Merton Clinical Commissioning Group Governing Body Date 6 June 2018

Transcription

1 Merton Clinical Commissioning Group Governing Body Date 6 June 2018 Report Title Lead Director Author Annual report & accounts Julie Hesketh/Neil McDowell Julie Hesketh Purpose Executive Summary: Approval X Discussion Noting /X The annual report and accounts were submitted to NHSE in their final format on 29 May The reports have been discussed at a previous audit committee and also an extraordinary audit/finance committee and then finally signed off -by prior arrangement of the Governing Body- at the Audit Committee on 22 May The reports must be uploaded onto the CCG website by 15 June This paper has been brought to this GB to discuss what elements of the annual report and accounts we may wish to include in a summary document for the general public. It will be helpful to look at the areas of success in the previous year and then the areas we want to focus on next year, linking to the operating plan we have recently refreshed for the coming year. This will then inform the public of the challenges going forwards but also celebrate the areas of achievement. We would like a version that is helpful to the public to enable them to understand the functions, responsibilities and current business of the organisation. Some suggested areas, some of which are in the operating plan refresh, could include, but are not limited to: Last year s financial position and the scale of challenge going forwards. Merton Health and Care Together Successful areas of engagement with the public and areas to focus on for the future. Referral to Treatment the CCGs continue to work with St George s to agree the recovery plan trajectory for 2018/19 however non reporting in 2017/18 currently prevents reporting against two of the waiting times standards. IAPT 17/18 performance, 18/19 plans and what this means for patients.

2 Personal Health Budgets our current performance and plans to improve The Governing Body is asked to discuss and comment on the items for inclusion. Key Issues: The summary report needs to be accessible to the public, written with no jargon so it is easy to read and translate in other languages additional to English. Conflicts of Interest: No conflicts of interest are currently highlighted in regards to this report Recommendation: The Governing Body is asked to: Note the report attached and highlight any areas for inclusion in the summary report.

3 Corporate Objectives This paper will impact on the following: The annual Plan and accounts takes into consideration all of the CCGs 5 objectives Risk This paper links to the following CCG risks: Performance, Quality and Financial risk are addressed in the paper. Financial Implications Printing costs for the summary document Has an Equality Impact Assessment been completed Are there any known implications for equalities Not for this actual report. An easy read version in languages other than English will be published. Patient and Public Engagement and communication The purpose of this report is to enable preparation of a version that is easily accessible and understood by the public. A discussion should take place at local engagement groups before a version is prepared for printing. Committees previously considered at Previous Audit and Finance committees. Supporting Documents Annual report and accounts.

4 NHS MERTON CCG Annual Report 2017/18 Page 1 of 87

5 Contents PERFORMANCE REPORT 2 Performance Overview Welcome 4 Who we are and what we do 6 Our partners 8 Merton's health and wellbeing 12 Delivering outcomes in 2017/18 14 Performance Analysis 23 How we measure and manage performance 25 Constitutional Standards 26 Better Care Fund 29 Improvement Assessment Framework 31 Financial performance 32 Sustainable development 34 Improving quality 34 Public and patient involvement 42 Reducing health inequalities 48 ACCOUNTABILITY REPORT Corporate Governance Report 51 Members Report 49 Statement of Accountable Officer s Responsibilities 54 Governance Statement 55 Risk management Remuneration and Staff Report 68 Remuneration Report Staff Report Parliamentary Accountability and Audit Report 79 ANNUAL ACCOUNTS 81 Glossary Page 2 of 87

6 1. PERFORMANCE REPORT Welcome Welcome to NHS Merton Clinical Commissioning Group s (CCG) Annual Report for the financial year 2017/18. The year has been a year of progress for the CCG the plans we set out to achieve in previous years are starting to come to fruition and delivering real benefits to our patients. We are very proud of the developments to our primary care services including our offer of access to a GP seven days a week, from 8am to 8pm. The social prescribing pilot has also proven to be a great success and I am delighted that we are now rolling it out to more practices across Merton. This year, we have also worked with our providers and Merton Health, our local GP Federation, to ensure more services are available locally so that local people can access more of their health and care appointments closer to home. Partnership working with our CCG neighbours, NHS providers, our local authority, voluntary sector, patient groups and the public has been key to our success in 2017/18. This has been our fifth year as a CCG and our first year as part of the South West London Alliance with our partners Kingston, Richmond and Wandsworth CCGs. Merton and Wandsworth CCGs also came together to form a Local Delivery Unit within the Alliance headed by James Blythe as Managing Director. Richmond and Kingston CCGs have also been operating in this way. Working together as an alliance in this first year has already helped us share expertise and use our resources more effectively. We are very pleased to welcome Sutton CCG to the alliance as of 1 April 2018 to further increase the benefits of this way of working. In this first year we have come a long way, and have huge potential to do more together in the coming years. Our South West London Health and Care Partnership published our refreshed strategy document for discussion with local organisations and stakeholders in November This reflects the feedback we have received over the last year from local people and our partners. We have strengthened our focus on partnership, prevention and keeping people well the greatest influences on our health and wellbeing are factors such as education, employment, housing, healthy habits in our communities and social connections. Page 3 of 87

7 We will continue to work together in partnership with the local NHS, local authority, voluntary sector and Healthwatch in Merton to develop our local health and care plans overseen by the Merton Health and Wellbeing Board. These plans will provide clear and detailed actions to address the local challenges we have set out in the discussion document and will be published in November In 2017 the South West London Health and Care Partnership made a joint commitment to champion children and young people s mental health and well-being as a shared health promotion and prevention priority. We look forward to this work taking further shape over the year to come so that collectively we can support children to have the best start in life. Our joint focus will help build on the strong health promotion and prevention activities that take place in each of our health and care organisations in Merton including stopping smoking, alcohol and obesity. Looking ahead our financial challenges across south west London remain significant. In everything we do we will need to continue to focus on improving the quality of all our services and prioritising our limited resources to address the needs of local people. We still have a long way to go, however, we are proud of the work we have achieved this year. As the NHS is turning 70 on 5 July this year, we are looking forward to marking this occasion. Many of our staff have worked for the NHS for a long time and this will be the perfect time to celebrate the achievements of one of the nation s most loved institutions, to appreciate the vital role the service plays in our lives, and to recognise and thank our extraordinary NHS staff. Finally, we would like to say that we could not have achieved anything without the dedication of our GP members, staff, health providers and our key partners and stakeholders, and we look forward to working with them and the public again next year to continually provide the best healthcare we can for the people of Merton. Sarah Blow, Accountable Officer NHS Merton CCG Dr Andrew Murray, Clinical Chair NHS Merton CCG Page 4 of 87

