% non recurrent investment funding
 Acceleration of QIPP plans
 Implementation of processes for demand management for activity related
budgets, e.g. mental health specialist services and continuing care.
 Undertake detailed review of all CCG budgets to identify in year flexibilities
to implement in-year recovery plan
Maintain strong internal financial controls and achieve a clean bill of
audit health
Actions being taken include:
 Deliver 2013/14 Internal Audit Plan and ensure that recommendations are
implemented. This is closely monitored by the CCG’s Audit Committee
 Embed understanding across Governing Body Members/Head of
Collaborative Forum of Internal and External Audit
 Revised Standing Orders, Prime Financial Policies and Scheme of
Delegation to best reflect needs of CCG
20
1.3 QIPP
The CCG’s 2013/14 QIPP forecast shows annual under-delivery of 3%.
Total QIPP
Annual
Contractual
/Guarantee
d Forecast
Outturn as
at month 8
Forecast
Outturn
Variance
(under)/Over
as at Month 8
Forecast
Outturn
Variance
(under)/Ove
r
Underlying
Forecast
Variance
(under)/ove
r as at
month 8
Underlying
Variance
(under)/Ove
r
£
3,513,549
£
1,545,682
£
-1,967,867
%
-56%
£
-1,967,867
%
-56%
Trust Led Acute
Schemes
2,325,000
2,325,000
0
0%
-1,162,500
-50%
Community Health
1,200,000
1,200,000
0
0%
-372,000
-31%
Mental health
2,957,000
2,807,000
-150,000
-5%
-1,301,000
-44%
Prescribing
1,203,000
1,703,000
500,000
42%
500
42%
Other client groups
322,500
322,500
0
0%
0
0%
Corporate
359,000
359,000
0
0%
0
0%
Total
11,880,049
10,262,182
-1,617,867
-14%
-4,802,867
-40%
Reprovision Cost
-1,864,000
-514,000
1,350,000
-72%
1,350,000
-72%
Total
10,016,049
9,748,182
-267,867
-3%
-3,452,867
-34%
CCG Led Acute
Schemes
The table shows underlying under delivery of 34% which reflects the fact that
QIPP savings are contractually secured for Trust led Acute, and Mental Health
and Community Schemes for 2013/14. It is essential that we ensure delivery
of the QIPP on an ongoing basis in order to mitigate the risk of the negative
impact of underachievement in financial and service terms on financial years
2014/15 onwards. Where a QIPP initiative is forecasting under delivery a
Recovery Plan has been drafted. Work on these plans is ongoing and
progress will be reported to the December Finance and QIPP meeting.
Lambeth CCG’s QIPP Programme is made up of Acute Trust led schemes,
CCG led admission avoidance schemes, CCG led care pathway redesign
schemes, mental health improvement, community health and prescribing.
21
The Acute Trust led schemes carry a total value of £2,325. These savings are
guaranteed to the CCG through contractual agreements. We do however
track the activity under these schemes to provide some assurance that the
service redesign work underpinning the required QIPP savings is having the
intended impact.
The CCG led Acute schemes are predominantly focussed on the redesign of
care pathways – typically referral into outpatients by GPs. The CCG carries
the risk for these schemes as the lever to enable the required referral change
sits outside acute and within primary care.
The performance reports on each initiative highlight a number of areas where
initiatives have either slipped or are not delivering the intended outcomes. The
Planned care (out patients) initiatives have been reviewed and
recommendations for action included in the recovery plan, this includes
recommendations on specific out patients specialisms for referral
management. This work is ongoing. The gynaecology work stream has been
scoped and recommendations for to uro-gynae referrals are included in the
recovery plan, as are recommendations on gynaecology consultant to
consultant led referrals and triage. Practice visits are being used to give
support to practices to enable them to deliver QIPP outcomes by providing the
necessary information on referral pathways, peer support and mechanisms.
These are led by CCG locality leads working in conjunction with
commissioning staff.
We are meeting with the Acute Trust teams on a fortnightly basis to ensure
delivery of both CCG led and Trust led schemes and ensure that measures
developed by Trust and CCGs schemes leads lead to QIPP gains across both
Outpatient First and Follow Ups.
The mental health and community QIPP savings are also secured through
contractual agreements with the exception of specialized mental health
services. Mental health QIPP includes the redesign of acute mental health
services which is being implemented working alongside SLaM, and the
decommissioning of MHOA continuing care bed capacity as a result of
redesign of the pathway and the development of more specialist services.
For mental health specialist services, a rigorous approach to applications to
panel has been implemented and review of consultant to consultant referrals
is being undertaken. A review of psychosexual and specialist ADHD services
is currently being carried out which is expected to positively impact on QIPP
delivery.
We are doing a detailed review of commissioning and administration cost
budgets in order to develop recovery plans in order to manage the level of
outstanding risk that exists in 2013/14 and significant financial challenges that
we face in 2014/15 and beyond. This is as outlined in Section 1.1 above.
22
2. Lambeth CCG QIPP Dashboard (M8)
The Lambeth CCG QIPP Dashboard provides an overview of the CCG’s performance across three QIPP programs of work: planned care,
unplanned care, and mental health. The dashboard highlights those areas where the CCG is currently on track or exceeding target (green
rated), varying from target (amber rated) or significantly varying from target (red rated). A detailed QIPP performance report is available and
reviewed at through the Finance and QIPP Group.
*RAG Status: 100% = Green, 75.99% = Amber, <50% = Red
PROJECT/SCHEME
Guaranteed/Not
Guaranteed
Project Delivery Rag Rating
PROJECT/SCHE
ME
Contractual Rag Rating
2.1 CCG Led Schemes - Acute Dashboard
2013/14 TOTAL
QIPP
PROGRAMMES
£'000
Plan
Year To Date
Variance
Over/(Und
Actual
er)
£'000
£'000
CCG Led
Schemes
Respiratory
Non Guaranteed
47.96
31.97
-
Acute
CVD/Cardiology
Non Guaranteed
33.61
22.41
Ophthalmology
Non Guaranteed
155.81
Diabetes
Non Guaranteed
Gynaecology
Endicronology
Other specialities
reduction
Urgent Care
Guaranteed QIPP
Sub Total CCG Led Schemes - Acute
2%
£'000
Varian
ce
%
Forecast Outturn
Variance
Over/(Und
Varian
er)
ce
£'000
%
Underlying Position
Variance
Over/(Und
Varian
er)
ce
£'000
%
%
Risk
Ratin
g
%
-31.97
-100%
-35.97
-75%
-35.97
-75%
25%
19.23
-3.18
-14%
-4.71
-14%
-4.71
-14%
100%
103.88
33.34
-70.53
-68%
-105.95
-68%
-105.95
-68%
100%
127.31
84.87
108.87
24.00
28%
-35.65
-28%
-35.65
-28%
100%
Non Guaranteed
418.93
209.46
-
-209.46
-100%
-314.20
-75%
-314.20
-75%
100%
Non Guaranteed
72.28
48.19
-
-48.19
-100%
-54.21
-75%
-54.21
-75%
100%
Non Guaranteed
951.29
634.20
-686.77
-108%
-951.29
-100%
-951.29
-100%
50%
Non Guaranteed
817.36
544.90
235.19
-309.71
-57%
-465.89
-57%
-465.89
-57%
50%
Guaranteed
889.00
592.67
592.67
0.00
0%
0.00
0%
0.00
0%
100%
3,513.55
2,272.54
936.73
-1,335.81
-59%
-1,967.87
-56%
-1,967.87
-56%
23
-52.57
Trust
Schemes
GSTT
Kings
PROJECT/SCHEME
Guaranteed/N
ot Guaranteed
Project Delivery Rag Rating
PROJECT/SCHEM
E
Contractual Rag Rating
2.2 Trust Led Schemes - Acute Dashboard
2013/14 TOTAL
QIPP
PROGRAMMES
Year To Date
£'000
Plan
Actual
Variance
Over/(Under)
Varianc
e
£'000
£'000
£'000
%
Forecast Outturn
Variance
Over/(Unde
Varianc
r)
e
£'000
%
Underlying Position
Variance
Over/(Unde
Varianc
r)
e
£'000
%
%
Risk
Ratin
g
%
Led
Excess Bed Days
Outpatient Follow up
ratios/shifts to nurse led
and non face to face
Guaranteed
236.00
157.33
157.33
0.00
0%
-
0%
-118.00
-50%
100%
Guaranteed
736.00
490.67
490.67
0.00
0%
-
0%
-368.00
-50%
100%
Patient Transport
In
year
QIPP
opportunities
Outpatient Follow up
ratios/shifts to nurse led
and non face to face
Guaranteed
70.00
46.67
46.67
0.00
0%
-
0%
-35.00
-50%
100%
Guaranteed
229.00
152.67
152.67
0.00
0%
-
0%
-114.50
-50%
100%
Guaranteed
400.00
266.67
266.67
0.00
0%
-
0%
-200.00
-50%
100%
Admission Avoidance
Guaranteed
160.00
106.67
106.67
0.00
0%
-
0%
-80.00
-50%
100%
Pharmacy Savings
In
year
QIPP
opportunities
Guaranteed
280.00
186.67
186.67
0.00
0%
-
0%
-140.00
-50%
100%
Guaranteed
214.00
142.67
142.67
0.00
0%
-
0%
-107.00
-50%
100%
2,325.00
1,550.00
1,550.00
0%
-
0%
-1,162.50
-50%
Sub Total Trust Led Schemes - Acute
24
-
PROJECT/SCHEME
Guaranteed/Not
Guaranteed
Contractual Rag
Rating
Project Delivery Rag
Rating
2.3 CCG/Trust Led Schemes – Community Dashboard
2013/14 TOTAL QIPP
PROGRAMMES
£'000
Intermediate Care (full year effect)
Guaranteed
Podiatry
Guaranteed
50.39
Estates Rationalisation
Guaranteed
300.00
Specialist Children's Services
Guaranteed
200.00
Minnie Kidd House
Guaranteed
244.00
Population/Incidence Growth
Guaranteed
Sub Total Trust Led Schemes - Community
114.06
Year To Date
Forecast Outturn
% Risk
Rating
Underlying Position
Plan
Actual
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
£'000
£'000
£'000
%
£'000
%
£'000
%
76.04
76.04
0.00
0%
-
0%
33.60
33.60
0.00
0%
-
0%
200.00
200.00
0.00
0%
-
0%
133.33
133.33
0.00
0%
-
0%
162.67
162.67
0.00
0%
-
0%
291.54
194.36
194.36
0.00
0%
-
0%
1,200.00
800.00
800.00
-
0%
-
0%
25
0.00
%
0%
100%
0.00
0%
100%
-150.00
50%
50%
-100.00
50%
50%
-122.00
50%
50%
0.00
0%
100%
-372.00
-31%
Guaranteed/Not
Guaranteed
Project Delivery Rag Rating
PROJECT/SCHEME
Contractual Rag Rating
2.4 CCG/Trust Led Schemes – Mental Health Dashboard
2013/14 TOTAL QIPP
PROGRAMMES
£'000
Review of Rehabilitation
Services
Year To Date
Forecast Outturn
% Risk
Rating
Underlying Position
Plan
Actual
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
£'000
£'000
£'000
%
£'000
%
£'000
%
%
Guaranteed
776.00
517.33
517.33
0.00
0%
-
0%
-776.00
-100%
50%
Spot Placements
Supported
Housing
Transfer
Guaranteed
144.00
96.00
96.00
0.00
0%
-
0%
0.00
0%
100%
Guaranteed
100.00
66.67
66.67
0.00
0%
-
0%
0.00
0%
100%
Acute bed reductions
Guaranteed
500.00
333.33
333.33
0.00
0%
-
0%
0.00
0%
100%
CAMHS
Guaranteed
200.00
133.33
133.33
0.00
0%
-
0%
0.00
0%
70%
Mental Health Older
Adults - continuing care
Guaranteed
750.00
500.00
500.00
0.00
0%
-
0%
-375.00
-50%
100%
Mental Health Older
Adults - acute HTT
Guaranteed
200.00
133.33
133.33
0.00
0%
-
0%
0.00
0%
100%
Specialist
Non Guaranteed
150.00
100.00
-
-100.00
-100%
-100%
-150.00
-100%
50%
Prescribing
Guaranteed
50%
Sub Total Mental Health - CCG Led Schemes
137.00
91.33
91.33
0.00
0%
2,957.00
1,971.33
1,871.33
-100.00
-5%
26
-150.00
-150.00
0%
0.00
0%
-5%
-1,301.00
-44%
2.5 CCG Led Schemes – Prescribing Dashboard
PROJECT/SCHEME
Guaranteed/Not
Guaranteed
Contractual
Rag Rating
Project
Delivery
Rag
Rating
2013/14 TOTAL QIPP
PROGRAMMES
£'000
Repatriation
of
Immunosuppressants
Implementation
of
London
Respiratory
Team key prescribing
messages
Delivery of Primary
Care QIPP Plan /
Scriptswitch
Implementation
Other schemes
Year To Date
Forecast Outturn
% Risk
Rating
Underlying Position
Plan
Actual
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
Variance
Over/(Under)
Variance
£'000
£'000
£'000
%
£'000
%
£'000
%
%
Non Guaranteed
200.00
133.33
133.33
0.00
0%
-
0%
0.00
0%
100%
Non Guaranteed
400.00
266.67
266.67
0.00
0%
-
0%
0.00
0%
100%
Non Guaranteed
403.00
268.67
268.67
0.00
0%
-
0%
0.00
0%
100%
Non Guaranteed
200.00
133.33
466.33
333.00
250%
500.00
250%
500.00
250%
100%
1,203.00
802.00
1,135.00
333.00
42%
500.00
42%
500.00
42%
Sub Total Prescribing - CCG Led Schemes
27
PROJECT/SCHE
ME
Project Delivery Rag Rating
PROJECT/SCHE
ME
Guaranteed/
Not
Guaranteed
Contractual Rag Rating
2.6 CCG Led Schemes Dashboard
2013/14 TOTAL
QIPP
PROGRAMMES
£'000
CCG
Schemes
Forecast Outturn
Plan
Actual
Variance
Over/(Under)
£'000
£'000
£'000
Underlying Position
Varian
ce
Variance
Over/(Und
er)
Varian
ce
Variance
Over/(Under)
Varian
ce
%
£'000
%
£'000
%
%
Led
Other
Client
Groups
Reduction
in
Corporate
corporate spend
Sub Total - Non Acute & Other CCG
Led Schemes
Non Acute
Year To Date
%
Risk
Ratin
g
Guaranteed
322.50
215.00
215.00
0.00
0%
-
0%
0.00
0%
100%
Guaranteed
359.00
239.33
239.33
0.00
0%
-
0%
0.00
0%
100%
681.50
454.33
454.33
0%
-
0%
28
-
-
0%
2.7 QIPP Totals Dashboard
PROJECT/SCHEME
2013/14 TOTAL QIPP PROGRAMMES
£'000
Total QIPP Savings
11,880.05
Reinvestment
Net QIPP Schemes
-1,864.00
10,016.05
Year To Date
Forecast Outturn
Underlying Position
Plan
Actual
Variance Over/(Under)
Variance
Variance Over/(Under)
Variance
Variance Over/(Under)
Variance
£'000
£'000
£'000
%
£'000
%
£'000
%
7,850.20
6,747.39
-1,102.81
-14%
-1,242.67
-43.00
1,199.67
-97%
6,607.54
6,704.39
96.86
1%
29
-1,617.87
1,350.00
-267.87
-14%
-4,303.37
-36%
-72%
1,350.00
-72%
-3%
-2,953.37
-29%
1.4 Equalities
NHS Lambeth CCG has adopted an equality objective for each of its seven
priority health goals which are the responsibility of the respective programme
boards to drive, monitor and report on.
The CCG is placing an emphasis on its core mission of improving health and
reducing inequalities through the material being used in developing and
implementing the Big Lambeth Health Debate discussions. Themes emerging
through the debate at this stage include:






Better engagement and support for carers
Use community groups to engage ‘hard to reach’
Better use of language
Service should be more ‘ person centred’
Health Living Champions – expand into larger workforce
More joined up services
Further feedback on BLHD prompted equalities themes will be brought to and
discussed at the EEC meeting and the new strategic plan of the CCG,
prepared on the back of the BLHD will pay close attention to issues of
inequality.
1.5 Performance Dashboards
The performance dashboards cover the National Standards as set out in the
national 2013/14 Assurance Framework.
The Performance Measures are listed with a description in the performance
dashboards (with data shown for providers and on a commissioner basis)
The Report describes where performance has been below the expected
standard and highlights risks to future delivery. The actions being taken are
summarised to give the Board assurance that performance issues are being
appropriately addressed.
30
Lambeth CCG Executive Summary
Finance
The month 6 acute performance position shows a year to date over performance of 4.6% for contracted activity and an over performance of 3.8% across all acute budgets, after the release of agreed over performance reserves. The forecast
outturn is a year-end contractual over performance of 4.7%, reducing to 3.9% for all acute budgets, again after the utilisation of acute budget reserves. Over performance against plan at KCH and non local contracts (excluding STG) continue to
be the key drivers of Lambeth’s over performance at Trust level. At service level the key drivers of the Lambeth position are non-elective admissions, new outpatients, critical care and drugs and devices, all over performing by more than 10% this is offset by continuing through reducing YTD under performance for elective admissions and unbundled diagnostics. In overall terms trends have remained as set out last month and the forecast outturn position is broadly static, although
there have been swings at individual provider and service level.
Key financial risks for 2013/14 are known and understood and include :

Expected in year increases in demand driven by population and incidence growth and waiting times pressures.

Delivery of activity reductions in line with CCG QIPP plans

The impact of new commissioning arrangements and specifically NHSE transfers

The impact of recording and charging related to new tariff arrangements, with particularly significant risk associated with the new maternity care pathways tariffs, plus more general case mix pressures.
Work is on going across the CCGs and SLCSU to mitigate as far as possible these risks, with work to address allocation and tariff related risks, on going delivery of CCG service redesign and demand management initiatives and the effective
management of the acute contracts utilising appropriate contractual levers in doing so.
Demand & Activity
The demand and activity section of the report provides a comparison of activity trends against prior year activity. It therefore differs to the information
provided in the Finance Section of the report, which assesses in year performance against 2013/14 plan. The two sections of the report will not therefore
reconcile but the activity section provides a helpful context against which to consider in year performance against plan and better understand year on year
trends. Where appropriate we have linked the conclusions of the activity section to the contractual position to try to make more explicit underling trends
and contractual issues.
Quality
Key issues in terms of compliance with quality dashboard indicators remain as reported last month - strong performance in relation to standardised
mortality, continuing required improvements in complaints response times at KCH, low levels of serious incidents, including grade 3 and 4 pressure ulcers
and some continuing challenges in meeting maternity standards and safeguarding training at KCH. A summary of the key issues discussed at the most
recent CQRGs is also included in this section of the Integrated Report.
Performance
A&E performance was sustained in September enabling both GST and KCH to meet the all type A&E performance standard for Q2. The latest YTD position however shows
under delivery against the A&E standard at KCH (Denmark Hill), but sustained performance at GST. A&E Recovery Plans continue to be implemented and winter plans for
2013/14 have also been agreed - with Urgent Care Board focused plans, underpinned by provider specific plans and a supporting SEL wide demand and capacity analysis.
On other key performance targets the CCG position shows breaches against a limited number of other targets, including over 52 week waiters (1 at KCH), 18 weeks
admitted RTT (KCH) and diagnostic waits (GST). On infection control C Difficile performance has been strong and is within targets and there have been no further MRSA
cases since the 1 GST reported case in June 2013. On RTT performance Lambeth narrowly missed the admitted performance threshold, there remains a RTT backlog at
KCH to be cleared over the remainder of the year and a planned RTT failure at KCH for the whole of 2013/14.
31
Commentary
Key Risks and Mitigations
NHSE transfer – there are a number of continuing risks associated with the NHSE transfer: the accuracy of start contract assumptions in relation to NHSE/CCG activity and
funding splits, the accuracy of in year coding to the correct responsible commissioner, differences between CCG allocation adjustments and provider/NHSE assessments of
transfer values and the residual budget shortfall associated with CCG to NHSE transfers following the latest adjustments made to CCG baselines. Work is on going to address
these issues through London wide reconciliation and consolidation exercise, with the objective of reaching agreed resolution for 2013/14 in December 2012.
Demand, Population and Incidence Growth - 2013/14 contracts are based on the previous year’s FOT and therefore reflect underlying demand but do not include provision
for in year general population and incidence growth. The expectation therefore is that there will be over performance against start contract plans, although over performance
at some providers and for some services is currently in excess of expectations in relation to demand, population and incidence growth. CCG budgets include some funding to
cover expected acute over performance, although the level of available reserves means that CCGs will need to work to manage demand where they have the ability to do so,
with delivery of CCG led QIPP initiatives vital in containing overall acute over performance over 2013/14. From a contractual perspective the CSU will continue ensure that
available contractual levers are effectively utilised – the contracts include a number of commitments providers have made to support CCG commissioning intentions and QIPP
plans in 2013/14. Stocktake meetings have taken place with to review performance YTD and QIPP delivery.
Waiting Times and Referral to Treatment Times (RTT) - 2013/14 contracts make provision for expected demand increases associated with the treatment of waiting list
backlogs at KCH and the sustained delivery of RTT targets at GST over 2013/14. To date elective activity has been less than planned with this under performance offsetting over
performance in other areas. It is expected that there will be some catch up over the rest of the year, which will be important in terms of ensuring a backlog does not develop
to be addressed in 2014/15 contracts.
QIPP - CCG QIPP targets have been reflected in start acute contracts for 2013/14. Initiatives all have an agreed lead and risk holder and a contractual framework has been
agreed to secure effective contractual levers and incentives to support delivery of QIPP. Based on YTD delivery a step reduction in outpatient referrals and A&E attendances
from current levels will be required to recover the QIPP position and get closer to delivering 2013/14 targets by year end. Actual delivery of Trust led initiatives is also taking
place to ensure that providers are making the operational and service changes agreed with commissioners to underpin agreed initiatives and reduce acute sector activity and
cost.
Price/Case Mix – 2013/14 contracts have been set on the basis of historic (2012/13 case mix). There are however a number of potential risks for 2013/14, including: increased
case mix complexity over 2013/14 (particularly emergency admissions) and risks associated with new tariff arrangements for maternity and unbundled imagining services. The
key case mix related issue YTD related to the impact of the new maternity care pathways with a step increase in the complexity of recorded birth case mix at GST and KCH and
antenatal case mix at KCH. Discussions are on going with providers to identify a mutually acceptable way of managing and mitigating these risks for 2013/14 in line with PbR
guidance.
32
33
Performance Summary
Indicator
Health Care Acquired
Infection
MRSA
1
YTD
30
23
Guy's & St Thomas'
Oct
95%
96.9%
Oct
95%
94.5%
YTD
0%
0
Sep
0
0
Sep
0
0
Admitted
Sep
90%
89.7%
Incomplete
Sep
0
1
Sep
99%
97.5%
A&E Trolley waits over
12hrs at Guy's & St
Thomas'
Ambulance Handover Time 30-60 Min
for Guy's & St Thomas'
> 60 min
Mixed Sex
Accommodation Breaches
Cancer Waiting Times
Actual
C'Diff
A&E Waiting Time – 4 hour
DTA, All types
King's Denmark Hill
18 weeks Referral to
Treatment Time (RTT)
Patients waiting 52+
weeks RTT
Diagnostic Waits Within 6
Weeks
Reporting National
Period
Target
YTD
0
Sep
0
0
All Cancer 2 week
standard
Aug
93%
94.9%
2 week standard for
Breast Symptoms
Aug
93%
98.1%
62 day standard
Aug
85%
90.0%
MRSA
There have been no further MRSA cases since June. PHE currently report 0 MRSA cases assigned to
Lambeth YTD compared to the one actual stated in this report. The CSU is investigating the reason for
this difference and the final figure will be reflected in future reports.
A & E Waiting times – 4 hour Decision to Admit
Whilst GST is above the performance threshold of October, KCH (Denmark Hill) was below. With effect
from 1 October, Princess Royal became part of the KCH Trust, the figures in the performance summary
relate to the Denmark Hill site only. One of the drivers behind the performance is critical care
availability. Infill Block 4 will provide additional critical care capacity, however Infill 4 will not be
operational until mid-November. In addition to this there are a number schemes within the trust
winter plan and expansion plans which are still due to come on line. A Commissioner/Provider
meeting is due to take place in November to review performance issues at the site.
18 weeks RTT – admitted
Performance below the threshold is driven by performance at KCH. The backlog of admitted patients
will continue to be reduced over the course of 2013/14, and will result in KCH’s performance being
below the threshold each month in 2013/14. The trust is using a combination of outsourcing to private
providers and additional elective capacity on the PRUH and Orpington sites. In addition the trust is
transferring some existing orthopaedic waiters, subject to patient agreement, to GST for treatment.
The trust should be in a sustainable position from April 2014
RTT– waiting more than 52 weeks, and still waiting (incompletes)
The long waiter is waiting for general surgery/bariatric surgery at KCH. KCH continues to outsource
bariatrics to private providers.
Diagnostics
The main driver for this under performance is endoscopy at GST. Although GST has opened a new
larger endoscopy suite, poor staffing levels has resulted in an increase in the number of waiters over 6
weeks. The trust has put additional sessions in place to increase staffing capacity using clinical fellows,
however it anticipates it will take until December to fully clear the backlog of long waiters.
Mixed Sex Accommodation breaches
Recent clarification from NHSE(L) on reporting patients that no longer require critical care has resulted
in a reduction in the number of reported MSA breaches, and for Lambeth for September, no breaches
of any kind have been reported.
34
Lambeth CCG Acute Performance Scorecard
Target
Apr
May
Jun
Jul
Aug
Sep
Quarter 1
Monthly Indicators
CB_A15: Healthcare acquired infection (YTD) (MRSA)
0
0
G
0
G
1
R
1
R
1
R
1
R
1
R
30
4
G
8
G
10
G
12
G
19
G
23
G
10
G
CB_B1: RTT 18 week compliance, admitted patients
90.0%
90.9%
G
89.5%
A
90.5%
G
90.6%
G
90.3%
G
89.7%
A
90.3%
G
CB_B2: RTT 18 week compliance, non admitted patients
95.0%
97.6%
G
97.8%
G
97.7%
G
97.0%
G
97.4%
G
97.2%
G
97.7%
G
CB_B3: RTT 18 week compliance, incomplete pathways
92.0%
94.0%
G
93.9%
G
93.7%
G
94.0%
G
93.8%
G
94.0%
G
93.7%
G
99.00%
93.0%
98.80%
94.5%
A
G
98.07%
96.5%
A
G
98.06%
96.6%
A
G
97.85%
95.4%
A 97.15%
G 94.9%
A
G
97.53%
A
98.06%
95.9%
A
G
CB_B7: Breast symptoms (cancer not initially suspected)
93.0%
94.4%
G
94.2%
G
96.4%
G
95.8%
G
98.1%
G
95.0%
G
CB_B8: Cancer first definitive treatment in 31 days
96.0%
100.0%
G
98.7%
G
96.3%
G
100.0%
G
97.4%
G
98.3%
G
CB_B9: Cancer subsequent treatment 31 days, surgery
94.0%
100.0%
G
100.0%
G
100.0%
G
92.3%
A 100.0%
G
100.0%
G
CB_B10: Cancer subsequent treatment 31 days, drug
98.0%
96.6%
A
100.0%
G
100.0%
G
100.0%
G 100.0%
G
98.8%
G
CB_B11: Cancer subsequent treatment 31 days, radiotherapy
94.0%
91.7%
A
96.4%
G
100.0%
G
93.9%
A
92.3%
A
95.5%
G
CB_B12: Cancer first treatment 62 days, GP referral
85.0%
84.2%
A
79.4%
R
82.8%
A
84.2%
A
90.0%
G
82.2%
A
CB_B13: Cancer first treatment 62 days, screening referral
90.0%
100.0%
G
100.0%
G
100.0%
G
83.3%
R
75.0%
R
100.0%
G
CB_A16: Healthcare acquired infection (YTD) (C-Difficile)
CB_B4: Diagnostic test waiting times
CB_B6: All cancer two week waits
CB_B14: Cancer first treatment 62 days, consultant upgrade
100.0%
66.7%
35
100.0%
100.0%
80.0%
81.8%
CCG Acute Performance Scorecard
Target
Apr
May
Jun
Jul
Aug
Sep
Quarter 1
Monthly Indicators
CB_B15_01: Ambulance category A (Red 1) 8 minute response
75.0%
77.8%
G
78.1%
G
77.6%
G
77.6%
G
76.5%
G
72.4%
A
77.8%
G
CB_B15_02: Ambulance category A (Red 2) 8 minute response
75.0%
75.8%
G
77.8%
G
75.9%
G
73.4%
A
74.1%
A
70.8%
A
76.5%
G
CB_B16: Ambulance category A 19 minute transportation time
95.0%
98.0%
G
98.5%
G
98.2%
G
97.8%
G
98.0%
G
97.2%
G
98.2%
G
CB_B17: Mixed sex accommodation breach count
0
18
R
4
A
8
A
10
A
6
A
0
G
30
A
CB_S6: RTTs in excess of 52 weeks: Admitted patients
0
8
R
1
R
3
R
2
R
4
R
3
R
3
R
CB_S6: RTTs in excess of 52 weeks: Non admitted patients
0
3
R
13
R
0
G
2
R
5
R
1
R
0
G
CB_S6: RTTs in excess of 52 weeks: Incomplete Pathways
0
4
A
8
A
4
A
2
A
1
A
1
A
4
A
Cancer waiting times – 31 day subsequent Radiotherapy
The performance relates to 2 of the 26 patients not been treated within the required timeframe. One was due to patient going on holiday and one was due to a planning scan.
Cancer waiting times – 62 day screening referral
The performance relates to 1of the 4 patients not been treated within the required timeframe. This was due to patient choice.
RTT– RTTs in excess of 52 weeks
Please note that the admitted and non-admitted data relates to patients whose treatment has been completed but at this point had waited in excess of 52 weeks. Contractual penalties apply to patients who are
still waiting post 52 weeks (incompletes), see CCG summary page for details.
36
Provider Performance Scorecard
Monthly Indicators
CB_A13: Friends and family response rate (A and
E)
CB_A13: Friends and family response rate
(Inpatients)
CB_A13: Friends and family response rate
(Combined)
CB_A15: Healthcare acquired infection (YTD)
(MRSA)
CB_A16: Healthcare acquired infection (YTD) (CCB_B1: RTT 18 week compliance, admitted
patients
CB_B2: RTT 18 week compliance, non admitted
CB_B3: RTT 18 week compliance, incomplete
pathways
CB_B4: Diagnostic test waiting times
CB_B5: A and E 4 hour waiting time compliance
CB_B6: All cancer two week waits
CB_B7: Breast symptoms (cancer not initially
CB_B8: Cancer first definitive treatment in 31 days
CB_B9: Cancer subsequent treatment 31 days,
surgery
CB_B10: Cancer subsequent treatment 31 days,
drug
CB_B11: Cancer subsequent treatment 31 days,
CB_B12: Cancer first treatment 62 days, GP
referral
CB_B13: Cancer first treatment 62 days, screening
CB_B14: Cancer first treatment 62 days,
Target
Guy's and St Thomas'
Latest
YTD
King's College
Latest
YTD
St George's
Latest
YTD
Aug
5.4%
Aug
11.6%
Aug
7.0%
Aug
35.9%
Aug
33.7%
Aug
32.3%
Aug
14.3%
Aug
15.3%
Aug
15.2%
0
Varies
Sep
Sep
3
18
R
G
Sep
Sep
2
21
R
G
Sep
Sep
3
22
R
G
90.0%
95.0%
Aug
Aug
93.1%
96.8%
G
G
Aug
Aug
87.1%
97.4%
R
G
Aug
Aug
92.6%
97.8%
G
G
92.0%
99.0%
95.0%
93.0%
93.0%
Aug
Aug
Sep
Aug
Aug
93.5%
94.9%
96.8%
94.1%
96.8%
G
R
G 95.8%
G 95.3%
G 94.9%
G
G
G
Aug
Aug
Sep
Aug
Aug
92.1%
98.7%
95.4%
95.3%
96.1%
G
R
G 95.6% G
G 96.9% G
G 98.0% G
Aug
Aug
Sep
Aug
Aug
94.7%
99.9%
94.6%
97.0%
98.9%
96.0%
Aug
96.9%
G 97.6%
G
Aug
97.8%
G 98.8% G
Aug
94.0%
Aug
98.7%
G 97.8%
G
Aug 100.0%
98.0%
94.0%
Aug
Aug
99.3%
94.0%
G 98.7%
G 96.0%
G
G
85.0%
90.0%
Aug
Aug
Aug
80.0%
71.4%
89.8%
A
R
R
R
37
3
18
76.6%
84.4%
91.0%
R
G
2
21
R
G
3
22
R
G
G
G
R
G
G
95.2%
97.2%
96.5%
G
G
G
97.2%
G
97.7%
G
G 98.1% G
Aug 100.0%
G
98.6%
G
Aug 100.0%
Aug
--
G 99.1% G
--
Aug 100.0%
Aug
--
G 100.0%
--
G
Aug 83.1%
Aug 86.1%
Aug 100.0%
A
A
Aug 86.0%
Aug 96.9%
Aug 100.0%
G
G
G
G
88.2% G
95.7% G
81.3%
85.0%
94.2%
100.0%
Provider Performance Scorecard
Monthly Indicators
CB_B15_01: Ambulance category A (Red 1) 8
minute response
CB_B15_02: Ambulance category A (Red 2) 8
minute response
CB_B16: Ambulance category A 19 minute
transportation time
CB_B17: Mixed sex accommodation breach
count
CB_B18: Cancelled operations not
rescheduled in 28 days
CB_S4: A and E attendances, type 1
CB_S4: A and E attendances, all types
CB_S6: RTTs in excess of 52 weeks: Admitted
CB_S6: RTTs in excess of 52 weeks: Non
CB_S6: RTTs in excess of 52 weeks:
CB_S7: Ambulance handover delays over 30
minutes
CB_S7: Ambulance handover delays over 60
CB_S9: A and E trolley waits over 12 hours
(YTD)
CB_S10: Urgent operations cancelled for a
second time
Target
Guy's and St Thomas'
Latest
YTD
0
Sep
0
G
9
0.0%
1.0%
10,086
13,183
0
1
0
R
0
0
0
Qtr 1
Sep
Sep
Aug
Aug
Aug
0
0
Sep
Sep
0
0
G
G
0
0
0
Aug
0
G
0
Aug
0
G
King's College
Latest
YTD
R
Sep
0
G
153
Qtr 1 4.5%
Sep 10,215
Sep 12,299
Aug
21
Aug
12
Aug
36
R
G
G
Sep
Sep
0
0
G
G
0
3
0
G
Aug
2
R
0
G
Aug
0
G
68,705
88,768
G
R
G
38
St George's
Latest
YTD
R
Sep
0
G
38
R
Qtr 1 1.2%
Sep 10,000
Sep 11,445
Aug
1
Aug
0
Aug
0
R
G
R
Sep
Sep
87
0
R
G
272
1
R
R
2
R
Aug
0
G
0
G
0
G
Aug
0
G
0
G
68,654
82,357
R
R
R
66,511
75,031
R
G
G
SECTION 2 OPERATIONAL DELIVERY
2.0 Planned Care Programme
Clinical Lead: Dr John Balazs
Executive Lead: Moira McGrath, Director of Care Pathway Commissioning
Programme Lead: Claire Hornick Interim Acute Commissioning & Redesign Manager
2.1
Long Term Conditions
Diabetes
 ‘Living with Diabetes’ – Structured Self-Management programme has been
launched. This programme is being delivered through the Lambeth Early
Intervention Programme
 46 practices across Lambeth signed up to the DMI/CCG Reward Scheme.
All of these practices have completed their action plans and a programme of
support has been agreed for practices that were identified as needing
additional support.
 10 practices have been identified that will benefit from a package of support
from the DMI and the DICT. These practices will be asked to commit to this
package of support.
 The 10 practices identified last year for this support have achieved more
than the Lambeth average for key metrics and continue to sustain this
improvement
 35 practices have attended at least two learning events focused on DMI
priorities.
 Community Clinic service has been evaluated and the Lambeth Diabetes
Action Group has made a recommendation to continue with the existing
service. This recommendation will go to the Governing Body meeting in
January 2014.
 Work underway to develop systematic approach to management of prediabetes patients. Across Lambeth and Southwark, 3,377 patients are coded as

