City and Hackney Clinical Commissioning Forum Thursday 2

City and Hackney Clinical Commissioning Forum Thursday 2 nd November 2017 St Joseph’s Hospice

1. Agenda Items Led by Welcome Clare Highton 2. NHS Counter Fraud Zed Eagling-Rana 3. A&E Well Family Service Melissa Britton 4. Prevention Commissioning Intentions Clare Highton 5. Planned Care Commissioning Intentions TBC 6. AAA Screening Harpaul Flora

Countering fraud and bribery Zed Eagling-Rana Senior Consultant Forensic and Fraud Risk Services

Session Objectives To continue to develop and increase your understanding of the Fraud Act 2006 To continue to develop and increase your understanding of the Bribery Act 2010 To inform you of your roles and responsibilities as an individual To provide you with reporting line information

Fraud Act 2006 Abuse of Position Failure to disclose False Representation

The Bribery Act 2010 Receive a bribe The second general offence is referred to as passive bribery and constitutes requesting, agreeing to receive or the accepting of a bribe Give a bribe This first general offence is referred to as active bribery and this constitutes the offering, promising or giving of a bribe Negligently failing to prevent a bribe A commercial organisation will be liable to prosecution if a person associated with it, bribes another person intending to obtain, or retain business, or an advantage, in the conduct of business for that organisation The Bribery Act 2010 Bribing a foreign public official There is also a specific offence of bribing a foreign public official

Penalties: individual and corporate • Maximum of 10 years imprisonment • Unlimited fine • Potential risk of disbarment from EU tendering • Directors struck off • Massive reputational damage

Bribery Act: gifts and hospitality What should be considered • Does the ‘event’ involve providing information about the product or service (better if it does justification) • Who benefits? (the inclusion of other family members will require greater justification) • Is the level of expenditure appropriate? (lavish expenditure will be harder to justify)

Conflicts of Interest – Ethical decision making Transparency - Am I happy to make my decision public, especially to people affected by it? Transparency Effect - Have I fully considered any harmful effects of my decision and how to avoid them? Effect Fairness - would my decision be considered fair for everyone affected by it?

Case Study Mental health manager and GP sentenced for £ 153, 000 fraud • • Lisa Hill and Dr Ian Walton, two respected mental health professionals Hill was a Senior Commissioning Manager for Mental Health and a registered nurse, while Walton was a GP and clinical lead for Mental Health. Created training businesses for financial gain Both pleaded guilty to Fraud (Contrary to Section 2 of the Fraud Act 2006) for defrauding their former employer, Sandwell and West Birmingham Clinical Commissioning Group (SWBCCG), of £ 153, 600, both sentenced to two years’ imprisonment, suspended for two years, plus 200 hours of unpaid work. Under a POCA order made at the court, they must pay back the full amount of £ 153, 600 in compensation (half each) within three months plus £ 7, 500 each in prosecution costs

What can you do? DO DO NOT þ Tell someone! ý Confront the individual with your suspicions. þ Make a note of your concerns! þ Note all relevant details, what was said, the date time and names of all parties involved. þ Keep a record or copy any documentation that arouses your suspicion. ý Try to investigate the matter yourself. ý Contact the police directly. ý Convey your suspicions to anyone other than those with proper authority to investigate. ý Do nothing!

Reporting concerns The Counter Fraud Team: Zed Eagling-Rana : 07436 268726 : zed. eagling-rana@rsmuk. com Gemma Higginson : 07800 718 680 : gemma. higginson@rsmuk. com • • • Joint Chief Finance Officers: Sunil Thakkar & Philippa Lowe National Fraud Reporting Line : 0800 028 40 60 Online reporting form at: www. reportnhsfraud. nhs. uk • Public Concern at Work: 020 7404 6609 Please also refer to the CCG’s anti-fraud, bribery and conflicts of interest policies

Thank you for your time and attention

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Building stronger families NAME OF PROJECT OR TOPIC HERE The A&E Well Family Service The A&E Well. Family Service Melissa Britton A&E Well Family Coordinator, Family Action 16

Building stronger families ABOUT FAMILY ACTION • A national, well established and trusted family charity • Supports over 45, 000 vulnerable families a year to build stronger futures ADULT CHILDREN ANDMENTAL HEALTH EARLY YEARS FAMILIES AND WELLBEING GRANTS 17

What our model is based on The Well. Family service has been operating in GP surgeries in Hackney for 20 years and has proved to be highly successful: • 95% of GPs found the Well. Family Service very or extremely useful for their patients • 90% of GPs using the service said Well. Family reduced repeat or inappropriate visits • One patient sample shows a 70% reduction in unnecessary GP visits • 25% of people supported by the Well. Family service had a decreased reliance on mental health services. We hope to replicate these results within Homerton A&E Department. Building stronger families 18

Our aims: • To reduce the number of repeat attenders to Homerton A&E. • To act as a preventative service by teaching clients the skills they need to cope when faced with adversity. • To reduce the reliance of service users upon A&E services. • To reduce the workload of GPs, staff at Homerton hospital, the out of hours services and emergency services. Building stronger families 19