8 Who we are and what we do Merton Clinical Commissioning Group (CCG) is responsible for planning, buying (commissioning) and monitoring health services for the people who live or work in Merton. This includes: Hospital care (for example outpatient appointments and routine operations) Services for people with mental health conditions Services for people who need long term care (for example people with learning disabilities and those who are physically frail) Urgent and emergency care (for example urgent care centres and A&E) Community health services (for example district nursing). We are also responsible for commissioning core GP services. Our GP practices work together with NHS partners to improve health and wellbeing, reduce health inequalities and make sure everyone has equal access to healthcare services. These partners include pharmacists, hospitals and mental health providers, the London Borough of Merton, and local community groups. We also work with NHS England which commissions health services from dentists and pharmacists, and specialised services such as transplant surgery and many screening programmes. The governing body oversees the delivery of our commissioning plan, leads and sets the strategy for the CCG, and is accountable for the delivery of our functions as a statutory body. All GP practices are entitled, through their member representatives, to elect members to the Board. This means that members are represented and contribute clinical expertise at the highest level within the CCG. You can find out more about us and our work on our website Our corporate objectives 1 Improving outcomes and reducing inequalities: Ensuring access to high quality and sustainable care. 2 Leading with ambition for our communities, driving transformation through innovation: Delivering better care and a better patient experience. 3 Working together: Continually improve delivery by listening to and collaborating with our patients, members, partners, communities and other stakeholders. 4 Meeting our performance and financial objectives: Make the best use of our resources to benefit our patients and communities. 5 Supporting our people: Provide the tools and environment for a healthy workplace and support our staff to do a great job. Be a learning organisation that encourages continuing improvement. Page 5 of 87

9 Our partners We work with a variety of partners to improve health and wellbeing in Merton and to reduce inequalities in health across the borough. Merton Council i) Public Health The London Borough of Merton leads on helping local people to stay healthy. We work together to support and encourage people to make healthier choices whatever their circumstances. The public health team at the council provide information and expertise to support our work and the Director of Public Health for Merton is a member of our governing body. More information about the London Borough of Merton s public health role can be found here: ii) Merton Health and Wellbeing Board (HWB) Health and wellbeing boards are designed to deliver strategic joined-up local leadership on health and care. The work of the Merton HWB is central to the commissioning of health and social care services in Merton. The Board brings together Merton Council, Merton CCG, Healthwatch Merton and the voluntary and community sector with a shared focus on improving health and wellbeing in Merton, tackling health inequalities and encouraging a greater focus on helping people to stay healthy and make healthier choices. Our Joint Health and Wellbeing Strategy sets out our shared approach to improving the health and wellbeing of everyone in Merton and reducing health inequalities between communities. A Local Delivery Unit with Wandsworth CCG Merton shares its management team with Wandsworth CCG through a structure called the Local Delivery Unit (LDU). There are clear benefits to closer working between the two CCGs, particularly when it comes to managing our larger contracts and the relationship with St George s University Hospitals NHS Foundation Trust. The LDU structure provides an opportunity to spend more of our running cost allowance on transformation. Both CCGs have benefitted from shared experience, expertise and resources in areas such as tackling delayed transfers of care, mental health placements, primary care resilience and social prescribing. The combined team brings out the strengths which both CCGs have brought to the LDU. At the same time, this change, like any, has attracted a number of challenges. Engagement of our partners at borough level, our staff, and our governing bodies and membership is critical, and we will reflect on our staff surveys and 360 degree feedback to identify how we can continue to improve on that over the next year. Page 6 of 87

10 The LDU Executive Team, led by the Managing Director, ensures that we engage at the right levels on the right issues, from locality, to borough, to LDU, with our colleagues across south west London and the wider NHS. South West London Alliance of CCGs The South West London Alliance is the result of five CCGs (Kingston, Merton, Richmond, Sutton and Wandsworth) in south west London having chosen to work together to share expertise and use resources more effectively. Kingston, Merton, Richmond and Wandsworth joined together as an alliance on 1 April 2017 with Sutton CCG joining on 1 April We remain close partners with Croydon CCG who are part of our South West London Health and Care Partnership, but not formally part of the alliance with their own accountable officer. Working together helps us to make stronger collective commissioning decisions, share best practice and expertise across a wider footprint, and reduce duplication. It also enables us to learn from our neighbours, bringing everyone up to the same high standards when planning and buying healthcare services. Making joint commissioning decisions for south west London Effectively commissioning healthcare services sometimes requires decisions to be made for more than just the residents of a single borough. Governing Body members from each of the six CCGs in south west London meet regularly in public as the Committees in Common to make decisions on issues that affect every borough. A recent example of a collective decision we have made is all six CCGs unanimously agreeing how to collectively fund transformation of primary care for 2018/19 across south west London. The General Practice Forward View set out a requirement for all CCGs in the country to ensure people can access primary care services from 8am to 8pm, seven days a week. In 2017/18, south west London received 4.58 million to implement this change. Using this funding CCGs have made it easier to access GP services through a range of models which have created around 18,000 extra appointments each month. For the year to come, south west London CCGs will receive 8 million which equates to 5.41 per head of the population. This will be used to continue to develop extended GP services, ensuring the extra appointments available are for patients with routine needs, such as managing a long-term condition or reviewing an existing condition, as well as urgent needs. The funding will also be used to enable NHS 111 and A&E departments to book appointments directly into primary care services for patients who would be better served by primary care. We will also use some of this funding to look at new ways of supporting primary care to work at scale across south west London. This is a way of meeting demands Page 7 of 87

11 placed on individual GP practices by working together in a new way. With our support, our practices are working together to design how this will work for each area and together we will find the best way to deliver working at scale. The potential benefits to practices, and our population, is that this way of working can help to spread best practice, offer more personalised and preventative care, tackle workforce issues and manage a range of administrative functions more efficiently. Working together gives us flexibility to use the money we will receive as a system. Making one decision across all six CCGs also ensures that everyone is able to make progress towards our collective vision. South West London Health and Care Partnership (SWLHCP) Over the last year the NHS, local councils, Healthwatch and the voluntary sector in south west London have strengthened their commitment to working together to deliver better care for local people as the SWLHCP. People told us, and we agreed, that a local approach works best. To support this the organisations providing health and care in our six London boroughs have come together as four local partnerships, acting as one team to keep people healthy and well in Merton, Wandsworth, Croydon, Sutton, Richmond and Kingston. We published our sustainability and transformation plan in November 2016 and spent the following year speaking to stakeholders and local people about what it means to them. Led by this feedback we refreshed our strategy and in November 2017 we published our draft refreshed strategy document The South West London Health and Care Partnership: One year on for discussion with local organisations and stakeholders. This discussion document reflects the feedback we received over the last year, and we have strengthened our focus on partnership, prevention and keeping people well the greatest influences on our health and well-being are factors such as education, employment, housing, healthy habits in our communities and social connections. We will continue to work together in partnership with the local NHS, local authorities, the voluntary sector and Healthwatch to develop borough health and care plans. These plans will provide clear and detailed actions to address the local challenges we set out in the discussion document. The final local plans will be published in November To support this work, we have established four Local Transformation Boards (LTBs) across south west London: Croydon Kingston and Richmond Merton and Wandsworth Sutton Page 8 of 87