‘at risk’ or ‘pre-diabetes’, with one practice having 325 patients with an HbA1c of
42-47mmol/mol .
Important to work together with the Local Authority to prioritise the following in
2014/15:
o Develop local guidelines and interventions to support patients control,
or reduce their HbA1c and therefore avoid or delay becoming diabetic
o Agree joint funding arrangements to support the delivery of the
intervention
o Include the detection and ‘holding’ of people with pre-diabetes in any
local incentive scheme
39
Young Diabetes Connections: Highly Commended
Young Diabetes Connections received a High Commendation from the judges for
'Best Improvement Programme for Children and Young People'. The award
recognises the innovative nature of the network, and how well clinicians and
managers from all three trusts, as well as the Diabetes Modernisation Initiative,
worked together to create an excellent new service for children and young people,
and their families, living with diabetes in South London.
Judges’ comments: “I liked the fact there was major stakeholder consultation with
kids and parents. The pilot had positive Hba1c results and there was impressive
peer support.”
Each Quality in Care (QiC) Programme highlights good healthcare practice and
effective collaboration between the NHS, private sector, patient groups and the
industry in specific therapy areas. This new approach to joint working is essential in
these challenging economic times as the NHS strives to continue offering a worldbeating service.
Diabetes Community services: Commended
The Southwark and Lambeth Community diabetes teams received a
Commendation from the Quality in Care for diabetes judges for good practice and
collaboration in diabetes. The judges were impressed by the teams' success in
bringing together staff from the local hospitals, community diabetes services and
social care to make real improvements in diabetes care. The resulting
improvements in care were highlighted as key achievements.
The Community Diabetes Services are provided in Lambeth by the Lambeth
Diabetes Intermediate Care Team , which is part of Crowndale Medical Centre.
The DMI Diabetes Patient Forum
The Forum has worked for over two years to improve local services, help patients
manage their condition and spread the word about diabetes in the community.
Among other achievements, it has brought about improvements in foot care, fedback patient experiences of GP practice and helped design patient information
packs.
The Diabetes Voluntary Group linkS in with a network of 400 similar groups across
the UK co-ordinated by Diabetes UK.
Primary Care Management
There are significant improvements in primary care management of diabetes
demonstrated in recently released QOF 12/13 data. Lambeth and Southwark
rankings nationally and in London are improving when nationally performance is
declining or plateauing.
-
Previously ranked 24th, and 19th respectively in London, Southwark and
Lambeth are now ranked 8th and 9th on blood glucose control for their
diabetic patients (DM27 Hba1c 64mmol).
40
-
-
The boroughs have moved from bottom quartile to second quartile on all
three levels of blood glucose control, when compared to national
performance.
We expect further improvement following the current 13/14 reward scheme
and support programme is fully completed, given the unprecedented levels
of sign up and engagement in the Reward Scheme from local general
practice.
-
There has been a sharp fall in emergency admissions for diabetes in the
under 65s over the last two quarters, and GP initiated referrals to hospital
continue to decline and this appears to be the trend.
-
Care Planning Minimum standards are well established in general practice,
with practices well on track to achieve the 40% target of people with
diabetes having a collaborative care plan with their primary care team. The
design principles of these minimum standards are further validated by
increasing confidence levels in patients through receiving the minimum
standards. This generic approach will have wider utility in all chronic
condition management, and wider adoption should be considered.
-
Community based diabetes services in the boroughs are performing very
effectively. Repeat evaluation demonstrates high quality of service, high
satisfaction levels, affordable services, appropriate case mix, and efficacy at
building competence in general practice.
-
Members of the London Assembly Health Committee visited to hear about
the DMIs approach. We have since been invited to attend the Committee,
with the London wide Diabetes Strategic Clinical Network and the South
London Health Innovation Network Diabetes programme to discuss tackling
variation in diabetes outcomes across the capital.
2.2 Sexual Health Commissioning Update
Lambeth is in the preliminary stages of developing a tri-borough needs assessment
to review service provision in line with local needs, available evidence and ensure
commissioned services are needs led and value for money. This intends to inform
the tri borough strategy, with the first draft document due in due in December 2013.
2.2.1 HIV Voluntary Sector
The ”Chemsex” study (research into MSM substance misuse and risk taking sexual
behaviour)is progressing well, on target at 90 days and drawing in positive publicity
as the only research of its kind in the UK .The first draft of the report with initial
findings will be available mid March and will be supported by a launch event.
The London HIV Prevention Needs assessment has been finalised, a new 3 year
programme is proposed commencing in 2014, which Lambeth LA will host. A
scaled down interim programme with two work stream will be in place until the new
programme has been procured. This interim London wide programme will contain
outreach (this service specification is being refreshed by the SH team) and condom
distribution.
41
African Cultural Promotions (ACP) had a contract for the distribution of condoms
within Safer Partnership, and the CEO was also chair of the African Health Forum,
contracted through the Rain Trust. ACP had additional contracts with the DH,
South West London partnership and other boroughs. Amidst investigation into
under performance and suspected mismanagement, ACP informed
Commissioners that it has gone into liquidation. LSL will ensure continuity of
service through the remaining Safer Partnership organisations.
The
commissioning team have met with the commissioned provider for the African
forum and, and have requested financial information and an improvement in
service provision.
SHAKA services, also a service with the Safer Partnership (and part of the Forum
umbrella organisations) is commissioned by LSL to deliver outreach and
Community Mobilisation. Without consultation, SHAKA invited Chelsea
Westminster GUM to their Worlds AIDS Day Event in Brixton on 28th November to
provide HIV testing. SHAKA had initially approached LSL commissioners as they
were keen to provide their own HIV testing service. However, due to concerns from
SH commissioning team regarding SHAKA’s lack of training and clinical
governance structures, they were advised to work with our local providers GSTT.
SHAKA were also seemingly unaware of the cost implication for involving
Chelsea and Westminster , and that Lambeth LA would have to pay GUM PBR
tariff for each test perform on local residents who have an HIV test at Brixton
library.
2.2.2. Lambeth, Southwark and Lewisham (LSL) HIV Care and Support
Review
At the last LSL SH programme board meeting in September it was decided that
from 2014/15 the contracts commissioned within the South London HIV
Partnership (SLHP) would be commissioned by the LSL SH team. The host
commissioner (Croydon LA), for the SLHP was given notice that Lambeth LA will
be commissioning directly with providers in the new finical year. This will allow the
SH team to retender and shape peer support services to meet local need s, tighten
up service specifications and performance framework. The SH team have met with
Croydon PH and lead commissioner who were concerned about the risks of
discontinuation of the programmes for the smaller boroughs. Croydon LA is due to
draw up a risk assessment paper highlighting the risks. The 2 nd meeting was held
with SH commissioner within the South London Partnership and 3rd meeting with
commissioned providers on 27th November 2013. The DPH’s for Southwark and
Lambeth have along with Lewisham been updated regarding this change in
commissioning arrangement and a briefing has been sent to the relevant CCG and
LA communications teams. The next HIV Care and Support Programme Steering
Group will be held on 10th December.
2.2.3 Sexual Health service redesign
The GP LARC enhanced service specification was refreshed along with the other
GP and community sexual health enhanced services. Within the LES it was made
clearer that they were two funding streams within the service specification for
contraception ( Sexual health responsibility ) and management of menorrhagia
42
(part of the CCG Gynaecology pathway CCG). Relevant Reads codes that can
distinguish between these different reasons for LARC activity are currently being
identified and will be included in the service specification.
2.2.4 Tariff Implementation
Discussion from the recent London SH commissioners meeting indicates that there
is an appetite amongst the London boroughs to implement the integrated sexual
health tariff. The integrated sexual health tariff would provide greater transparency
with GUM activity and allow cross charging for Reproductive and integrated sexual
health services. The next commissioners meeting are due in January where it is
the intention that Pathway analytics attend to do a presentation and continue the
discussion on the next steps.
2.2.5 Termination of Pregnancy (TOP)s
A pan provider TOP meeting is planned for the 5 th December 2013; data report will
be presented, to start discussion on data requirements going forward. Additional
issues to be discussed include the need to reduce repeat TOP, by reviewing the
post TOP contraceptive pathway and increasing contraceptive uptake post TOP.
There have been no Serious Incidents in the last quarter.
2.2.6 Sterilisations & Vasectomies
British Pregnancy Advisory Service will continue to provide Vasectomies for
2013/14 for Lambeth, Southwark and Lewisham. Volumes for this service are
relatively low, in October 2013 there were a total of 13 vasectomies performed
across LSL. Please see table 1 below for break down by CCG.
Table 1 Number of Vasectomies by LSL CCG
Clinical
l
Commissioning Number of Vasectomies
Group
Lambeth
5
Southwark
2
Lewisham
6
TOTAL
13
–Source: bias activity data October 2013.
2.2.7 Contracting
GUM
The initial 2014/15 GSTT contract negotiation meeting was held on 21 st November
2013, where clarity was provided by Lambeth LA on the current situations within
Councils and the transferred PH budgets. Lambeth LA position was also outlined
along with the scale of financial challenges facing Lambeth LA It was also made
clear that there is no additional funding to support budget overspend. GSTT were
informed of the current financial forecast of £1.12 million over budget for SH PbR
GUM activity, which will wipe out any growth margins allocated to the PH budgets,
and present the potential for significant cost pressures. Possible contractual
parameters were raised such as re introducing 2012/13 prices, cap on growth with
marginal rates, use of SH24, and recapturing patient flows to Chelsea and
Westminster GUM was received cordially. The SH team will continue dialogue with
GSTT, especially in relation to achieving GSTT RSH QIPP and will meet with
43
GSTT again in January 2014.
scheduled shortly.
A meeting with Kings GUM and RSH is to be
Primary care
The LSL Sexual Health and Lambeth substance misuse enhanced service
specifications were refreshed and adapted for the Public Health contract in
preparation for the next financial year. These documents were sent out for
circulation to the members of the primary care working group for comments by 2nd
December 2013. The next step will be to seek clinical engagement. Recent
meetings with the LMC and medicines management in Lambeth indicated that they
were keen to be involved in the sign off process but capacity may need to be
bought in for the development of PGDs. The next steps will involve a primary care
communication plan to inform stakeholders of our intentions for contracting primary
care in 2014/15. Further work streams are also focused on identifying the
governance; information; and business administration systems and processes that
require implementation, to enable effective local management of these and other
primary care enhanced services included in the public health transfer. There is the
urgent need to review the data pathway and activity reporting systems across
primary care. As there appears to be an indication of discrepancies between QMS
validated performance extracts and self reported activity within some contracted
service areas. This has considerable implications for both financial management
and public health analysis.
2.3 South East London Community Based Care
To enable better ways of team working and consider changes in the traditional
roles of primary care practitioners, creating the opportunity to design new ways of
working which will reshape the boundaries between primary care, hospital and
other associated services.
Primary Care/Urgent Care Workstream
SEL CBC Transformation Board has approved key areas for focus and action for
delivery in the first year of the three year implementation period. It is proposed the
workstream should be understood as a 'Super Enabler' as PCC will underpin the
full ambition of CBC.
The Primary and Community Care team is currently pulling together a business
case to develop Primary Care Locality Networks. This business case focuses on
developing Primary Care Network Localities to support implementation of the
Primary and Community Care workstream of the Community Based Care
Strategy and describes the work underway to develop Primary Care in Lambeth so
we continue to sustain the highest quality general practice in Lambeth.
The workstream has developed and issued three interdependent implementation
proposals to progress delivery in primary and community care, which have been shared
and approved by the NHS Lambeth CCG Governing Body.
44
Area 1: Development (Variation)
 Development of primary care to reduce variation
 Interface with NHSE to secure continuous improvement in the quality of primary


