Panel Report

1. Panel Report NHS North East Essex Updated 03.02.09

2. Overview • First, the panel thanks NHS North East Essex PCT for participating in this round of assessments for World Class Commissioning. • The panel asks the PCT to accept this report in the spirit in which it is intended: a support tool on the journey to world class commissioning as a considered perception of the organisation’s strengths and weaknesses based on the insight the PCT itself gave the panel into its commissioning approach. • During our review of NHS North East Essex, the panel developed an overall impression of the organisation, which is that the PCT is in a very strong position to become a world class commissioner, but must recognise that its strategic plan must deliver a clear roadmap to that goal. • The PCT has a number of strengths that it should build on. First, the PCT has a strong Board that is passionate about improving health for the people in NE Essex. and a very competent executive team that is able to deliver the PCT’s chosen aims. Second, the PCT has a track record of delivery, which is reflected in the competency ratings for contracting and performance management. Third, the PCT has a strong clinical orientation at the corporate level, which is reflected in the PCT’ s planning. Lastly, the panel was also impressed by the work the PCT has done with the LA on identifying the critical health needs of the population. • The panel feels that the results from the competencies self-assessments mostly match the panel’s perceptions during the assurance test. • The panel identified 3 main recommendations that the PCT will need to consider as the PCT positions itself to drive transformation of health and healthcare in North East Essex.

3. Commentary (1/2) • The panel identifies 3 major areas for consideration by the PCT at this stage on its journey: • 1. Headline: The PCT must tell its story in a way that is understandable to its public and stakeholders • Observation: The PCT is a fairly new organization and must make sure that it establishes itself prominently in the public eye and communicates clearly what it is trying to achieve in the next 5 years. The panel was struggling to see the ‘big ticket items’ that the PCT promises to deliver. The PCT has a lot of good ideas amongst its nine commitments in the strategic plan and 64 initiatives. The panel found it difficult to identify a consistent theme and did not see an “elevator pitch“. The panel is concerned that partners, the community, and clinicians would struggle to see these. The PCT agrees that this is an area for further development. • Recommendation: The panel recommends that the PCT shortens the strategic plan significantly, distilling the message to the core elements of what the PCT is aiming to achieve and to which the public should hold them to account. • 2. Headline: The PCT must refocus its strategic plan • Observation: One of the uses of the strategic plan is to communicate messages to different audiences: to the public, about what the PCT is aiming to do; to providers, including market opportunities for them; and to the clinical community. The panel felt that the SP, as it stands today, does not hold together as a logical, coherent document, and so fails in its purpose as a communication vehicle. • Recommendation: The panel recommends a major overhaul of the strategic plan. Elements that should be considered are (1) the top line story, (2) the hierarchy of the top line objectives, and within that the the number of initiatives that deliver those objectives -today, the panel is not sure whether the 8 clinical areas are of equal importance to the PCT. The PCT’s priorities should drive the structure of the plan. (3) SMART objectives and initiatives, including metrics, baselines, targets at a specific point in time, and a trajectory. With that, the Board will be able to know if the PCT has successfully delivered the strategy. The PCT should also distinguish between the top line objectives and targets, which are communicated externally, and the internal indicators that the PCT needs to measure progress. Finally, the PCT should work through the impact of individual initiatives. In the current SP, the panel observed a mix of very ambitious targets and areas where there appeared to be very limited improvement planned with no clear rationale (e.g., childhood obesity is very ambitious whereas the smoking target is less ambitious).

4. Commentary (2/2) • 3. Headline: The PCT must underpin the strategy with a coherent and aligned strategic financial plan • Observation: The PCT is in a strong financial position. It has a good track record of financial delivery, expected income growth for the next years is one of highest in the EoE, and it has deposits with the SHA. The panel felt that the current financial plan is not yet a strategic investment plan. First, the investment analysis must be thought through and completed, as there is still a substantial amount of unallocated investment. These proposed investments must match the PCT’s priorities in the strategic plan; currently this relationship is not clear. Second, the PCT must make sure that it future-proofs the financial plan, as there are many uncertainties in the system. To do that, the PCT should prioritize investments: Which are the ones that the PCT will hold at the heart of the strategy? Which initiatives do not require net investments? (e.g., end of life care, long term conditions); and the PCT should rigorously prioritize those initiatives that require a net investment. Third, the PCT must think through productivity opportunities in detail with the same rigour as investment plans. Fourth, the PCT must define and quantify areas for disinvestment. • Recommendation: The PCT must complete the financial planning, write a strategic financial plan and future-proof its financial plan as described above.

5. OUTCOMES COMPETENCIES GOVERNANCE Current • Level 4 Previous • 100th percentile • 0 National Average 100 • Level 1 Strategic Priority PCT rate of change, % M F • Local leader of NHS • Strategy 0.4 1. Life expectancy M M F A 0.3 National F • Collaborates with partners 2. Health Inequalities n/a • Patient and public engagement 4. Smoking quitters -2.0 5. Clostridium Difficile infection rate 24.3 • Clinical leadership • Finance A 8. GP access survey n/a • Assess needs Regional 9. Dental access n/a • Prioritisation 10. Patient experience* n/a • Stimulates provision 11. Childhood obesity n/a • Innovation • Board G 12. MMR immunis-ation by 2nd birthday -1.1 • Procurement and contracting Local 13. Diabetes controlled blood sugar 11.6 • Performance management 14. CHD controlled BP 2.4 • Potential for improvement • The PCT has a strong history of performance, with a strong and effective Board. The panel has every confidence that the PCT will move forward and reach level 3 in a year’s time, but it must focus its strategy for the benefit to the PCT, public and its partners.