12 This local approach has been welcomed by our local authority partners. To further strengthen our partnerships with them we will be giving further consideration to how health and wellbeing boards can play a bigger role in the development of local borough health and care plans and have stronger links to the LTBs. It is essential that the borough health and care plans are co-produced with all of our partners, including the voluntary sector, and we look forward to doing this over the coming months. Merton and Wandsworth Local Transformation Board (LTB) Our achievements in 2017/18 included: making it easier for patients who need help to prevent their blood clotting (anticoagulation) to receive their treatment closer to home monthly meetings by health and care workers to share information relating to the quality of care being provided in care homes. This means we can respond more quickly to concerns and agree action plans where appropriate. the roll out of a health and social care reablement/rehabilitation pathway at St George s University Hospitals NHS Foundation Trust. This uses a discharge to assess principle. All agencies ensure support is put in place for the patient to go home and assessments for care are made in the patients home rather than in hospital. In the initial three month pilot all social care referrals made by participating wards were responded to with a decision within two hours. Patient and public engagement We are committed to ensuring that the views and experiences of local people are at the heart of our plans. Conversations with local people are ongoing and help ensure that the needs of people who live and work in Merton are central to what we do. There are a number of ways that local people have been involved in shaping our plans in 2017/18: Direct engagement 25 patient and public representatives from across south west London take part in our clinical workstreams. The representatives are supported by the South West London Engagement Manager and a buddy on their workstream to ensure they can meaningfully contribute to meetings. A Patient and Public Engagement Steering Group (comprising Healthwatch, CCG lay representatives and the voluntary sector) oversees this work. Wider engagement An extensive programme to engage with local grassroots communities is also ongoing. The engagement team visit groups across south west London to speak to local people we don t normally hear from. Local organisations who support seldom heard groups are invited to apply for a small sum of money to run an activity that their community will enjoy. The engagement team then attends the Page 9 of 87

13 session to speak to people in an environment they feel comfortable in about their experience of local services. This work is delivered with the help and support of local Healthwatch organisations. Since the grassroots programme began in April 2016 the SWLHCP engagement team, together with CCG colleagues, have attended more than 110 sessions and reached over 6,000 people. A You said, we did and are doing report details what we are doing as a result of the feedback received. To complement the outreach work we held a health and care forum in each borough in 2017/18. This give interested members of the public an opportunity to share their views with us. Feedback from both the outreach work and the forums can be found here Phase two of the grassroots 2018/19 programme, which began in May 2018, will inform the development of the borough health and care plans. Targeted pieces of engagement work to shape specific services/pathways Sometimes we need to do specific pieces of work to shape local services and we tailor our approach to the needs of each project. For example, we may run a focus group or hold one to one interviews with people affected by a particular condition or service. Community perinatal mental health service In August 2017 we worked with women who had experience of mental health services during or after pregnancy to help inform a bid to provide a community perinatal mental health service. South west London does not currently have a specialist perinatal community mental health team that meets national guidance set out by the Royal College of Psychiatrists (RCPsych). To ensure that the voice of women and families were at the heart of the bid we undertook a three-fold engagement exercise to develop what the model of care could look like. The engagement included a focus group, one-to-one interviews and a workshop with voluntary sector colleagues. We will continue to involve women and families in the implementation and delivery of the new service. A report from the work so far can be found here Prostate cancer passport In July 2017, we ran a focus group with 12 men from across south west London who had experience of prostate cancer. The aim was to codesign and test a new patient held record (a passport ) to help men keep a record of their prostate specific antigen (PSA) levels. Attendees were able to share their prostate cancer treatment experiences, highlighting what worked well for them and what could be improved. We then asked everyone what would be a helpful tool for them to enable them to take more control over their care. The men were also invited to join the Prostate Cancer Working Group as patient representatives. As a result Page 10 of 87

14 two of the men are now members of the working group, having joined in August The feedback from the focus group gave us the detail we needed to develop a PSA passport. The first draft of the PSA passport was circulated to the who attended the focus group and their comments will be incorporated into the next iteration which will be tested by 100 men from across south west London. A report from the session can be found here Healthy London Partnership (HLP) Merton CCG, along with all London CCGs and NHS England (London), funded HLP in 2017/18 to bring together the NHS in London and our partners to deliver the capital s 10 ambitions to transform health and care. HLP supports the aim to make London the healthiest global city in the world by uniting all of London to deliver the ambitions set out in Better Health for London: Next Steps and the national NHS Five Year Forward View. During 2017, HLP set up the Urgent and Emergency Care Improvement Collaborative to transform the way that Londoners receive unplanned urgent care and support. The collaborative aims to bring together leaders from health and social care to define what work needs to happen in London, drawing on best practice from across the country. Highlights for 2017/18 included: Thrive LDN an initiative to improve mental health and wellbeing. Community workshops and problem solving booths were held across London as part of Thrive s Are we okay London? campaign which reached 15.5 million people in 2017/18 Great Weight Debate - The findings from HLP s year-long engagement with Londoners on childhood obesity were published in Nine out of 10 Londoners who responded to the Great Weight Debate survey said tackling London s childhood obesity epidemic should be either the top or a high priority for the capital. The findings are informing every London borough s childhood obesity strategy and informed the Mayor s London Plan which includes a policy to prevent new hot food takeaways from opening within 400 metres of a school. In 2017 HLP developed and published online training for GP receptionists to help people who are homeless access GP practices. More than 60,000 my right to access healthcare cards were also distributed for people who are homeless to make sure they can get equal access to healthcare given that they are more likely to use emergency services. A plan to cut rates of new HIV infection and eliminate associated discrimination and stigma was launched in early 2018 with the Mayor s Office, NHS London and Public Health England. Page 11 of 87

15 Acute sustainability - working with Sutton and Surrey Downs CCGs Epsom and St Helier University Hospitals NHS Trust has faced significant challenges for many years in terms of the suitability of its buildings and how its acute services are organised. In autumn 2017 the trust set out its own view of these challenges and how it believed commissioners should respond to them. Merton, Sutton and Surrey Downs CCGs are now working together to look in detail at the challenges faced by the trust and how to best ensure that the hospitals continue to deliver high quality, safe and sustainable services for local people in the years ahead. As the trust is raising significant concerns, it is right that commissioners undertake a rigorous assessment and carefully consider their response. The CCGs have already said that they are clear that there will continue to be a need for both hospitals. Together, the three CCGs will look at all the evidence and work with the trust, clinicians in primary and secondary care and local people to decide the best way forward. Merton s health and wellbeing In 2018, Merton has an estimated resident population of 210,250 which is projected to increase by about 3.5% to 217,550 by The age profile is predicted to shift over this time, with notable growth in the proportions of young people between the ages of 11 and 15 years (17%), and those over 50 years old (10%). The young and the old have more complex health needs. Increasing numbers of our local population are living into older age with multiple long-term conditions such as heart disease, diabetes, cancer, mental health conditions, and dementia. Merton has developed a falls prevention service, an older people s memory clinic and a Holistic Assessment and Rapid Investigation Service (HARI) to better support the needs of older residents. The HARI service was widened in 2017/18 to support a broader age group of people with complex needs. The service also now also offers diabetic eye screening. Currently, 37% of Merton s population are from a Black, Asian, or Minority Ethnic (BAME) group. By 2025 this is predicted to increase slightly to 38% with a greater proportion living in the east of the borough. Children and young people from BAME backgrounds make up 67.9% of those attending a Merton school which is lower than the London average (72.2%) but higher than England (30%). The CCG increased its engagement with minority ethnic groups in 2017/18 to ensure we understand their experience of healthcare and their health and wellbeing needs. Overall, Merton s population is comparatively healthy and life expectancy is higher than the national and London average for both men and women. However, there are Page 12 of 87