medical services
Standard NHSE operating policies/procedures including personal medical services
assurance framework
Best possible triangulation of data/intelligence to inform the assurance process and
to identify and resource development activity in support of primary care
Area 2: Commissioning (Scale)



Implementation plan seeks to establish common principles for commissioning ‘at
scale’
Primary and Community services that give focus to and incentivise delivery of
population outcomes on a locality basis
Principles for locality based commissioning would be co-produced
Area 3: Organisational Development (Capacity)



Common set of design principles for delivery of primary care at scale
Establish organisational development fund that allows groups of providers to bid
against in order to explore and implement new models of primary and community
care – that respond to the collective intention to commission community based care
on a locality basis
Significant strain on General Practice – support development of better integrated
care and play a central role in commissioning
NHS Lambeth CCGs implementation plans will focus on development, co-ordination and
delivery of these three areas of work, which seek to address current variation in Primary
and Community Care and establish Commissioning and Organisational Development
approaches that allow future delivery of locality based or population focused care at scale
in the future.
45
3.0 Unplanned Care Programme
Clinical Lead: Lisa LeRoux & Ray Walsh
Executive Lead: Moira McGrath, Director of Care Pathway Commissioning
Programme Lead: Therese Fletcher, AD Primary Care and Community
Commissioning/Liz Clegg, AD Older People & Client Groups
Lambeth continues to have a high number of non-elective admissions compared to
London and England and have a high level of reliance on hospital based care.
Local audits show that between 40-60% of people attending A&E could have their
care provided safely and appropriately in primary and community settings. The
major service challenge include the need to improve equitable access, quality and
capacity/capability of primary care services to manage care more effectively
including out of hours, to identify areas that require a whole system pathway
redesign.
3.1 Urgent Care
St Thomas UCC Reconfiguration - Main areas of reconfiguration in line with
the phased implementation of the revised service specification:
 Contractual Negotiations around specific tariffs and agree KPIs – December
2013
 Operational changes, 24/7 model, phased implementation of revised front
ended UCC specification – Qtr2 14/15
 Improvement of the following pathway elements:
1. Clinical streaming/PALS redirection of patients to alternative Primary
Care services – Qtr 1 14/15
2. Minors/primary Care Pathway operational 24/7 - completed
3. Paediatrics – Implementation of the revised Paediatric pathway –
January 2014
4. UCC GP’s – partnership with local GP Practices – March 2014
5. Development of the ENP role – March 2014
6. OOH being based within the UCC – Jan 2014
There is a detailed project plan to support this phased implementation.
Winter Pressures Review/Planning:

The Lambeth & Southwark Winter Pressure Surge Plan has been
completed for 2013/14.
 Lambeth and Southwark Urgent Care Network has submitted the Recovery
and Improvement plan to NHSE on behalf of Lambeth and Southwark CCGs
 Key documents including recovery plans for both GST and KCH were
submitted to NHS England, on behalf of Lambeth & Southwark Urgent Care
Network.
 Continue to manage and monitor performance and ensure that proactive
steps are taken to ensure system is resilient. Teleconferences have now
commenced and will continue during the winter period. This is an effective
46
mechanism to raise operational issues such as delayed discharges or
repatriations.
 Winter Campaign launched in December.
Implementation of NHS SEL 111 Programme


London Ambulance Service (LAS) took over the NHS 111 service on 19th
November 2013 on an interim basis until March 2015.
Development of specification and subsequent procurement has commenced
for provider of NHS SEL 111 service beyond March 2015
A&E Diversion Schemes

GSTT has recruited to the PALS officer role at St. Thomas’ ED and report
on the number of patients appropriately diverted from A&E. They also report
the number of unregistered Lambeth residents who have registered with a
local GP.
Primary Care Diversion scheme operational via Waterloo Health Centre and
Lambeth Walk. NHS LCCG is currently reviewing the service to ensure maximum
utilisation of the allocated slots.
3.2 Southwark and Lambeth Integrated Care Programme (SLIC)
Southwark and Lambeth Integrated Care is a partnership between local GPs,
King’s College Hospital, Guy’s and St Thomas’ Hospitals, the South London and
Maudsley Mental Health trust, social care in both local councils, and Lambeth and
Southwark Clinical Commissioning groups, with local people.
It is funded by GSTT Charity and the first wave of the programme is focusing on
care of frail older people. The current work streams are:





Early intervention – this includes setting up GP registers, case finding, case
management and establishment of locality based Community
Multidisciplinary Care Teams (CMDTs)
Establishment of geriatrician hot lines and clinics
Admission avoidance schemes included Enhanced Rapid Response and
Homeward
Simplified discharge
Care pathway development for falls, nutrition and treatment of infections
Dementia.
The care home and home care workers as early alerts work streams have been
deprioritised and will now be taken forward from February 2014.
The programme applied for Pioneer Status as part of the Pioneer Programme for
health and social care integration, however the bid was unsuccessful.
47
STATUS REPORT – OLDER PEOPLE’S PROGRAMME
SEPTEMBER 2013 OPERATIONS BOARD
Main summary points from the last month
 Achieved target of 80% older people in Lambeth and Southwark, covered by signed up practices
 Significant improvement in number of registers created, with 75 % now completed.
 Following August’s Operations Board, we are in the process of re-evaluating HHAs and the process, to ensure that
deliver an acceleration in our performance.
 Recruited substantive project team for the Older People’s Programme within SLIC
 Simplified Discharge testing has begun, with testing of the referral process. Live patient testing will start in October
2013

Better proactive identification of need & intervention
48
we
An alternative urgent response
Maximising independence before long-term care is finalised





49
Live testing on-going
Numbers being discharged from testing remains lower than
predicted
Significant lessons surrounding the low volumes are:
reducing need for transfers of care, improving access to
therapy support and need to ensure early sharing of
information between health and social care.
The testing has been expanded to all over 65 geriatric
medicine wards
The next stage of testing which will be progressing the
design and ‘Early multi-disciplinary information sharing’ is
now under development and will commence testing as
soon as possible.
Improved clinical pathways
Falls