How do we work? - During the initial meeting we will work with the client to identify the reasons why they attend A&E and set various goals aimed at tackling these issues. - Clients will receive 6 -8 face to face sessions where they are supported to work towards achieving their goals. Interventions used: - Supportive counselling. - Practical support and guidance when tackling social difficulties. - Confidence building. - Promoting social inclusion e. g. volunteering opportunities, leisure activities or support to return to work. - Sign posting and referring clients on to long term community support services. Building stronger families 20

Who do we support? The service provides support to those who have presented to A&E or have a history of attending A&E for inappropriate reasons. We provide support to individuals (aged 16+), couples and families facing the following difficulties: - Low to moderate mental health issues e. g. depression, anxiety, posttraumatic stress disorder, self-harm, or eating disorders. - Housing/financial difficulties. - Bereavement. - Relationship difficulties. - Social isolation. - Exam stress. - Drug/alcohol dependency. - Sexual & physical abuse. - Harm practices such as FGM. - Carer stress. - Domestic violence. - Social isolation. Building stronger families 21

Who can refer? • Staff from any department from within Homerton Hospital. • GPs who are aware of patients within their practice who have attended A&E for an inappropriate reason or have a history of doing so. • Community services who have clients that repeatedly attend A&E for inappropriate reasons. • The client can self-refer Please note that non-Hackney residents are also suitable for referral. To refer please complete a copy of our referral form and submit to a&ewellfamilyreferrals@family-action. org. uk or contact coordinator Melissa Britton on melissa. britton: family-action. org. uk Building stronger families 22

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Prevention Commissioning Intentions GP Confed Contract 2018/19 Potential indicators for inclusion / revision in the Long Term Conditions Contract

Prevalence and case-finding: Replace existing hypertension prevalence measure with a more targeted approach Include COPD and Asthma prevalence measures via accredited spirometry Introduce a case finding tool e. g. GRASP / APL to identify patients with Atrial Fibrillation and optimise treatment Replacement of pulse checking with use of mobile ECGs for AF detection in some practices Reviews and screening: Include AF template including exception reporting in LTC annual reviews Incorporate cancer as an LTC e. g. via time to talk Include SMI as an LTC for referral to smoking cessation Consider including HIV screening

Treatment targets: Reduce post-stroke BP target to 130/80 Review and consolidate statin targets, incentivise HI statin Introduce triple treatment target for people with AF: BP; anticoagulation; high intensity statin Other: Exclude FHV extension patients from access to Time to talk (likely overlap of these groups otherwise) Link social prescribing, group consultations and quality of care plans Consider smoking quit rate Consider introducing an indicator to monitor adherence in patients on NOACs Consider review of adherence to CVD medicines (specialist pharmacy)

Primary Care at Scale In 2018/19 GP Confed Contracts will be amalgamated and payment process made simpler i. e. more population based pricing and less item of service; The single contract will define the outcomes for the service and allow the GP Confed flexibility to decide how and where the outcomes are achieved – this should be aligned to the neighbourhood model and within a fixed budget; The GP Forward View supports primary care working at scale and achieving 100% population coverage with primary care services in a sustainable way. Possible implications for LTC Contact More flexibility for practices to work together with other practices in the neighbourhood to achieve indicators for the whole registered population; Over time, LTC indicators can be amalgamated into over-arching outcomes; The single contract will be for 7 years and outcomes can change over the duration of the contract.

City and Hackney Diabetic Foot Amputations 2013 -2016 2010 -2013 Area Annual minor amputation rate per 10 000 adults with diabetes 10. 6 24. 0 34. 6 16. 4 34. 5 50. 9 8. 1 19. 8 27. 5 7. 2 20. 8 27. 5 9. 1 19. 5 28. 6 8. 1 21. 0 29. 1 NHS City and Hackney CCG London CCGs Average All England CCGs average 2013 -2016 2010 -2013 Major 33 26 Minor 90 47 Annual total amputation rate per 10 000 adults with diabetes Annual major Annual minor Annual total amputation rate per 10 000 adults with diabetes Annual major amputation rate per 10 000 adults with diabetes Total number 123 73

Plan • Root Cause Analysis (data difficult to obtain from RLH) • Diabetes UK “Putting Feet First” campaign – encouraging patients to get their feet checked • City and Hackney remain the best in the UK at performing diabetic foot checks (96. 95%) • Other suggestions?