16 stark differences between different areas of the borough and life expectancy is significantly lower in the most deprived areas in East Merton. A key focus for Merton in 2017/18 was the development of the east Merton model of health and wellbeing and a social prescribing pilot to help address these inequalities. The main causes of ill health and premature deaths in Merton are cancer and circulatory disease (including coronary heart disease and stroke). Known risk factors (unhealthy diet, smoking, lack of physical activity, and alcohol) account for around 40% of total ill health. Consequently, changing patterns of unhealthy behaviour is an important focus for prevention efforts. In 2017/18, the CCG worked collaboratively with London Borough of Merton s public health team to support initiatives to tackle childhood obesity and encourage people to make healthier lifestyle choices (for example blood pressure checks, stopping smoking, getting more exercise and reducing alcohol consumption). The CCG is also actively working with local community groups to improve diabetes awareness and diagnosis and to develop better service user involvement to improve clinical outcomes for patients with diabetes. Full data on Merton s health needs is taken from the Joint Needs Strategic Assessment which informs the Council and the CCG to develop its shared strategy for health and wellbeing Health and wellbeing strategy Merton has longstanding health inequalities between the east and the west of the borough. Our commissioning activities and our primary care strategy acknowledge these inequalities and seek to ensure that services address these needs and that prevention is built into all of our plans. Key areas of work to support prevention in primary care include: improving uptake of bowel screening identification of frailty with a view to proactively preventing ill health ensuring strong uptake of immunisations in both children and adults prevention of diabetes complications by focussing on those with the least well controlled diabetes. In addition, we have developed schemes to focus on frequent users of urgent care and patients with chronic obstructive pulmonary disease. Both of these issues are more prominent in the east of the borough and are linked to higher rates of long term conditions, smoking, deprivation and mental health problems. Wilson Campus development The model of health and wellbeing for the east of the borough will be delivered from new premises based at the old Wilson hospital site in Mitcham. We hope that the combination of a health and wellbeing campus with easy access to community based Page 13 of 87

17 medical care will reduce health inequalities in the east of the borough by addressing the main determinants of ill-health in one model. There has been significant community input into the future design and work is ongoing with practices in the east of the borough to develop the primary care provision. We have had conversations with the community, doctors, nurses, local politicians, public health professionals, voluntary sector organisations and many others. They have told us of the services that they want the Wilson Campus to deliver. As a result, we plan to offer: Bookable GP appointments from 8am 8pm, seven days a week Adult mental health services Support for people with long term conditions like diabetes and lung disease Community café X-ray and other diagnostics like ultrasound and phlebotomy Physiotherapy to treat conditions that affect joints, bones and muscles Rehabilitation services Children s development centre Lifestyle and preventative services. We hope the campus will open its doors to local people in summer Before then there are a number of steps to take in the planning process. Social prescribing Social prescribing is a way of linking patients in primary care with sources of nonmedical support within the community. It helps free up the professional time of GPs while connecting people to their community and its resources. It is an important tool to help address some of the non-medical determinants of health such as social isolation and employment issues. A pilot has been underway since January 2017 with a social prescribing navigator working out of Wide Way and Tamworth House GP practices. The pilot is supported by the London Borough of Merton and Merton Voluntary Services Council. A separate but parallel care navigation service is also available at the Nelson Health Centre. The pilot has focused on supporting patients with low levels of anxiety and stress, and those experiencing social isolation and loneliness, to help improve their health and wellbeing. An independent evaluation, supported by the south west London Health Innovation Network, showed an increase in health gains reported by patients and a statistically significant reduction in GP visits. For more details on our work to reduce health inequalities see page Page 14 of 87

18 Delivering outcomes in 2017/18 Primary care Local people told us that they struggle to get an appointment with a GP. They also told us that other healthcare professionals, such as pharmacists, could play a greater role in primary care but that more would need to be done to build public confidence in their remit. Many people, including carers, said that they found the health system difficult to navigate. Given what we ve heard, and in line with delivering the key aims set out in the General Practice Forward View, we have focussed on the following: Developing schemes (including Care Navigators and Medical Assistants) to support non-clinical staff in the community with better training so that they can be more patient facing. We think this will both support patients to navigate the system more effectively and help GPs to manage their time more efficiently when seeing patients. These schemes are being piloted and co-ordinated across south west London by our borough based Community Education Provider Networks (CEPNs). CEPNs support the training needs of health and social care communities in a local area). Delivering 100% extended access to GP appointments allowing local people to book routine GP appointments in the evening, at weekends and over bank holidays. Progressing our work towards providing online consultations. We have had additional funding of over 400,000 approved across south west London to support the roll out of the GP Forward View for online consultations. Key achievements in Merton include: Increased investment to provide increased and better quality access to primary care services. Merton GPs offered around 50,000 extra GP appointments in 2017/18 (around 4,000 extra appointments every month). Two new GP hubs. Over 90% of patients using the hubs say they feel they have easy access to the new service and 95% would recommend the service to friends and family. Improving access to primary care Extended hours we fund all Merton practices to offer more appointments in both core and extended hours, including dedicated slots for children needing same day access. Some practices have used the additional funding to employ new team members, such as nurse practitioners and physician assistants, and to extend the role of existing staff, such as health care assistants. The primary care team have also supported a Merton wide bid, involving 12 practices for clinical pharmacists which is being considered by NHS England. Page 15 of 87

19 Hubs The two hubs offer on the day and advance appointments and are open Monday to Friday 5pm-8pm and 8am-8pm on a Saturday. One hub is also open 8am-8pm on a Sunday. Both are open 8am-8pm on bank holidays. Wound care is delivered by nurses on site. Clinicians in the hub have full access to medical records (with patient consent). This improves patient safety and experience and ensures that hub consultations are offered in an integrated way rather than as a stop gap or duplication. Help for vulnerable groups We are funding an access scheme to support frontline staff to help vulnerable groups. The scheme s content was designed using feedback from patients (both locally and using the national patient survey) and with suggestions from Merton Healthwatch. This work comprises four modules and seeks to improve the understanding and skills of frontline staff. The modules focus on telephone skills, improving the experience of carers and making registration easier for vulnerable groups such migrants and homeless people. Proactive care There is a continued focus on proactive care to improve outcomes for vulnerable patients and high users of services through earlier inventions. Key achievements in 2017/18 were: the introduction of a service to ensure that all categories of frailty are identified on primary care registers so that patients can be offered self-care support and education A funded Frequent A&E Attenders Scheme for adults and children to offer these patients a longer appointment in primary care to see if their needs can be met more appropriately elsewhere A chronic obstructive pulmonary disease (COPD) winter scheme identifying patients at higher risk and working with them to prevent hospital admission A care home scheme open to GP practices who are caring for a significant number of patients in care homes. The scheme provides resources to support advanced care planning and improved end of life care for the most severely frail patients to help prevent unnecessary hospital attendances and admissions. Estates improvement Modern, fit for purpose primary care estates are vital for the provision of high quality care. The Merton primary care team has supported practice applications to NHS England s Estates and Technology Transformation Fund (ETTF) to help them to improve their premises. The ETTF is a multi-million pound investment (revenue and capital funding) in general practice facilities and technology across England (between 2015/16 and 2019/20). It is part of the NHS commitment for more modernised buildings and better use of technology to help improve GP services for patients. Page 16 of 87