Stakeholder session held to continue to develop options for ensuring adherence and engagement of well elderly.
Testing of the new Falls interventions is underway, in Brixton Clapham Elm Park, and Streatham as well as Dulwich, Walworth and Peckham.
New information leaflet drafted.
Infections
 UTI Checklist, Cellulitis Pathway, Catheter Passport testing on-going with measure in place to review impact.
 Working group meeting to agree KPIs beyond top-level SLIC benefits.
 Planned Flu-vaccination to social-care staff in Southwark with Boots Plc.
Dementia
 This project is ready to move into the testing phase, awaiting formal agreement regarding line management by GSTT. Once agreed recruitment can
begin.
 This red-rated due to the on-going issues with agreeing line management for the nutrition staff.
 Nutrition Working Group met to recap and scope new models of education and provision.
 Need to develop and test new models of education and provision in the new year.
 Planned Flu-vaccination to social-care staff in Southwark with Boots Plc.
50
4.0 Mental Health Programme
Clinical Lead: Drs Ray Walsh and Raj Mitra
Executive Lead: Director of Integrated Commissioning
Programme Lead: Denis O’Rourke, AD Integrated Commissioning Mental Health/Liz
Clegg AD Older People & Client Groups.
4.1 Transforming primary care and community mental health services
The Living Well Network, the new front end to the support system for people
experiencing severe mental illness commenced operation on 18 November 2013 in
the North of the borough. The network brings together staff from the Voluntary and
community sector, social care and SLaM together with peer supporters who work
as a multi-agency team to provide support to people who require help and support.
The ambition is that the LWN will provide support much earlier to people who need
it; a major criticism of the current system is support is provided too late and often
only when people are in crisis. The network will support the objective of reducing
demand on secondary care, a key QIPP target for the CCG.
The Lambeth Living Well Collaborative (LLWC) won the London NHS Leadership
Recognition Award for NHS Leader in Patient Inclusivity in November 2013. CCG
board members collected the award together with peer supporters. This is
recognition of the value of involving people who use services in the design and
delivery of services and especially the contribution of Missing Link and Solidarity in
Crisis, two key peer support initiatives developed by the Collaborative.
Plans are being worked up with the LLWC Provider Alliance Group to develop
personalised packages of care and support for people currently placed in
residential social care placements(140 people) and SLaM rehabilitation beds (52
patients). These services cost c£10.7m, it is proposed to deliver a QIPP saving of
£2.7m over the next 3/5 years and deliver this integrated care programme through
an alliance contracting approach. Discussions are being held with the DoH and
NHSE as to how this might be structured.
The CCG and PAG are working up the business case for developing a primary
care/community incentive scheme to support the management of people with
severe mental illness, as part of the LWN infrastructure. This fits with the SE
London Community strategy and will form a key element of the evolving Living Well
Network. This will support the aim of reducing demand on secondary care services
a key element of the CCGs QIPP for 14/15 beyond.
The changes to the front end of the system runs alongside proposed changes to
Adult Mental Health (AMH) community and acute services provided by SLaM. The
aim is for a greater focus on early intervention and recovery and an improved
interface with primary care. These proposals were outlined to the CCG Board
51
seminar on 17 July 2013. Service changes will now commence April 2014, a delay
of three months from that previously reported. The CCG is working with SLaM to
help inform modeling of service activity levels and its impact on QIPP targets for
2014/15 and beyond.
All SLaM boroughs have seen an upsurge in demand for acute psychiatric beds in
line with a national trend which has been highlighted in the regional and national
media. The position for Lambeth CCG is that we currently have an overperformance of c25 beds against our commissioned baseline of 72 beds. SLaM
has been working with CCGs to ensure better understanding of the activity levels
and is seeking support to address this over performance. It is expected that
negotiations to address pressures in the short term will conclude across all four
CCGs by 6 December 2013. The sustainable solution to this increased demand is
the full implementation of the system changes outlined above during 2014/15 – the
LWN and the SLaM AMH redesign programme.
4.2 Integrated Talking Therapy services
The evaluation of the first six months of the integrated talking therapy service
provided by SLaM has been completed and was considered at the November CCG
Board. An action plan is being worked up to address areas requiring improvement.
4.3 Criminal Justice mental health pathways
The CCG has been contributing to a commission led by the Health and Well Being
Board (chaired by Cllr Ed Davey, chair of the Adult health and social care scrutiny
committee) into issues faced by people from BME communities when they access
mental health services. This is partly in response to the high numbers of people
from the Caribbean and Black African communities whose initial contact with
mental health services is via the criminal justice system such as police custody and
prison.
4.4 Dementia
Lambeth & Southwark Memory Service (Memory Service)
 The Task & Finish group has identified a building that could potentially be
used for outpatient appointments with the capacity to house the MDT from
SLaM, KCH and GSTT, however refurbishment is required and will take
approximately 12-18 months. Alternative outpatient clinic space is being
sought in the interim.
 Monitor the affect the acute hospital CQUIN for detecting dementia is having
on referrals to the memory service, and the outcomes of these referrals.
 The Shared Care Protocol for prescribing dementia medication has been
reviewed by the SEL Medicines Management Committee and approved.
GPs will be sent information regarding prescribing and initiating antidementia drugs and the memory service Clinicians will then review the
patient 3 months post starting them.
52


A recent analysis of ethnicity of patients attending the memory service was
carried out, which showed that the BME population is very well represented
with the black population presenting slightly higher than their population
percentage in the borough.
There will be a mental health Protected Learning Time on 16 th January
where the memory service will be presented.
4.5 Specialist mental health continuing care older adults
Following LCCG agreement to consolidate specialist mental health continuing care
to the Greenvale site located in Streatham, all Woodlands patients have been
assessed and moved to appropriate care environments and the Woodlands unit is
now closed.
4.6 Older Adults Home Treatment Team
Evaluation of the clinical effectiveness of the service is now complete. Financial
modelling is being sought for indicative savings.
53
5.0 Staying Healthy
Clinical Lead: Dr John Balazs
Executive Lead: Helen Charlesworth-May, Director of Integrated Commissioning
Programme Lead: Therese Fletcher, AD Primary & Community Commissioning
5.1 Smoking quitters
 NHS Lambeth CCG achieved the 2012/13 target. 2012/13 performance
figures show 2303 smoking quitters, against the target of 2262. The target
remains the same for 2013/14 with current year to date figures at 378
quitters against a year to date trajectory of 538. Work is underway to review
the dip in performance and to work with practices and providers to chase up
the lost to follow ups.
5.2 Healthy Living Pharmacy (HLP) Project
 62 out of 64 Pharmacies signed up to HLP initiative (aim to have all
pharmacies signed up by the end of the year)
 3000 plus alcohol intervention carried out by HLC’s
 Reaccreditation of phase 1 completed and action plans agreed
 Accreditation of phase 2 pharmacies completed action plans agreed.
 450 NHS health checks carried out in Pharmacies as at the end of
November 2013.
5.3 NHS Vascular Health Checks
 As at Q1 9% of the eligible population were offered a Health Check against
a quarterly target of 5% for 2013/14. In Q2 1728 health checks have been
carried out across all providers.
 2nd phase of cross borders pilot started with Lewisham and Southwark.
 Dementia included within current dataset. LSL joint approach, including
marketing.
 New standardised template rolled out to all practices.
 Further work required to ensure patients take up offer
5.4 Alcohol Harm Reduction:
 2013/14 CQUINS are in place for community and acute services.
 Health Visitors and Sexual Health staff in the community have completed
training in alcohol brief intervention and are offering the interventions in line
with agreed CQUIN.
 Joint Alcohol Prevention Group (APG) is developing ‘Out of Hospital’ Bid
 Evaluation underway for Alcohol Recovery Centres that went live in
Lambeth for 8 week pilot in December 2012: Medical Model at St Thomas’
Hospital and social model at Clapham Methodist Church.
 Pharmacies currently accredited as a HLP provide Alcohol screening
54
5.5 Healthy Weight
Childhood Obesity Healthy Weight Programme
The data collected for the 2012/13 academic year National Child Measurement
Programme (NCMP) was submitted in July 2013. The NCMP for 13/14 academic
year will be complete by end of Dec 2013. Letters have been sent to parents/carers
informing them of the process and asking if they wish to opt out.
Work is on-going towards achieving Stage 2 UNICEF Baby Friendly Initiative (BFI)
accreditation. Public Health are conducting a rapid breastfeeding needs
assessment which will be complete by January 2014, findings from this work will
help support the implementation of some of the recommendations to achieve stage
2 accreditation. A BFI co-ordinator is being recruited and will hopefully be in post
by January 2014.
The Breastfeeding Peer Support Programme is being further rolled out. 15
voluntary peer supporters are being trained throughout 2013 and will support
mothers at the milk spot cafes in children Centres across the borough. Some of
these peer supporters will then undertake a yearlong training programme to
become Breastfeeding Supervisors, once they complete the training they will be
able to run Milk spots and support the community midwives.
Health child weight Programmes:
 Level 1 Children’s Health Weight training continues to be delivered to health
and non-health professionals including school staff. The school healthy
weight promotion programme has completed training in 16 primary schools
to date.
 The Level 2 weight management service – Lambeth Ready Steady Go!
Have received 57 referrals in 13/14 Q2 (an increase from 46 in Q1).
 The Level 3 specialist weight management service offers support for
overweight and obese children with additional medical and or complex
social needs. All children/families identified through NCMP results have
been contacted (520). 473 children/families provided with advice. 7
children have been referred for level 3 interventions.
Monitoring, review and evaluation continues to be important components of the
Lambeth childhood obesity programme. These not only help to ensure that the
services are being delivered to achieve maximum outcomes but also are
contributing to the local and national evidence base around weight management.
55
6.0 Children and Maternity Improvement Programme
Clinical Lead: TBC
Executive Lead: Helen Charlesworth-May, Director of Integrated Commissioning
Programme Lead: Emma Stevenson, AD Children and Maternity
6.1 Children & Families Early Intervention & Prevention
An integrated approach to commissioning and service development continues to
be a priority for Children’s services. The Early Intervention & Prevention Integrated
Commissioning Strategy (2013-16) was signed off at the Children’s Trust Board
(CTB) in July 2013. It was informed by the Children’s JSNA and identifies 4
overarching priority outcomes:




Improve Family Stability
Reduce risk taking behaviour in adolescents
Improve educational aspiration & attainment
Reduce Health Inequalities
Work is on-going to implement this strategy through an innovative and integrated
delivery model. This is being informed by findings from the Big Lambeth Health
Debate; the Council’s outcome based budgeting work and developments from the
Big Lottery Bid – Fulfilling Lives.
6.2 Big Lottery Bid – Fulfilling Lives
Lambeth has been shortlisted from 140 submissions down to a final 15. The final
Big Lottery bid has to be submitted on February 28 th 2014 and 3 or 5 areas will be
selected to receive approx £30m over a 10 year period to improve services for
pregnancy to 3yrs. Lambeth’s bid is focused on 4 wards; Vassal, Coldharbour,
Stockwell and Tulse Hill but the aim is to ensure successful interventions and
systems will be scaled up across the whole borough. A multi-agency project group
is taking forward a number of work streams which include; reviewing range of
evidence and science based interventions; community engagement; capital bid;
Needs assessment, Fund mapping across the partnership and workforce
development. Engaging GP’s is key and visits to the Practices either in the wards
or on the boundaries will take place over the next couple of months. A 2 day
strategy event facilitated by Dartington Social Research Unit is planned for January
16 & 17th to work up the overarching strategy for the bid.
Children’s Integrated Care Pathway
Children’s ICP is being developed through the Evelina London Child Health
Programme (ELCHP). This programme is GSTT charity funded for an initial 30
month period to look at improving both vertical (primary, secondary, tertiary) and
horizontal (health, education, social care) integration. Hilary Cass, Consultant
Paediatrician and President of the Royal college of Paediatricians is championing
the work. Six sub groups of the Programme Board have been set up looking at
specific cohorts of children including, the well child, Mild Acute, Emergency etc. A
56
data analyst is now in post to ensure detailed analysis of activity and finance flows
across primary and secondary informs the programme and potential delivery model
6.4 Maternity
The SEL Transforming Care Programme by the Quality Unit of NHS England,
London Region is focusing on Maternity across South London. Two workshops
have taken place so far and outcomes from the workshops will inform the
commissioning intentions and plans across the area and the work of the Maternity
Network. On a local level findings coming out of the preparations for the Big Lottery
Bid is informing the Maternity work, looking at how best to implement effective
maternity pathways across community based children Centres, Primary care and
acute. This includes looking at how and where antenatal classes are delivered,
developing effective shared care protocols with GP’s and ensuring early
identification and support is available for vulnerable pregnant women.
6.5 Breastfeeding
Breastfeeding rates continue to improve at 6/8 weeks: 13/14 Q2 97.97% Coverage
(Q1 97%) and 83.41% Prevalence (Q1 81%) Q2 data will be available end of
October. Both the Operational Breastfeeding Group and Strategic Breastfeeding
Group meet on a monthly basis to take forward this work and ensure improved
outcomes.
Since mid 2011 LB Lambeth participated in the Department for Education Payment
by results in children’s centres trial. There were 26 trial areas nationally testing a
set of six national measures. Lambeth identified four local measures, one of which
was to improve breastfeeding rates. In 2013 Lambeth received an exceptional
performance reward by improving numbers breastfeeding at 6-8 weeks. Lambeth is
the only area nationally to qualify for the exceptional performance reward on any
measure. Some of the exceptional performance reward funding will be used to
support achievement of BFI stage 2 Accreditation and support more vulnerable
women to continue to breastfeed during the first year of infancy
57
7.0 Continuing Healthcare
Clinical Lead: TBC
Executive Lead: Helen Charlesworth-May, Director of Integrated Commissioning
Programme Lead: Liz Clegg AD Older People & Client Groups.
7.1 Any Qualified Provider (AQP)
Phase 2 of the AQP process went live on 1 October 2013, with a number of additional
providers across London added to the London wide Framework contract, thus increasing
local capacity. The CCG is continuing to try to use the AQP list of providers for placements
for patients over 65 years, but on occasions needs to make placements off the contract.
Costs for non AQP providers are negotiated on a case by case basis. Based on
comparison data with placements costs for last year, evidence has shown that by using
the AQP contract, we have managed to make some savings on placement costs.
7.2 NHS Lambeth CCG Continuing Healthcare Choice Policy
The policy was ratified at the IGC in October 2013, and is now in operation.
7.3 Personal Health Budgets
We are continuing to attend the Department of Health’s national personal health budgets
delivery programme for CHC. We have arrangements in place with Lambeth Council,
which enables us to continue to provide Direct Payments to individuals already receiving
Direct Payments, who then become eligible for CHC. We are finalising a paper which looks
at budget setting and the benchmarking of hourly rates for direct payments across London,
and it is anticipated that this paper will be presented to the QIPP and Finance meeting in
December or January.
7.4 National Retrospective Appeals
We are in the process of information gathering for individual cases, focusing on the
shortest claim periods first.
58
8.0 Medicines Optimisation
Clinical Lead: Dr Sadru Keraj
Executive Lead: Moira McGrath, Director of Care Pathway Commissioning
Programme Lead: Vanessa Burgess, AD Medicines Management
Current Overall Performance 2013-14 (Month 6)