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Planned Care Workstream Summary Outpatient Transformation: Working with the Homerton to transform our model of outpatient care locally by: • Preventing unwarranted first attendance/referral- advice and guidance, MDT/GP discussion and feedback, triage to community/primary care/other pathways, GP Education/Training, Patient Self. Management • Reducing unnecessary face-to-face follow ups- patient centred tools, enable self-management, virtual/telephone/primary care follow up • Optimising what should be done in secondary care and by whom- links across specialties to avoid/reduce internal consultant to consultant referrals; e-consultation in patient home/GP premises; group consultations where similar patients are consulted in a group; extended scope practitioners/advanced nurse practitioners/specialist nurse for targeted follow up allowing consultants to focus on complex/surgical work Enablers: • e-RS/Follow up arrangements to standardize across specialties (less clinician variation) • Advice and Guidance – First line for GPs and where consultants can shape the next steps to the most appropriate diagnostic/service pathways • Technology – Appointment system updates, Skype FU/Virtual MDT review/Virtual review for FU • MDT review for complex multi issue patients • Triage systems to review referrals for community/other services instead of secondary care

Improving Cancer Care: • Increasing Cancers detected earlier by supporting primary care with education and access to diagnostics tests, decision support tools and audits • Improving screening uptake by working with Prevention Workstream on every contact counts regarding reducing risk factors and behaviours in local population • Supporting patient recovery moving towards a focus on cancer as a LTC and opportunity for increasing time to talk support from GP Confederation • Bereavement Services- plan for continued support of Bereavement services at St. Joseph’s Hospice Anti-Coagulation: • Implementation of the anti-coagulation service with the GP Confederation Continuing Healthcare and Residential Care: • Improve delivery of continuing healthcare locally by implementing recommendations from recent review • Review opportunities within mental health pathways for increased recovery and step-down for patients in existing placements, particularly those outside of borough • Review arrangements for people with learning disabilities in receipt of health and social care packages • Consider opportunities for further integration of CHC within LA arrangements for brokerage and for jointly planning against known gaps in local provision (e. g. nursing care, intermediate care) Obesity Pathway: • Working with Prevention Workstream on new obesity pathway including surgical options

Other Planned Care service changes: • We plan to commission alternative providers for abortion services. Presently we only commission the Homerton and alternative providers will allow more choice and enable women to seek services outside of the borough if needed. • New Any Qualified Providers (AQP) will be commissioned for providing GP direct access hearing testing and fitting of hearing aids from April 2018. • Community ENT Service: looking to develop some paediatric ENT services • Teledermatology: Pilot was completed successfully; now pursuing how a service can be implemented across all quadrants, implementing key lessons learnt which may require more resources allocated to provide quadrant hubs. • e-RS Advice and Guidance services to continue to be rolled out covering 75% of services by end of 18/19. • 100% e-Referrals (choose and book) are to be implemented by Oct 2018

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NEL AAA Screening program: City & hackney CCG Mr H S Flora MSc, MRCS (Lon), FRCS(Gen surg) Consultant Vascular Surgeon Clinical Director AAA screening Programme Clinical Director for Vascular Surgery Yaa Baffour-Awuah AAA Screening Programme Manager Prabhjot Batth AAA screening/Vascular Nurse Practitioner

Background to AAA screening program • MASS trial • • AAA related mortality ↓ 53% QALY £ 36, 000 to £ 10, 000 after 10 years 3, 000 lives can be saved per year Agreed in principle by the NSC and Secretary of State for Health, to be rolled out in 4 phases between 2009 and 2013. • North East London rolled out from April 2013 • Single aortic US for all 65 yr old males • • • Reliably visualises Aorta in 99% of people. It is painless and non-invasive It is cost-effective

Screening uptake 2016 -17? North East London • Eligible population- 6325 • Screened- 5007 (79. 1%) City & Hackney CCG • Eligible population- 778 + 11 self referral • Men on surveillance-134 • Screened-543 (69. 7%) • Men on surveillance- 14 • Men referred for surgery- 8 • Men referred for surgery-02

City & Hackney CCGs GP Surgeries Uptake 2016/17 City and Hackney Average= 69% National Average =75%

Screening Sites Current Clinics De Beauvoir Surgery 30 Hertford Road N 1 5 QT The Hill Medical Practice 2 a Northfield Road N 16 5 RN The Neaman Practice 15 Half Moon Ct EC 1 A 7 HF The Nightingale Practice 10 Kenninghall Road E 5 8 BY Clinic sites required (Due to poor uptake) N 16, N 15 – St Anne’s Hospital E 5 – Homerton Hospital N 1, N 4, E 8, E 9, N 18, EN 3, N 18 (Tottenham, Islington, Clapton, Enfield, Hackney)

How to improve uptake? • Attend PTI meetings to engage with GPs • Campaigning- at Supermarkets, Boots, sent packs to churches, Mosque, Sports Centres/local, Gyms, Women’s Advisory group, GP practice and Golf Clubs etc. • Feedback forms from patients • Looking into Barts Health website and social media to promote AAA screening

Sector wide GP Engagement? • To be aware of the programme in order to answer patient/colleague queries: • GPs will not need to do anything specifically for this programme other than be aware of the programme: • Attend update meetings to keep abreast of developments (we will send out details as they become available) • To encourage patients to attend screening (opportunistically, as appropriate) • Recommend screening sites/locations in the City & hackney CCG. • To alert us of any issues and where/if possible help us overcome these (eg non engagement of particular groups/DNAs)

Thank You harpaul. flora@bartshealth. nhs. uk 07711670623 Secretary: Jacquie Asquith Tel: 02035941204 SOPD- Tuesday Am Yaa. baffour-awuah@bartshealth. nhs. uk Tel: 02035946405

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Venue Change December’s CCF will be held at West Reservoir 4 4