20 Key projects undertaken in 2017 included: Central Medical Centre - a loft extension with ground floor extension and other improvements James O Riordan Medical Centre - introduction of automated door-closer equipment Wide Way Surgery - six new consulting rooms. Successful ETTF bids have also been secured for Colliers Wood Surgery s colocation to new premises at Merton Vision on Clarendon Road, and for Princes Road Surgery s relocation to refurbished premises at Patrick Doody Clinic on Pelham Road. Training and education - workforce development Training and education is central to our strategy to deliver a highly skilled primary care workforce and evidence based care. We have prioritised educated events called Protected Learning Time for teams and provided learning and development opportunities for all clinical and non-clinical primary care staff. Subjects covered include diabetes, cardiology and mental health. Dementia Friend training has also been provided. Integrated care Better Care Fund (BCF) plan The Better Care Fund (BCF) joins up health and care services so that people can manage their own health and wellbeing, and live independently in their communities. The BCF supports the most vulnerable people by placing them at the centre of their own care and providing them with integrated health and social care services. The scheme allows more care to be offered out of hospital, to reduce hospital admissions and supporting timely discharges. The Improved Better Care Fund (ibcf) was first announced in the 2015 Spending Review and is paid as a direct grant to local government with a condition that it is pooled into the local BCF plan. The ibcf funding can be spent on three purposes: meeting adult social care needs, reducing pressures on the NHS including supporting more people to be discharged from hospital when they are ready, and ensuring that the local social care provider market is supported. In September 2017, we transferred 5.5m to the council to support the BCF and ibcf. In addition to the CCG s contribution, the London Borough of Merton has also been allocated ibcf funding of 2.745m. Together, we decided that there are three priority workstreams for the next two years: Page 17 of 87

21 Integrated locality teams (which will include both social care and health workers) Intermediate care and rapid response Enhanced support to care homes. Merton GP practices have agreed to work in four clusters to support the development of integrated locality teams. Merton Community Services (delivered by Central London Community Health) and some functions of the London Borough of Merton are also in the process of aligning their teams to these four clusters to further support greater integration of services. Support for patients with complex needs We have improved the proactive identification of people with frailty concerns and their onward referral to appropriate support services, for example falls prevention, case management or the Holistic and Rapid Investigation Service (HARI) at the Nelson Health Centre. Alongside this we adapted the Age UK Healthy Ageing booklet to include local voluntary support services for frail, elderly and vulnerable people and gave it to all Merton GP practices, community services, local libraries, social care staff and the voluntary sector. Improving hospital discharge Once people no longer need hospital care, being at home or in a community setting (such as a care home) is the best place to continue recovery but sometimes there are delays to the person being discharged. We have worked hard this year to reduce unnecessary delays. Throughout the year agencies across Merton worked with local acute trusts to identify patients who might require support following a hospital admission. As a result, a new pathway started in February 2018 for patients who may be eligible for NHS continuing healthcare. Patients who may be eligible for NHS continuing healthcare are now assessed out of hospital in order to help bring their care back into the community and reduce unnecessary time in hospital. Practitioners across Merton review patients on a daily basis to see what support can be offered to support discharge. As a result of this, and in spite of increased pressures over 2017/18, Merton achieved the second lowest delayed transfers of care in London in January This was second only to the City of Westminster. We are also introducing a national programme, Enhanced support to care homes, in Merton. A multi agency Merton Joint Intelligence Group has been established and the Merton Care Home Forum has been reinvigorated. The Merton Care Home Forum is a multi-agency support forum run in conjunction with local community group, Merton Seniors. The Red Bags Scheme Page 18 of 87

22 We introduced red bags into 21 Merton care homes in January The bags are a tool to help us reduce the time care home residents spend in hospital and to make their stay less stressful. When a care home resident needs to go into hospital a red bag is packed for them. The bag holds their personal details, information about their health conditions, supplies of regular medicine, personal items (such as glasses and dentures) and a change of clothes for when they are ready to be discharged. The bag is handed to ambulance staff who give it to hospital staff. This guarantees that essential documents and items follow the resident from arrival at hospital to discharge back to their care home. Vital information in the red bag enables hospital staff to provide quicker effective care and treatment and reduces delays in getting patients home from hospital. The scheme has initially been rolled out at Merton nursing and residential homes for older residents. We intend to expand it further in 2018/19 to cover homes that support people with learning disabilities and mental health conditions. Fire, Safe and Well Merton is one of five boroughs in London chosen to pilot Fire, Safe and Well. This London Fire Brigade initiative will see visits being carried out to older and vulnerable Merton residents to reduce their risk from fire as well as from slips, trips and falls. Two community safety advisors have been recruited and trained by London Fire Brigade to carry out the visits and a cross-merton group set up to support the project. The advisors can refer people directly to the Merton Community Falls Prevention Service and will consider health, social and lifestyle factors alongside the physical risks of fire in someone s home. There can be a clear link between these factors and someone s vulnerability to fire. We hope that this initiative will help reduce hospital admissions by identifying those at risk earlier alongside improving home fire safety. Maternity Local people told us that their care would be improved if they had the same midwife throughout their maternity journey. People wanted to be empowered to have more choice in their care. Above all, people told us that their safety and the safety of their child was of paramount importance. This feedback informed the maternity plan for south west London that we submitted to NHS England in January The plan focuses on action being taken across south west London. This includes making sure women have a choice about where to have their baby and access to information to help them make decisions about their care, including where they can get support centred on their individual needs. To help us to achieve this we have launched a pilot for a new My Maternity Journey booklet across south west London. The booklet is designed to support choice for pregnant women by setting out all the services available across south west London to help them navigate their pregnancy care. Page 19 of 87

23 Children and young people We have continued to work with the London Borough of Merton to develop joined-up services for children and young people. Two CCG staff are now co-located with the Children, Schools and Families team and the Public Health team at the London Borough of Merton to make sure our work is integrated. Child and adolescent mental health services (CAMHS) Our CAMHS Local Transformation Plan was refreshed in 2017 and is focused on ensuring people have better access to services and that these services are of a high quality. An autism strategy has been developed by the local authority in partnership with the CCG. The strategy was developed following extensive engagement with local people. The neurodevelopmental pathway for children received additional investment to ensure open access for diagnostic assessments. Local engagement and listening events were held for local families and stakeholders to contribute to the future planning process for an improved neurodevelopmental pathway. We have also continued to invest in services to support young people s mental health in the community. This includes counselling services offered by local agencies Off-the-record and The Wish Centre. You can read more about progress during 2017/18 and priorities for the next four years in Merton s Children and Young People s Transformation Plan. In 2017 the South West London Health and Care Partnership made a joint commitment to champion children and young people s mental health and well-being as a shared health promotion and prevention priority. Merton is playing a leading role in this work. The project is being led by Merton GP and CCG Chair Dr Andrew Murray, London Borough of Merton Chief Executive Ged Curran and John Goulston of Croydon Health Services NHS Trust. Other work with our south west London CCG partners has included: Developing a specialist eating disorder service which is now operational and improving outcomes for young people. Work is also underway to develop a service model in line with national targets for assessment and treatment of eating disorders in 2017/18 Consistent 24/7 crisis care for children across south west London in line with new guidelines published by Healthy London Partnership in October 2016 Developing transition services for young people aged who are suffering from neuro-developmental disorders. Page 20 of 87