Overall the prescribing budget (year to date) is under spent at Month 6 by
£560,803 (3.2%). The North, South West and South East localities were under
spent by 5.0%, 4.3% and 0.4% respectively.
Overall spend per APU at CCG level has decreased to £1.69/APU in M6
(compared to a peak in M4 £1.92/APU).
Cumulative growth (analysed monthly) on primary care prescribing is -1.2% in
month 6 (compare to 0.1% in month 4).
Quality, Innovation, Productivity and Prevention (QIPP) Performance.
2013/14 Primary Care Prescribing QIPP Plan and Dashboard.
QIPP AREA
Spend per ASTRO-PU
per month
Emollient bath and
shower preparations
spend per 1000 APU per
month
Silver Wound Dressings
Spend per 1000 APU per
month
Honey dressings Spend
per 1000 APU per month
Tadalafil Spend per 1000
APU per month
Specials Total Spend per
month
Immunosuppressants
Spend per month
2013–14
Scriptswitch
Summary.
ScriptSwitch-Actual savings
ScriptSwitch-Potential savings
TARGET
M6 v M4
£1.77
↓ (below target)
≤ £12.55
↓ (below target)
≤ £2.42
↑ (above target)
≤ £0.54
↓ (below target)
≤ £12.91
↓ (below target)
↓
↓
£16K/month saving
Exceeding target
April
May
June
July
August
Sept
£19,231
£12,291
£19,571
£29,069
£27,435
£33,041
Oct
£33.981
£62,999
£57,195
£46,344
£56,151
£54,166
£62,539
£56,728
59
Local, London and National Prescribing Performance:
Data source: Q2 2013/14 (July-September)
We remain in the top performing CCGs in London and nationally in many of these
areas. Since Q1 2013/14 (April-June), there has been significant movement to
green in ‘Specials spend per 1000 patients per month’ and in ‘Trimethoprim 3 days
ADQ/Item’.
Practices continue to undertake the associated reviews for each comparator to
support further improvement towards red to amber and amber to green.
Full data and London/national ranking as follows:
Comparator
(RAG rated against NHS Lambeth CCG Primary Care
Dashboard Q2)
Spend of Specials* per 1000 patients per month
% Metformin & Sulphonylureas items of all antidiabetic
agents
% Fentanyl items of all opioid items
Antidepressants ADQ/STAR PU
Antibacterial Items/STAR PU
NSAIDs: Ibuprofen & Naproxen % Items
Hypoglycaemic agents % Items
Hypnotics ADQ/STAR PU
% Items Long acting insulin analogues
Generic Prescribing percentage
3 days Trimethoprim ADQ/ITEM
NSAIDs: ADQ/STAR PU
Minocycline ADQ/1000 Patients
% items for plain prednisolone 5mg as % of all prednisolone
5mg plain & e/c items
Low cost lipid modifying drugs % Items
Laxatives ADQ/STAR PU
Antidepressants % first choice items
% items for immediate release venlafaxine as % total
venlafaxine immediate and extended release items (tablets
and capsules)
Silver Wound Dressings Spend per 1000 APU per month
% Oxycodone items of all opioid items
Omega-3-fatty acids spend per 1000 APU per month
% of Low Cost PPI items as % of all PPI items (low cost
defined as omeprazole capsules, lansoprazole capsules and
pantoprazole tablets)
Tadalafil spend per 1000 APU per month
60
National
ranking
(Q2
2013/14)
Out of 211
CCGs)
N/A
N/A
London
ranking
(Aug 2013;
out of 32
CCGs)
26th
2nd
N/A
6th
7th
9th
11th
11th
15th
20th
20th
26th
36th
N/A
2nd
N/A
N/A
3rd
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
54th
93rd
100th
N/A
N/A
N/A
N/A
2nd
N/A
N/A
N/A
N/A
6th
3rd
8th
N/A
N/A
N/A
Honey Wound Dressings Spend per 1000 APU per month
Emollients bath and shower preparations spend per 1000
APU per month
% statin items prescribed as low cost statins of all statins
including ezetimibe (and combinations) & generic
atorvastatin
Lipid modifying drugs: Ezetimibe % Items
Cephalosporins & Quinolones % Items
% items ACE inhibitors
Omega-3 ADQ/STAR-PU
Wound care products NIC/Item
% reduction in High dose inhaled corticosteroids as a % of all
inhaled corticosteroids (compared to Quarter 3 2012-13)
N/A
N/A
N/A
N/A
N/A
N/A
125th
106th
130th
149th
203rd
N/A
N/A
10th
N/A
N/A
N/A
N/A
GREEN (already achieved) = Locally: >75% of practices achieving comparator;
London and national: CCG is in top 25th centile
AMBER (significant improvement nearing maximum achievement) = Locally: <75%
but > 50% of practices achieving comparator; London and national: CCG is in 25th
to 50th centile
RED (Further improvement required) = Locally: < 50% of practices achieving
comparator; London and national: CCG is in bottom 50th to 100th centile
The following indicators are currently rated RED:
i.
ii.
iii.
iv.
High dose inhaled corticosteroids as a % of all inhaled corticosteroids.
A successful PLT event was attended by 120 clinicians with positive
feedback on learning. This event consolidated the educational support to
practices on COPD and asthma. The Integrated Respiratory Team and
Medicines Team continue to provide virtual clinics and are on schedule to
complete by end of March 2014. The four inhaler technique training
workshops were also successfully completed for practices and community
pharmacists.
Wound care products NIC/Item
Adherance to the wound dressings formulary and request form by practices
and district nurses continues to be followed up with exception reports
investigated on a case by case basis. Targeting interventions with 3
practices to manage spend on dressings in nursing homes has been
initiated.
Omega-3 ADQ/STAR-PU
Practices with high prescribing have been encouraged to complete the
Omega-3 fatty acids review tool in the Medicines Optimisation Plan 2013-14
Cephalosporins & Quinolones % Items
Promotion of the local antibiotics guidelines continues alongside promotion
of the national campaign of ‘European Antibiotic Awareness Day’.
61
General Update
i.
Medicines Optimisation & QIPP Plan for 2013-14.
At the time of writing all but two overspending practices have participated in
a joint recovery plan meeting with the Medicines Team and when
appropriate the GP clinical lead. The two outstanding practices are
scheduled in December.
Individual Scriptswitch reports are being received by practices quarterly and
practices are required to review and report back reasons for rejected
messages.
ii.
Highlights - Area Prescribing Committee Meeting, October 2013.
Approved:
Position Statement on Novel Oral Anticoagulants for
stroke prevention in Atrial Fibrillation.
Dementia shared care guideline.
Rivaroxaban in Venous Thromboembolism – transfer of
care document.
Ongoing:
Mapping of a therapeutic pathway for Inflammatory Bowel Disease.
A business case for the IT workstream of the Community Based Care
strategy for a software solution for better dissemination of clinical guidelines
to practices.
Support from the CSU in unbundling the current tariff for wet age-related
macular degeneration.
New Drugs Panels, October and November 2013
Not recommended: Combodart for Benign Prostatic Hyperplasia
Recommended:
Lisdexamfetamine for Attention Deficit Disorder in children
aged 6 years and over when response to methylphenidate is considered clinically
inadequate – Amber (for specialist initiation).
Deferred for a resubmission: Rituximab for Idiopathic Thrombocytopenic
Purpura.
62
9.0 Cardiac and stroke
Clinical Lead: Dr John Balazs
Executive Lead: Moira McGrath, Director of Care Pathway Commissioning
Programme Lead: TBC.
9.1 Stroke survivor advice, support and signposting
The Lambeth Council contract with Stroke Association for advice, support and
signposting for stroke survivors and their carers at six weeks is being extended to
31 March 2014.
The contract with Stroke Association for review of stroke survivors and their carers
at six months is jointly commissioned with Southwark CCG using admission
avoidance funding. Extension of the contract is confirmed to 31 March 2014.
The Lambeth service is currently being re-specified for a commissioning position
from 1 April 2014 with the potential to commission across Lambeth and Southwark
being considered.
CCGs have been asked to lead on the accreditation of local Hyper Acute Stroke
Units and Stroke Units. Lambeth CCG has agreed to take a lead role coordinating
the visits for 2014 across the sector working closely with each CCG lead and the
London Stroke Network.
9.2 Cardiac
The Community Arterial Fibrillation and hypertension service is now in place with
further clinics planned to commence in Autumn 2013.
10.0 Cancer services
Clinical Lead: Cathy Burton
Executive Lead: Andrew Eyres, Chief Officer
Programme Lead: Liz Clegg, Assistant Director Older People
10.1 Performance monitoring
Role of Lambeth and Southwark Cancer locality group reviewed and TOR revised
to include a focus on performance management now that the SELCN no longer
exists. Membership will include commissioning representatives from both CCGs,
the CSU and the Cancer Commissioning Team, cancer service management and
nurse leads from GSTT and KCH, voluntary service and user representatives.
10.2 Prevention
Kings College Hospital has now been fully accredited and bowel cancer screening
age extension roll out will go live in Lambeth and Southwark on the 1st January
63
2014. Uptake of bowel screening in Lambeth remains static at 40% which is one of
the lowest in London.
10.4 National cancer patient experience survey 2012/13
GSTT and KCH are static against targets compared to 2011/12, however overall
comparative performance for both Trusts is below national and London average.
Communication and access to Clinical Nurse Specialist advice and support are
main areas for improvement identified at both Trusts. Actions plans are being
developed and will be monitored by the cancer locality group and the CQRC
Primary care detection and support following diagnosis also identified as areas for
improvement.
10.5 Primary care
Lambeth Macmillan GP now visiting practices to support early detection of cancer,
focussing on lung, prostate, breast and colorectal. Lambeth Macmillan primary
care nurse post supporting improved patient-centred services, early diagnosis and
post-treatment support in primary care, to be advertised as an 18 month
secondment.
11.0 Enabler Programmes
11.1 Primary Care Development – ‘Super-Enabler’
NHS Lambeth CCG six high-level Primary Care objectives
1. To support primary care services in being more responsive and
accessible and provide high quality primary care services that meet
patients every day and urgent care health needs
2. To develop more effective partnership working across organisational and
professional boundaries to provide more effective and integrated team
working;
3. To facilitate more informed, proactive engagement and involvement of
people in local communities and practitioners in the use, planning and
delivery of services;
4. To put in place a robust Primary Care Education strategy that secures a
primary care workforce fit for purpose;
5. To reduce variation in the quality of Primary Care provision and reduce
health inequalities across the borough;
6. To encourage and enable patients to positively manage their own health,
in partnership with health professionals and their carers

NHS Lambeth fully engaged in Community Based Care (CBC) work
(Primary and Community Care)
64
o Key focus areas: Development (reducing variation) Commissioning
(at Scale) and Organisational Development (capacity)

Lambeth & Southwark CCGs together with two borough LMCs are
developing joint bid to GSTT Charity for Primary Care Development

This will be a two phase charity bid with opportunity to scope the
requirements across both boroughs and implementation that focuses on
integration and sustaining the highest quality General Practice for the
populations of Lambeth and Southwark

Practice Visits are currently underway, which gives practices the opportunity
to discuss their A&E attendance, Emergency Admissions and GP First
Outpatient referrals. Practices are completing practice improvement plans,
which indicate the actions necessary to support an improvement against the
current trend.

Work is already underway to develop the GP Delivery Scheme for 2014/15.
The scheme will be rolled out on the 1st April 2014 and gives practices the
opportunity to focus on reducing their acute spend during 2014/15.

NHS LCCG has developed matrix for 'Reducing Variation' across practices
and improving quality of primary care. Practice Data Pack updated so
variation can be mapped across practices and split by Locality. Dashboard
also includes data from GPHLI, GPOS and triangulated with EPACT data.