24 Mental health Local people told us that they were worried that not enough money was being invested in mental health services in order to meet the growing demand. People felt more should be done to provide 24/7 crisis support for adults and children with mental health conditions and their families. We have listened to what local people want and are committed to improving how we prevent, support and care for people experiencing mental health problems and make sure we treat their mental and physical health together. Examples of our key successes in south west London include: Providing 24/7 psychiatric liaison services in all our A&E departments from April 2018 due to nearly 1.5 million of funding received Faster access to crisis mental health care with St. George s NHS Foundation Trust and Croydon University Hospital Trust offering access to specialist mental health staff 24/7 with a one hour response to emergency referrals known as the Core 24 standard. Kingston Hospital NHS Foundation Trust and Epsom and St Helier University Hospitals Trust also began providing this from April We have also put in a bid for national funding for new specialist perinatal community mental health teams to support women experiencing mental health problems in the few weeks before or after giving birth. The teams will help women and their families, and work with other healthcare professionals, to provide education and training around perinatal mental health. Sunshine Recovery Café A Recovery Café, provided through South West London St George s Mental Health Trust, launched in Wimbledon in April The café offers a safe and welcoming space for those struggling to cope and aims to reduce anxieties and crisis. It is open to all south west London residents 365 days a year. The Recovery Café, and its sister site in Tooting, have proved to be extremely popular. You can find details of the cafés here Online talking therapies service In early 2018, we added weekend and evening online talking therapies to the current talking therapies offer in Merton. The provider, IESO, provides Cognitive Behaviour Therapy (CBT) with a fully qualified therapist in real time over the internet. Online talking therapy helps meet demand for out of office hours appointments and offers valuable access for patients with mobility or social anxiety issues. The online CBT sessions follow the same format as traditional face-to-face therapy but take place in a secure online therapy room. This allows people to have the therapy from wherever they feel most comfortable and means the sessions can be Page 21 of 87

25 accessed discreetly with no need to visit a GP. For some people talking online can also help alleviate the pressure of having a face-to-face conversation. The service is free, confidential and is designed to help with many mental health problems including depression (including perinatal), fears and phobias, panic attacks and social anxiety and shyness. Transforming care Transforming care is all about making health and care services better so that more people with a learning disability, autism or both can live in the community, with the right support, and close to home. We have continued to work with providers to ensure that the recommendations made in Transforming Care: A national response to Winterbourne View Hospital are implemented. Working with local providers and when necessary those that are out of area we continue to make sure that the recommendations from The Five Year Forward View for Mental Health are implemented and incorporated into day to day care. Cancer Local people told us that getting an early diagnosis is really important in order to avoid the need for more aggressive forms of treatment. People valued screening programmes but felt more could be done to reach all parts of our diverse community. Once diagnosed, people felt that the NHS provides excellent clinical care but more training could be given around delivering news sensitively. Working together across south west London, we are focusing on: Ensuring early and timely diagnosis and treatment and consistently meeting national standards of receiving first treatment within 62 days following an urgent referral Working alongside Royal Marsden Partners to secure transformation funding for further roll out of follow-ups in primary care for prostate cancer Improving uptake of bowel screening as rates in south west London are lower than the national average. We are introducing a Bowel Cancer Screening Communication Service to contact patients directly to talk them through the screening process, why it is important and to address any concerns they have Reviewing a project that is underway in Kingston to increase screening uptake for people with learning disabilities this will inform a potential roll out across south west London Putting in place a follow-up programme for prostate cancer patients. GPs and practice nurses will regularly follow-up care and monitor patients so that they do not need to attend hospital for unnecessary appointments. This is already in place in Croydon and Sutton and has been shown to improve care and patient experience. It will be rolled out across south west London. Page 22 of 87

26 In 2017/18 Merton s Cancer Task Group joined with Wandsworth Cancer Clinical Reference Group to bring a more streamlined and joined up approach to planning, commissioning and monitoring of local cancer services. It has also helped us improve communication with primary care and other key stakeholder groups. Over 2017/18 we have increased the number of out of hours clinics to give women greater and more convenient access to cervical screening. We have also worked hard to increase the number of Cancer Care Reviews carried out in primary care. The reviews help identify early signs of complications or poorly controlled symptoms. We also worked with local hospitals to ensure that Health Needs Assessments are completed and returned to GPs and that Treatment Summaries contain all the necessary information to support effective management in primary care. Planned care Musculoskeletal services (MSK) From April 2017 patients registered with Merton GPs became able to self-refer to the Merton musculoskeletal service. This is instead of waiting to be referred by their GP or another healthcare practitioner. This speeds up access to assessment and treatment in the service, plus the service can arrange any injections, scans or onward referrals (i.e. orthopaedic consultants) if required in a timely manner. Over 600 people have taken advantage of this new way to access treatment. Initially patients book a phone consultation to speak to a physiotherapist within a few days. The physiotherapist can then (or post) them exercise videos (or sheets), education leaflets and other resources so they can start helping themselves straight away. The patient and physiotherapist can also agree the appropriate next steps in their care and get this in motion straight way. This could include face to face assessment with a rehabilitation therapist, into our fully equipped rehabilitation gym or our educational seminars. The pathway is endorsed by the Charted Society of Physiotherapy and NICE. Selfreferral pathways are shown to be safe, effective, reduce waiting times and decrease GP workload and costs. Diabetes The Community Diabetes Services (Tier 3) was expanded in 2017/18 and we focussed on making it easier for people to access advice and support from primary care when they needed it. We also worked with primary care services to boost the number of people offered structured diabetes education programmes to help patients learn about their condition and how to maintain a healthy lifestyle. Neurology Page 23 of 87

27 We have agreed five pilot areas as part of for the development of an Integrated Neurology Service. We are now working on proposals for further investment into community neuro-psychology support services. Urgent and emergency care Local people told us that too many people use A&E because they can t get an appointment with their GP or don t know where else to go. People said that it is hard to change behaviours and we should consider co-locating other services in A&E departments. Concerns were also raised about discharge from hospital - with some people being discharged late at night and without care packages in place when they returned home. We are committed to improving services for people when they are at their sickest and are in need of urgent or emergency care ensuring that, for those with non-life threatening but urgent needs they are treated as close to home as possible, and those with more serious or emergency needs are treated in centres with the very best expertise and facilities. These are some examples of how we are achieving these aims: Introducing an extended NHS 111 service to help our residents receive the most appropriate healthcare. Our new 111 service has employed more clinicians so that over half of calls are now handled by a clinician. The service can also now book patients directly into their local GP practice. Improving front door streaming at A&Es which means finding the best ways of patients being initially triaged, treated or referred onto the most appropriate service for them as swiftly as possible Establishing new locality teams to offer multidisciplinary support both to patients with long terms conditions and those who are discharged from hospital and need additional support. As part of these teams there will be in reach teams who actively go into hospitals to ensure that patients who are ready to go home are not delayed. Ambulatory care Ambulatory care is a service which provides same day emergency care to patients at our acute trusts. This means that patients are assessed, diagnosed, treated and are able to go home the same day, without being admitted overnight. It is a way to avoid unnecessary hospital admissions. In 2017/18, St George s University Hospitals NHS FT have expanded their existing ambulatory care service, almost doubling its capacity. It will now meet NHS England standards in delivering a service that is available to our patients seven days a week, 14 hours a day. Page 24 of 87

28 1.2 Performance analysis How we manage performance We are committed to ensuring that NHS care is provided safely and to the highest quality possible for all patients. We measure performance and quality standards based upon the national CCG Assurance and Assessment Framework 2017/18, which focuses on key constitutional pledges for patients including key waiting times targets. In an environment where NHS organisations across the country have experienced unprecedented growth in demand for NHS care with a tighter limit on resources, we have worked hard to maintain and improve the performance and quality of care for Merton patients by setting firm expectations of standards with our healthcare providers. Our Governing Body has ultimate responsibility for making the final decisions and ensuring the CCG is performing as it should. It is accountable to NHS England and to member practices, as well as to the public. We report performance and quality standards each month to our Governing Body and hold monthly meetings with our key acute, mental health and community care providers to review performance. Where we feel closer involvement is required, we meet providers on a regular basis to work with them to bring about performance improvement and ensure plans are effective. Performance is monitored and measured through the Integrated Governance and Quality Committee held in common with Wandsworth CCG. The committee scrutinises performance for both CCGs and reviews areas of concern and reports to the Governing Bodies as appropriate. How we measure performance We measure and monitor quality and performance metrics with all our health service providers, framed around the NHS Constitution and local quality measures. The CCG performance and information team reviews performance metrics alongside commissioning and contracting managers on a regular basis. These metrics are combined with local intelligence and information to produce a monthly Performance Report, presented to our Integrated Governance and Quality Committee, and our CCG Assurance Report which we present to our Governing Body and publish on our website: The format of the report has changed to show longer term trends, benchmarking information and areas to note by exception across the health economy. Root causes relating to issues of concern are distilled with the mitigating actions detailed. Page 25 of 87

29 The performance report provides: An update on CCG and related providers operational performance against national and locally agreed standards. This includes 18 weeks referral to treatment (RTT), cancer waits, A&E waits and ambulance handover times, delayed transfers of care Detailed information on underachieving indicators including trends and direction of travel are included where there are measurable thresholds. Constitution Standards The NHS Constitution includes a set of pledges which the NHS is committed to achieve. The Constitution states that while these are not legally binding, and cannot be guaranteed for everyone all of the time, they express an ambition to improve. In our role as a commissioner of health services, Merton CCG works closely with service providers; assessing how well they are performing against these standards, and identifying where improvements need to be made. The table below summarises the end year position against each of the Constitution standards. Performance Measure 2016/ /18 Referral To Treatment 18 weeks (incomplete pathways) 92.1% 90.1% Diagnostics test waiting time 98.5% 99.1% A&E waiting times 91.6% 88.4% Cancer two weeks 93.0% 92.5% Breast symptoms 2 weeks 94.6% 94.7% Cancer first definitive treatment 31 days 97.0% 96.2% Cancer subsequent treatment 31 days, surgery 97.8% 94.8% Cancer subsequent treatment 31 days, drug treatment 99.7% 100% Cancer subsequent treatment 31 days, radiotherapy 98.6% 96.3% Cancer composite, 62 days first treatment plus rare cancers 84.1% 84.6% Cancer first treatment 62 days, screening 96.8% 89.4% Page 26 of 87

30 Ambulance red 1 8 minute response 86.7% *(Month 9: Dec-17) 80.7% Mixed sex accommodation breaches 0 10 RTT 52 weeks (incomplete pathways) MRSA (PIR assigned) 2 0 C Difficile Improving Access to Psychological Therapies recovery rate 49.8% 47.9% Improving Access to Psychological Therapies entering treatment Improving Access to Psychological Therapies Treatment within 6 weeks Improving Access to Psychological Therapies Treatment within 18 weeks 9.3% 10.64% 86.1% 79.6% 97.5% 98.0% Dementia diagnosis rate 71.1% 71.0% Early Intervention in Psychosis 73.5% 59.7% Referral to Treatment (RTT) The NHS Constitution includes the Referral to Treatment (RTT) operational standards. This includes the target that 92% of patients who have not yet started treatment should have been waiting no more than 18 weeks. The CCG s main provider, St George s University Hospitals NHS Foundation Trust, took the decision to suspend national RTT reporting in June 2016, due to significant concerns about the quality of data. An extensive programme of waiting list data validation has taken place since then. In February 2018, the trust introduced a new patient pathway management system and is working towards the standards required to recommence formal reporting. The trust established a Clinical Harm Review Group. This provides a process for reviewing whether any patients who had long waits experienced harm as a result of their wait. The CCG participates in this group together with NHS England and other CCGs. Page 27 of 87

31 In conjunction with Wandsworth CCG, we commissioned additional capacity for two of the most challenged specialties to treat long-waiting patients. We have introduced new models of patient review and new advice and guidance options to support GPs. The CCG has also been supported the deployment of capacity alerts on the e-referral system, which highlight services with limited capacity and suggest alternative providers with shorter waiting times. The RTT performance issues emphasise the importance of ensuring that, where appropriate, clinical pathways are designed to provide out-of-hospital options which are convenient to access for patients. A&E waiting times Despite not achieving the 95% target throughout the year, St George s University Hospital s NHS Foundation Trust have a number of work streams underway to help improve performance levels as well as provide better outcomes for our patients. The work streams underway include: The Unplanned and Admitted Patient Care programme aims to provide patients with alternatives to emergency admission and to accelerate discharge to reduce overall bed occupancy A new Ambulatory and Acute Assessment pathway has been developed. SAFER bundle is being rolled out to improve patient safety and remove delays for inpatients. Waiting times for cancer treatment There are eight cancer waiting times standards for patients with, or suspected to have cancer. Five of the eight standards are currently being met, with the remaining three measures marginally missing the standards. While the two-week cancer wait standard did not meet target, improved performance levels for the later part of the financial year were seen with this measure consistently remaining above target for each month from August 2017 to March Continuous efforts to maintain and improve cancer performance are being led by the south west London System Leadership Forum (SLF). Ambulance response times London Ambulance Service NHS Trust (LAS) The London Ambulance Service continues to deliver good response times for the residents of Merton with the majority of months during the financial year remaining above the London average. The London Ambulance Service implemented the Ambulance Response Programme (ARP) effective from 1 November The new performance standards associated with ARP will not be reported until April Page 28 of 87