Primary Care Commissioning and Quality Group (NHSE represented) is
developing programme of support. Focus support on practices below agreed
threshold

Primary Care Training Programme booklet has been updated and
redistributed to all our practices
65
12.0 Estates
West Norwood Health and Leisure Centre:
 Integration Manager has been appointed to achieve the benefits of
integration across Health and Leisure at the West Norwood Health and
Leisure Centre
 Implementation of operational plan underway
 Develop procurement strategy with NHSE for GP Suite 2
 Commence procurement process
 Implement/evaluate Service Integration Plan
Nine Elms and Vauxhall (NEV)
 Joint Project Manager has been appointed
 Programme Board has been set up/TOR agreed
 GP Capacity
o Scope potential capacity in current practice sites
o Financial impact for 2014/15
o Consider medium/long term commissioning issues
(governance/funding)
 Community Services (including Mental Health)
o Use population assumptions and PACT/OOH shift to scope 14/15
o Consider financial impact for 14/15
o Consider estates rationalisation work
 Urgent Care – Walk-in/Minor Injuries Capacity
o Use population assumptions and BSBV shift to scope capacity
requirements for 14/15
o Consider Battersea Locality and potential expansion in urgent care
facilities (e.g. Clapham Junction)
o Consider financial impact for 14/15
 Public Health and Social Care Commissioning
o Health promotion, Sexual health and DAAT requirements
o Consider capacity in Vauxhall as current hub
 Submission of Health bid for CIL monies – Jan 2014
66
SECTION 3 ORGANISATIONAL DEVELOPMENT
12.0 Organisational Development
Clinical Lead: Adrian McLachlan and Raj Mitra
Executive Lead: Andrew Parker, Director of Governance & Development
12.1 Organisational Development
Summary
Clinical Lead
Adrian
McLachlan & Raj
Mitra
CCG Director
Andrew Parker
Impacts on:
CCG objectives
Enabling
Qrt 1 milestones
Qrt 2 milestones
Qrt 3 milestones
Qrt 4 milestones
Met (Green)
7
5
4

In progress (Amber)
1
1
2

Not met (Red)
0
1
0



Comments on current performance – on track
67
Key Milestones and planned actions/mitigations
Qtr
Q3
Q3
Q3
Achiev
ed
(RAG)
Summary Milestone
1. Governing Body – mid-year development review undertaken (JC/LD)
2. Collaborative Forum – Support provided for October 2014
Collaborative Forum meeting (KA)
Mitigation Planned
Date
Mitigation
to be
Completed
G
G
3. Develop the membership and localities – Actions for continued
improvement in communications/engagement at practice and locality
level agreed (TF/TB)
G
Q1
4. Clinical Network – Work and development plans for Clinical Network
members established (AS)
G
Q2
4. Clinical network – engagement input and relationship with Board
agreed (AS)
G
Q3
4. Clinical Network – Systematic and effective working across
managerial and clinical commissioning roles in place. (AS)
A
Q2
5. Lambeth Commissioning Teams - Objective and PDP process
completed (JC/LD)
R
Q3
5. Lambeth Commissioning Teams - The CCG business system, and the
way we work, to reflect the new organisation and our values. (JC/LD)
G
68
121s with all Clinical leads have taken
place. Management leads are agreed and
relationships are being re-established.
Further reminders issued.
Training
proposal in development for wider
engagement.
Objectives and PDPs to be concluded for
end of March.
January
March
Q1
6. Stakeholder Relationships – Commissioning relationships defined to
inform stakeholder management (AP)
A
Governing Body membership elected and
discussions underway to develop and
agree specialist portfolio areas.
December
Q2
6. Stakeholder Relationships – Action plan to manage stakeholder
arrangements agreed (AP)
A
Review in line with new emergent
strategy post Big Lambeth Debate.
March
A
Action plan implemented to identify and
develop key stakeholders in order to
deliver commissioning responsibilities and
discussion of stakeholder management
arrangements at GB meeting in January.
Ongoing
Q3
6. Stakeholder Relationships – Action plan implemented to identify and
develop key stakeholders in order to deliver commissioning
responsibilities. (AP)
This performance report shows current Q3 OD activity and highlights outstanding actions (A&R) from previous quarter
69
12.2 Engagement and Communications
Engagement and
communications
Clinical Lead
Executive Lead
Reports to:
Engagement,
Communication
s and Equalities
Committee
Raj Mitra
Andrew Parker
Work area
Purpose
PM
Success measure
Qtr
Implementing
Communications
and engagement
strategy
Build public and
stakeholder
confidence in
CCG and its
leadership
AP/CS
U
Accessible website for
CCG up and running
with opportunities for
feedback published
CCG has profile in local
media
Regular briefings held
with Scrutiny and
HealthWatch; presence
of and presentation by
clinical members at
Scrutiny
Engagement is part of
new Governing Body
members' PDPs and
part of development
plan for Governing Body
as a whole
CCG commissioning
areas and QIPP
programmes have
engagement and
communications plans
in place
Established cycle of
meetings/communicatio
n with Lambeth PPG
Network and with
HealthWatch Lambeth
Records of engagement
on strategic plan 201415
Engagement in strategic
planning, service
redesign and service
quality monitoring
(patient experience) has
been discussed at
Engagement, Equalities
and Communications
Committee
Media policy developed
for CCG
Board meetings held in
Qtr1
Achieved
(RAG)
G
Qtr2
G
Qtr3
On track
Qtr4
G
Qtr1
G
Qtr2
A
Qtr3
G
Qtr4
G
Qtr1
A
Qtr2
G
AP/CS
U
CF
CF/JC
Implementing
Communications
and engagement
strategy
Systematically
involve patients,
their carers and
communities in
the
commissioning
of health
services for
local people
CF
CF
CF
CF
Implementing
Communications
and engagement
Demonstrate
open and
transparent
AP/CS
U
CF
70
strategy
Implementing
Communications
and engagement
strategy
governance and
leadership
Promote
equality through
engagement
work
CF
CF
AP/CS
U
CF
public
Good attendance and
range of issues raised at
stakeholder premeetings
Needs of protected
groups incorporated into
engagement plans
Equalities stories
included in stakeholder
bulletin(s) and
publications
Local communities have
been involved in
reviewing progress on
CCG's equalities
objectives and in
refreshing objectives for
2014-15
Qtr3
G
Qtr1
and
ongoing
Qtr3
G
Qtr4
On track
On track
12.3 Human Resources:
Workforce Report Q2 2013-14
The full CCG establishment is 45.75 whole time equivalent posts (51 posts) with
47.42 WTE currently filled (this includes agency staff). Vacancies have reduced
(from seven and then three at end of Q1) to two, both posts are currently being
covered by external secondment. Three staff are currently on maternity leave and
a further two are on career break or secondment. Turnover remains low with one
leaver for July to September (6.3% cumulative).
The workforce system was re-launched in April. Staff and managers have been
reminded of the importance of ensuring that all sickness absence must be
recorded on the system to ensure absences are recorded and the appropriate
payroll action is taken. The sickness absence rate for July to September ranged
from 1.4% to 2.5%. This amounts to 84 calendar days lost. Sickness absence will
continue to be monitored over the coming months to identify any trends and
changes, and to determine future actions. There is one long-term case of sickness
absence over the quarter.
There are no changes to occupational health services and employee assistance
programmes for NHS Lambeth CCG staff since the last report.
A revised programme of statutory and mandatory training for completion during
2013/14 has been agreed as below:
Course
Equality, Diversity & Human Rights
Health, Safety & Security
Counter Fraud & Bribery
Information Governance
Frequency required
Once
Once
Annual
Annual
71
Fire Safety
Safeguarding Children Level 1
Safeguarding Vulnerable Adults
Moving and Handling
Annual
Annual
Annual
Every three years
31 staff have completed counter fraud and bribery training but uptake on remaining
mandatory training is currently low. This may be due to electronic recording issues
and will be reviewed for next quarter.
All staff have been agreeing their objectives and personal development plans.
There was a successful CCG Awaytime on 25th September primarily aimed at staff.
Material on the content, evaluation and next steps is available on request. The
event provided a good opportunity to continue the development of the CCG living
our published values and the link to the appraisal process. This will be further
developed at the monthly staff briefing.
The Director of Integrated Commissioning has now assumed her new role in the
Local Authority and staff members have been informed of interim management
arrangements to ensure the appropriate management of all core functions at the
staff briefing on 10th October and a subsequent written communication.
Under the transfer scheme staff transferred with their existing terms and conditions
of employment, including HR policies. A timetable to review the existing policies
has now been agreed. Key policies have been identified as policies for priority
review and first drafts for consideration by the CCG will be prepared between now
and the end of the year. These include the most frequently used such as sickness
absence, grievance, flexible working and disciplinary.
CCG Employees Equalities profile as at 30th September 2013
The following tables are a profile of CCG employed staff, relating to five of the nine
protected characteristics. Monitoring will continue to identify any priority areas to
address.
Ethnicity
50.00
40.00
30.00
20.00
10.00
0.00
72
Gender
Disability
2%
20.00
2%
18%
No
Male
Not Declared
Female
Undefined
Yes
80.00
78%
Religion
3% 0%
0%
0%
4%
Age Band
Atheism
0%
2%
0%
Buddhism
3%
1%
21-25
26-30
2%
31-35
10%
17%
Christianity
20%
41-45
38%
46-50
Hinduism
42%
51-55
17%
3%
36-40
I do not wish to
disclose my
religion/belief
73
20%
56-60
61-65
18%
66-75
SECTION 4 QUALITY ASSURANCE
13.0 Governance & Assurance
Clinical Lead: Adrian McLachlan
Executive Lead: Andrew Parker, Director Governance & Development
Programme Lead: Marion Shipman, AD Governance and Quality
13.1 Provider Quality Report
The NHS is the only healthcare system in the world with a definition of quality
enshrined in legislation. An organisation delivering high quality care will be offering
care that is clinically effective, safe and delivering as positive an experience as
possible for patients.
The
Q2
Provider Quality Report Summary which
follows (Appendix
1
http://www.lambethccg.nhs.uk/NewsPublications/Publications/Pages/default.aspx)
provides information pertaining to our main healthcare providers, Guy’s and St
Thomas’s NHS Foundation Trust, King’s College Hospital NHS Foundation Trust,
South London and Maudsley NHS Foundation and St Georges Healthcare NHS
Trust. It covers information on key quality issues and action plans, patient
experience, patient engagement issues – specific to Lambeth CCG, quality alerts
and clinical visits and audits.
13.2 Lambeth Quality Summit
Challenging reports from Francis, Keogh and Berwick have put the spotlight on
quality and patient safety, and highlighted the importance of involving patients,
carers and members of the public as equal partners in the design and assessment
of their local NHS.
The Lambeth Quality Summit was held on 2nd October 2013. This was a
multiagency event co-hosted with Healthwatch Lambeth, with the main aim of
considering how we could as individuals, groups, organisations, providers and
commissioners work together better to improve the quality of health in Lambeth.
Nearly 100 participants engaged in a lively debate, exploring how we can prevent
problems from happening, while ensuring that when issues do occur they are
detected and acted upon quickly –learning from any mistakes made across the
system.
A final report of the event is available on the Lambeth CCG website, has been
shared with those who attended the event and is included in the IGC papers for
information. People were very keen to continue the dialogue and NHS Lambeth
CCG will work with Healthwatch Lambeth and other participants to further integrate
the use of ‘co-production’ within service developments, delivery and evaluation to
ensure this happens. The report recommendations include the following:
74




Report to be shared with all participating organisations to reflect on their
own Francis Inquiry responses and consider how they could more fully
address the specific themes identified in the report.
Lambeth CCG to update its Commissioning for Quality Framework
Healthwatch Lambeth to update its definition of ‘quality’ to reflect the shared
importance of communication and partnership working between
commissioners, providers, user and carer groups and members of the
public.
Further Quality Summit to be planned for 2014.
13.3 PALS and Complaints
There were a total of 58 complaints and PALS enquiries during Q2. Of these, 16
have been formal complaints, 1 informal complaint and 41 PALS enquiries. The
number of complaints and PALS enquiries has reduced over the quarter, and it is
of note that formal complaints are significantly lower – July and August recorded 7
formal complaints each month, whereas in September there were a total of 2
formal complaints.
25
20
15
PALS
10
COMPLAINT (In-formal)
5
COMPLAINT (Formal)
0
July
August
September
PALS Enquiries – offering information and advice to patients, carers, the public and staff to ensure
quick resolution of enquiries or questions raised about services provided by or commissioned by
the local CCG.
Complaints – (Informal) – a complaint or concern raised that can be resolved locally and without a
full investigation taking place, and where the response to the concerns raised contain no complex
issues.
Complaints – (formal) – an expression of dissatisfaction about any aspect of service that the CCG
provides or commissions and requires a formal investigation and a written response that
addresses all of the concerns raised.
Prior to July 2013, complaints were not separated into formal or informal, so the
following graph shows the total number of complaints over the 6 months since 1
April 2013 and the total number of PALS enquiries during that time period.
75
20
15
10
5
0
Complaints
PALS
When the data for quarters 1 and 2 are considered together, there is a gradual
increase in PALS enquiries noted.
Complaints
1. Mode of Receipt
Complaints may be received by email, letter or telephone. The majority of
complaints are written and as such the number of telephone complaints is low. The
graph below shows the data for quarter 2 only, as this information was not
consistently collected or reported on in quarter 1.
6
4
Email
2
Letter
0
Telephone
July
August
September
2. Themes of Complaints
The overall number of complaints received is relatively small, so it is difficult to
make a detailed analysis of the themes generated by complaints.
The complaints received in Q1 and the complaints received in Q2 have little in
common with regards themes. The themes recorded for Q1 related to GP cases
(6); sexual health (1); continuing care (1); 111 service (1) and legacy complaints
pre-April 2013 (2). None of these themes are captured in quarter 2 complaints. The
reasons for this may be:
- Changes within the SLCSU complaints data collection process, which
means that categories/themes have changed
- Reduced input from SLCSU on GP complaints, which are directed to NHS
England for action.
The graph below shows the data for complaints received in quarter 2, and the
themes that are emerging.
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4
3
2
1
July
0
August
September
The main themes of complaints are as follows:
1. Treatment (5)
2. Referrals (3)
There were 3 complaints sent to the SLCSU complaints team for information only.
These are logged but require no action.
Complaints about treatment are a recurring theme amongst the total complaints
received across the service in quarter 2.
3. Complaint Acknowledgment
94% of complaints received (15/16) were acknowledged within 3 working days in
Q2.
PALS
1. Mode of Receipt
Most PALS enquiries are received over the telephone (36). This is appropriate
given the nature of the PALS service which is largely concerned with offering
advice and information. The SLCSU has a dedicated complaints and PALS
telephone line, which is operated 9-5, Monday to Friday. The graph below shows
the data for quarter 2 only, as this information was not consistently collected or
reported on in quarter 1.
15
Email
10
Telephone
5
Letter
0
July
August
September
2. Themes of PALS Enquiries
With the exception of enquiries regarding contact information, there is no clear
theme emerging from PALS enquiries over the last 2 quarters. Again this may be
because as the service has developed, themes are categorised in a different way.
The number of PALS enquiries related to contact information indicates that patients
and the public continue to have difficulty navigating systems within organisations,
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and that there is continued work to be done to ensure that internet sites, leaflets
and letters include information to enable patients and the public to contact services
with ease.
It is of note that enquiries relating to GP and primary care cases appear to have
reduced, although it is likely that these are now contained within the theme of
contact information, as the raw data suggests that many of these calls are
redirected to NHS England.
3. PALS Acknowledgment
Where PALS acknowledgement is concerned, the target is 2 working days. Of the
41 PALS enquiries received, 40 were acknowledged on the same day and 1 the
next working day.
MP and Ombudsman Cases
There have been 2 MP cases in Q2 as detailed below. MP cases were not
separated out from other complaints and PALS data in Q1, therefore the
information shown below does not include data from that quarter.
July
1
Prescribing/medicines
management
Treatment
Total
1
August
1
1
There were no MP cases recorded for September 2013. Overall, the volume of MP
cases remains low.
There were no new Ombudsman cases during the quarter.
A final Health Services Ombudsman report was received 7 th November for a
complaint raised by Dr B regarding her mother’s hospital stay and subsequent
discharge to a care home. Actions have been taken by NHS Lambeth CCG as a
result of the report. The full response can be found on the Health Service
Ombudsman’s website.
Conclusion
Overall both complaints and PALS enquiries have shown an upward trajectory over
the past 6 months, excluding September 2013 when there were a reduced number
of complaints received. Changes in the structure of the team, the development of
data recording and reporting since the inception of SLCSU have meant that the
data for Q1 is not easily comparable with that of Q2. It is anticipated that at the end
of Q3, it will be easier to show trends and themes as the reporting and data
collection will remain consistent from Q2.
In Q1, 64% of all complaints and 46% of PALS logged by SLCSU on behalf of
Lambeth CCG were forwarded to NHS England and other organisations as they fell
outside the scope of the CSU PALS and complaints team, many were related to
GP issues. This pattern is not repeated in Q2, although changes to the way data is
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recorded could have had an impact on this – these complaints and PALS enquiries
may now fall under the heading of contact information, as the remit of the SLCSU
team would now be to ensure that people contacting them are given the correct
contact information for the organisations to which their complaints and enquiries
should be directed.
13.4 Information Governance
The Information Governance Steering Group is a sub group of the Integrated
Governance Committee (IGC). An Information Governance update was provided to
the October IGC meeting. Lambeth CCG will be the first to use a new flow
mapping and information asset risk assessment tool for the control of information
risk and the identification of opportunities in the context of multiple providers and
stakeholders.
A new Information Governance Policy Suite which set out the expected standards
and controls around the use of information was approved by the October IGC.
These include: Information Governance Policy; Information Governance
Management; Information Governance Quality and Information Governance
Security.
13.5 Incidents
From 1 April 2013, NHS England were responsible for providing a system for GPs
to report patient safety and staff safety incidents, including ‘near misses’. Until 31
March 2013 this had been the responsibility of the former PCT via a Datix Incident
Reporting database accessible at all Lambeth PCT GP practices.
NHS England have not provided a system / database to replace Datix and have
advised that primary care providers will need to develop their own system for
recording incidents and to notify NRLS directly themselves for each incident that
occurs. However, to support Lambeth GP practices and other primary care
providers, the CCG has developed a Quality Alert, Incident and Commendation
reporting system (QUIC). The system allows for NRLS reportable (patient safety)
incidents) to be reported to the NRLS via an upload directly to NRLS by the CCG
on behalf of Lambeth services
The CCG have taken advice from the CSU information Governance team and
confirmed that as we are not accessing any patient identifiable data or processing
information in incident reports, it is acceptable that the CCG follow this process.
13.6 Serious Incidents
The definition used both nationally and in the recent NHS SEL Serious Incident
Reporting Policy and Procedure for serious incidents is: ‘out of the ordinary and
unexpected incidents or events resulting in:
i. Unexpected or avoidable death of one or more patients, staff, visitors or
members of the public;
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ii.
Serious harm where the outcome requires life-saving intervention,
permanent harm or shortens life expectancy or results in prolonged pain or
psychological harm;
iii. A serious risk to the organisation’s operations and its ability to provide care
or service;
iv. Allegations of abuse;
v. Adverse media coverage or public concerns about the organisation or wider
NHS;
vi. One of the core set of ‘Never Events’.
It should be noted that when viewing Serious Incident data that evidence suggests
that high reporting organisations are high performing organisations. The National
Patient Safety Agency noted that, 'Consistently high reporting levels tend to be a
mark of high reliability organisations. Research shows that organisations with high
and consistent levels of incident reports are more likely to demonstrate other
features of a stronger safety culture such as high NHS Litigation Authority ratings’
(Nov 2009).
Incidents Requiring Investigation
In Q2, 2013/14 a total of 68 Serious Incidents were reported. Of these, 12 were
subsequently de-escalated, and 26 were closed without an investigation report
required. The remaining 30 incidents required an investigation, as noted by
provider in the table below:
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Table 1: Serious Incidents Requiring Investigation Reported by Provider, Q2, 2013/14 –
Lambeth residents only for KCH and SLaM, all patients for GSTFT
July 2013
August 2013
September 2013
TOTAL
GSTFT
2
3
11
16
Provider
SLaM
3
1
2
6
KCH
4
1
1
6
Other
2
0
0
2
TOTAL
11
5
14
30
NOTE: GSTFT = Guy’s and St Thomas’s NHS Foundation Trust; KCH = King’s College Hospital NHS Foundation
Trust; SLaM = South London and Maudsley NHS Foundation Trust
Chart 1: Serious Incidents Requiring Investigation Reported by Provider, Q1 and Q2, 2013/14
– Lambeth residents only for KCH and SLaM, all patients for GSTFT
12
11
10
9
8
6
55
4
4
2
3
2
33
3
3
2
2
11
1
1
0
0
GSTFT
Apr-13
KCH
May-13
000
SLaM
Jun-13
2
00
Other
Jul-13
Aug-13
Sep-13
De-escalated Incidents
Of the total number of incidents reported, as illustrated on the following table, a
number of incidents were de-escalated. Incidents are only de-escalated if it is
agreed by the CCG and provider that the incident should be reported by another
provider, e.g. if a patient is admitted with a pressure ulcer that occurred at a
different hospital, that hospital must then report the Serious Incident and complete
the investigation. This is done to prevent any ‘double-counting’ of incidents.
Table 2: Serious Incidents De-escalated / De-escalation Requested - by Provider, Q2, 2013/14
– Lambeth residents only for KCH and SLaM, all patients for GSTFT
July 2013
August 2013
September 2013
TOTAL
GSTFT
1
2
5
8
KCH
0
1
3
4
81
Provider
SLaM
0
0
0
0
Other
0
0
0
0
TOTAL
1
3
8
12
Incidents Closed without an Investigation Report Required
Serious Incidents can also now be closed on STEIS by the CCG if it is agreed that
a report is not required, e.g. for a pressure ulcer incident where a patient is
admitted to an acute Trust and there has been no previous involvement / care
package provided by community services. This is only done when confirmation
has been received by the CCG that an appropriate care package has now been put
in place and safeguarding referrals have been completed
Table 3: Serious Incidents closed with investigation report - by Provider, Q2, 2013/14 –
Lambeth residents only for KCH and SLaM, all patients for GSTFT
July 2013
August 2013
September 2013
TOTAL
GSTFT
10
11
3
24
KCH
2
0
0
2
Provider
SLaM
0
0
0
0
Other
0
0
0
0
TOTAL
12
11
3
26
The categories of the Serious Incidents that Required an Investigation, by
Provider, are as in the table below:
Table 4: Serious Incidents Reported - by Provider, by Incident Category, Q2, 2013/14 –
Lambeth residents only for KCH and SLaM, all patients for GSTFT
StEIS Category
GSTFT
Child Death
Delayed Diagnosis
Failure to Obtain Consent
Maternity Service – Maternal death
Post Mortem
Pressure Ulcer – Grade 3
Pressure Ulcer – Grade 4
Serious Incident by Outpatient (in receipt)
Sub-optimal Care of the Deteriorating Patient
Suspected Suicide
Unexpected Death of Inpatient (in receipt)
TOTALS
KCH
Provider
SLaM
Other
1
1
1
1
13
2
1
2
1
1
1
16
6
4
1
6
2
TOTAL
1
1
1
1
1
15
3
1
1
4
1
30
NOTE: GSTFT = Guy’s and St Thomas’s NHS Foundation Trust; KCH = King’s College Hospital NHS Foundation
Trust; SLaM = South London and Maudsley NHS Foundation Trust
The pressure ulcers highlighted in the table are total numbers and not just
attributable cases to the provider unit.
Of the 16 Serious Incidents that required investigation by GSTFT for Quarter 2,
2013/14, the top two categories are:
 Pressure Ulcer Grade 3 (13 = 81%)
 Pressure Ulcer Grade 4 (2 = 13%)
No other category had more than one incident reported for GSTFT
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Overall, the categories of Serious Incidents that Require an Investigation for Q1
and Q2, 2013/2014 are as noted below:
Table 5: Serious Incidents Reported - by Provider, by Incident Category, Q1 and Q2, 2013/14
– Lambeth residents only for KCH and SLaM, all patients for GSTFT
Provider
StEIS Category
GSTFT
Child Death
Delayed Diagnosis
Failure to Obtain Consent
Homicide by Outpatient (in receipt)
Maternity Service – Maternal death
Maternity Service – Unexpected neonatal death
Other (ITU ECMO / amputation incident)
Post Mortem
Pressure Ulcer – Grade 3
Pressure Ulcer – Grade 4
Safeguarding Vulnerable Child
Serious Incident by Outpatient (in receipt)
Slip/Trips/Falls
Sub-optimal Care of the Deteriorating Patient
Suicide by Outpatient (in receipt)
Surgical Error
Suspected Suicide
Unexpected Death (general)
Unexpected Death of Inpatient (in receipt)
TOTALS
KCH
SLaM
Other
TOTAL
1
1
1
1
1
1
1
1
1
31
8
1
1
2
2
1
1
4
1
1
61
1
1
1
1
1
1
25
5
1
6
1
2
1
1
1
1
1
1
1
1
4
1
35
14
1
10
2
The number of pressure ulcers reported that require an investigation report for
GSTFT was 18 in Q2, 2013/14 , an increase from 15 in Q1 2013/14, which was an
increase from 8 in Quarter 4 2012/13.
A total of 38 Serious Incidents were de-escalated or closed without report in Q2.
37 of these were pressure ulcers, the majority (31) of which related to pressure
ulcers at GSTFT that occurred prior to admission to hospital or care by community
services.
The 38 de-escalated, request received for de-escalation, or closed without report,
pressure ulcer incidents have been reviewed to identify the reasons for deescalation, which are as in the following table:
Table 6: De-escalated, request received for De-escalation, or Closed without report
Pressure Ulcer Serious Incidents - Q1, 2013/14 – Lambeth residents only for KCH and
SLaM, all patients for GSTFT
Reason for De-escalation / Closure
No community nursing involvement prior to admission
Pressure ulcer acquired at Hospice / Nursing Home
Pressure ulcer acquired at another hospital
83
Number of
incidents reported
22
2
7
Reason for De-escalation / Closure
TOTAL
Number of
incidents reported
31
The providers have confirmed that safeguarding referrals have been made for the
incidents noted above where the pressure ulcer was acquired at a nursing home or
hospice. A process is in place at Lambeth CCG to receive assurance that
safeguarding referrals have been made before pressure ulcers serious incidents
are de-escalated.
Pressure ulcers form part of the NHS Safety Thermometer requirements for
2013/14 CQUINS. The NHS Thermometer is a local improvement tool for
measuring, monitoring and analysing harms and ‘harm free’ care. Data is a snap
shot of Pressure Ulcers, Urinary Tract Infections, Venous Thromboembolism and
Falls events at an agreed monthly date. This data is then submitted nationally.
13.7 Never Events
Definition: ‘serious, largely preventable patient safety incidents that should not occur if the
available preventative measures have been implemented by healthcare providers’.
There were no reported Never Events in Q2, 2013/14.
All serious incident issues reported are followed up at ongoing provider Serious
Incident Monitoring meetings for each provider. These meetings are chaired by a
Clinical Commissioner or the CCG Clinical Quality Lead and include a review of
current reported serious incidents and signed-off once there is assurance about the
implementation of action plans. The process for review and closure of Grade 2
Serious Incidents and Never Events has been reviewed and the Terms of
Reference for the Serious Incident review group amended to include input from
NHS England in this process.
13.8 Quality Alerts
Quality Alert information is available by clicking the link below:
http://www.lambethccg.nhs.uk/NewsPublications/Publications/Pages/default.aspx )
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