32 Mixed-sex accommodation breaches All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient. There have been ten breaches of this standard for Merton CCG patients where this ambition was not achieved. Each breach is investigated by the relevant Clinical Quality Review Group (CQRG). Patients are advised of the issues at the time of the breach. Infection prevention and control The NHS is committed to reducing the incidence of avoidable harm, including infections from Methicillin-resistant Staphylococcus aureus (MRSA) & Clostridium Difficile (C Difficile). As part of this, infection control has been a high priority for all NHS providers, and each case of MRSA or C Difficile is investigated and reviewed at the relevant provider CQRG. There have been no cases of MRSA for Merton CCG patients. There were 26 cases of C Difficile. Quality Premiums improving health outcomes The Quality Premium (QP) scheme is about rewarding CCGs for improvements in the quality of the services they commission. The scheme also incentivises CCGs to improve patient health outcomes and reduce inequalities in health outcomes and improve access to services. The 2017/18 scheme has been designed to support the delivery of the major priorities for the NHS, as well as local priorities identified for Merton. The CCG Improvement and Assessment Framework is the mechanism by which progress is monitored; therefore the national QP indicators are aligned with those in the CCG Improvement and Assessment Framework. By taking this approach, the scheme focuses on those things already identified as critical to delivering the vision. Better Care Fund (BCF) The Better Care Fund (BCF) is a programme spanning both the NHS and local government which seeks to join-up health and care services, so that people can manage their own health and wellbeing, and live independently in their communities for as long as possible. The BCF has been created to improve the lives of some of the most vulnerable people in our society, placing them at the centre of their care and support, and providing them integrated health and social care services, resulting in an improved experience and better quality of life. Merton s BCF Plan for 2017/18 sought to continue to build on the work already undertaken and strengthen the relationships and collaboration between multiple providers in Merton with a focus on the following key areas: Page 29 of 87

33 Performance Metric Rationale 2017/18 Non-elective admissions (aligned to the Merton Health & Wellbeing Board) Admissions to residential and nursing care homes of older people (65 and over) Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services Delayed transfers of care - delayed bed days (aligned to the Merton Health and Wellbeing Board) Good management of long term conditions requires effective collaboration across health and care system to support people managing conditions and promote swift recovery and reablement after acute illness. There should be shared responsibility across the system so that all parts of the health and care system improve the quality of care and reduce the frequency and necessity for non-elective admissions. Avoiding permanent placements in residential and nursing care homes is a good measure of delaying dependency, and the inclusion of this measure in the BCF framework supports local health and social care services to work together to reduce avoidable admissions. There is strong evidence that reablement services lead to improved outcomes and value for money across the health and social care sectors. Reablement seeks to support people and maximise their level of independence, in order to minimise their need for ongoing support and dependence on public services. Measuring delayed transfers of care is an important marker of the effective joint working of partners, and is a measure of effectiveness of the interface between health and social care services. Minimising delayed transfers of care, enabling timely discharge to the most appropriate care setting and promoting smooth flow through the system for medically optimised patients, is one of the desired outcomes of social care. Quarter 3 (Oct-Dec) 5,333 admissions Quarter 3 (year to date) 68 patients Annual reporting Not yet available Quarter 3 (Oct-Dec) per 100,000 population BCF Performance There were challenges in meeting the Health and Wellbeing Board targets for nonelective admissions during 2017/18. While Quarter 3 (October - December) shows performance close to target and in-line with the previous financial year, year-to-date performance (April December) shows a larger variance and increased activity reported particularly in the earlier periods of the year in comparison with 2016/17 reporting period (as seen in the below graph). The final Year End 2017/18 is not yet available at the time of publishing this report. Page 30 of 87

34 Reablement services provide personal care and help with daily living activities. This is usually in the patient s home, and they are offered to people with disabilities and those who are frail or recovering from an illness or injury. They are intended to encourage people to develop the confidence and skills to carry out these activities themselves and continue to live at home. The reablement performance indicator Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services, is collected on an annual basis based on clients discharged between 1 October and 31 December and of those clients, the number that were still at home 91 days later. At the time of publishing this report the 2017/18 Year End position is not yet available. We are on track to meet the target for permanent admissions of older people to residential and nursing care homes, although the final year end position is not yet available. While there are continued challenges with ensuring the most-timely discharges from hospital and stretching targets were set for 2017/18, Merton s overall performance has been better than the London average throughout winter with the lowest level in London for social care delays in January The number of delayed days attributable to the NHS has also improved and Merton s performance is in the best quartile nationally. Improvement and Assessment Framework (IAF) Our performance as a clinical commissioning group is monitored by NHS England through the CCG IAF which assesses us against four domains: Better Health; Better Care; Sustainability and Leadership The CCG is given an annual assessment rating against the IAF based upon performance of key performance indicators (KPIs) during 2017/18 covering Quality, Page 31 of 87

35 Constitutional Targets, Effective Leadership and Commissioning and Financial Sustainability. We anticipate our 2017/18 assessment results will be published in June Key IAF 2017/18 highlights at time of publishing We are achieving good results (best quartile nationally) in the areas of: appropriate prescribing of antibiotics in primary care; provision of high quality care for adult social care; reducing delayed transfers of care attributable to NHS; and increasing the percentage of the GP-registered population who are able to benefit from extended access to pre-bookable appointments. Additionally, under the clinical priority areas of mental health, cancer, dementia, diabetes, learning disabilities and maternity, the CCG performance in these areas at the time of publishing, shows that one-year survival from all cancers; people with an urgent GP referral having first treatment for cancer within 62 days of referral; reducing the reliance of specialist inpatient care for people with a learning disability and/or autism, continued prioritisation of action to reduce smoking at delivery (maternal/pregnancy) and choices in maternity services are all achieving results within the best quartile nationally. The CCG estimated diagnosis rate for people with dementia aged 65 is currently 70.4% placing Merton above the national 66.7% benchmark for this measure. Performance information for diabetes measures for 2017/18 at the time of publishing this report are not yet available for comment and are expected to be published by NHS England in June Financial Performance Overview Our main financial objective is the delivery of financial performance against our allocation. Performance against this allocation is monitored throughout the year, allowing prompt action to be taken to alleviate any particular financial pressures that should arise. In all but exceptional cases, CCGs are set a target to achieve a surplus against their annual allocation (known as their Revenue Resource Limit or RRL). This ensures that the NHS as a whole has a degree of flexibility for unforeseen events. In 2017/18 Merton CCG was set a target of a break-even position. The year has been challenging for us financially, due to increasing cost pressures, driven by increased demand for health services attributable to demographic growth and an increasing prevalence of long term health conditions among our population. Page 32 of 87

36 Despite this, we have achieved the required breakeven position for the year against our overall budget of 282.7m. Expenditure In 2017/18, we spent 282.7m on the commissioning and provision of healthcare services as shown in the chart below: The CCG s largest providers of healthcare are: St George's University Hospitals NHS Foundation Trust (acute hospital and community services), Epsom and St Helier University Hospitals NHS Trust (acute hospital services), South West London and St George's Mental Health NHS Trust (mental health services), Central London Community Healthcare NHS Trust (adult community services). Release of the 0.5% non-recurrent reserve As set out in the 2017/18 NHS Planning Guidance, CCGs were required to hold a 0.5% reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. In line with national guidance, Merton CCG has released its 0.5% reserve to the bottom line. This additional surplus has been offset against other cost pressures from the current financial year, in particular relating to the availability and price of pharmacy stocks. Page 33 of 87