6. 55.0 • National average Outcomes • PCT score • Life expectancy: Males • Years • Life expectancy: Females • Years • National • Health inequalities • Multiple deprivation score • GP Access and Responsiveness • % of respondents satisfied • Dental Access • % accessing services • Panel observations on outcomes: The panel observed that the PCT • robustly explained the rationale for its choice of outcome measures • had set stretch targets for most outcome measures, but had not articulated them clearly in the SP • C.difficile infection rates • Per 1,000 patients aged >65 yrs • Smoking quitters • Per 100,000 population aged >16 yrs • Regional • Childhood obesity • Prevalence % • Recommendations: The PCT should ensure that • selected outcomes reflect core top priorities (i.e health inequalities, mental health and children) • each selected outcome has clear metrics, a recorded baseline, a stretch target, and a trajectory to achieve stretch targets • top line outcome objectives are more prominently reflected in the SP • Patient Experience* • % of respondents satisfied • Long Term Conditions • Emergency admissions as a % of expected • Long Term Conditions • % of those registered on the 19 LTC QOF • registers with a personal health plan • Diabetes controlled blood sugar • % diabetic patients with HbA1c < 7.5 mmol/l • Stroke admissions receiving physiotherapy • within 72 hours • % of stroke admissions • Local • CHD controlled cholesterol • % CHD patients with cholesterol < 5 mmol/l • MMR immunisation: 2nd birthday • % children receiving MMR immunisation

7. 55.0 • PCT Self-Assessment • Topline introduction • The panel agreed with 19 of the PCT’s 30 self-assessment ratings. However, the panel found it necessary to adjust the remaining ratings. • The most important areas to highlight are areas with the largest discrepancies between the self-assessment and 6, 7, 8, and 9 • Level • 1 • Level • 2 • Level • 3 • Level • 4 • Competency • 1. Locally lead the NHS • 2. Work with community • partners • 3. Engage with public • and patients • 4. Collaborate with • clinicians • 5. Manage knowledge • and assess needs • 6. Prioritise investment • 7. Stimulate market • 8. Promote improvement • and innovation • 9. Secure procurement • skills • 10. Manage the local • health system • PCT's Self Assessment Overview - Competencies • Uncalibrated Panel Assessment

8. PCT's Self Assessment Competency 1: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Are recognised as the local leader of the NHS • Reputation as the ‘local leader of the NHS’ • Reputation as a change leader for local organisations • Position as the local healthcare employer of choice • Rationale for scoring: The panel agrees with the PCT’s self assessment • Key stakeholders agree that the PCT is the local leader of the NHS and participates in the local agenda with a key stakeholder survey score of 5.2 against the SHA average of 4.8. There were no written comments. There is evidence to suggest that the PCT has an understanding of its current and intended reputation with strategies in place to address this, including a rebranding plan. Two of the five priorities set out in the communications strategy directly relate to the PCT’s reputation as the local leader of the NH. There is evidence that the PCT participates in the local health agenda, with clear accountability by the PCT for targets set out in the LAAs for both Colchester and Essex. (e.g., Director of Public Health at PCT is the lead for ‘Community well being and older people’). There is evidence to suggest that the local population agrees that the local NHS is improving services with a perception survey result of 53% of respondents somewhat agreed that ‘my local NHS is improving services for people like me’ against the average SHA score of 54%. The PCT gave examples of being a key driver in the development of the JSNA and LAA. • There is evidence to suggest that key stakeholders agree that the PCT significantly influences their decisions and actions with a survey result of 4.9 against the SHA average of 4.7. Overall, written feedback was positive. There was evidence of good connections between the JSNA and LAA (e.g., children and young people). The PCT demonstrated involvement in sustainable community strategies, but appeared to be a contributor than a real lead in LAA issues. • There is evidence to suggest that the employment offer to current staff and potential recruits is an area for improvement. 46% of respondents agree that they have received the training and development that has been identified in the plan (vs. a 50% national average). 59% of respondents agree that managers have supported them on training, learning and development (vs. a 61% national average). The PCT acknowledged capacity gaps in some areas, has developed a high level plan and is putting arrangements in place to tackle that (e.g., director of Commercial Services) Recommendations going forward: Recommendation: improve leadership on engagement and partnership mechanisms to achieve a better public perception rating and influence on partners

9. PCT's Self Assessment Competency 2: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities • Creation of Local Area Agreement based on joint needs • Ability to conduct constructive partnerships • Reputation as an active and effective partner • Rationale for scoring: • The panel agrees with the PCT’s self assessment • An LAA was developed by the Essex LA and the Essex Partnership, which is made up of all the Essex PCTs and a range of public, private and third sector organisations. There is evidence to suggest that the LAA agreements are based on joint needs assessed by the JSNA, as the LAA health priorities and targets are consistent with prioritised health and social care needs identified in the JSNA. (e.g., improvement of childhood obesity rates, mental health and smoking). There is evidence that the PCT and the LA are independently accountable for LAA targets, with individual directors from the Colchester and Essex LAs and the Public Health Department of the PCT as named target leads. The LAA had a focus on children and older people, with improvement stated in intermediate care services and involvement in the personalization agenda. There is reference to a community well-being centre and connected care services. • There is evidence to suggest that stakeholders agree that the PCT proactively engages their organisation to inform and drive strategy with a score of 5.1 vs. 4.4 SHA average. Written responses confirmed the positive opinion of key stakeholders. Strength in partnership work is evident in the Health and Social Care award won by the PCT for partnership work around youth health trainers in schools. There is evidence that the PCT has worked with partners to produce JSNA. The PCT has produced an Annual Public Health Report & Needs Assessment focusing on the needs specific to the local population served by North East Essex, in addition to the JSNA which covers the Essex County overall. There is evidence to suggest that the role of the PCT in the delivery of local targets is effective. There is some evidence of partnership working on adult social care, but in terms of joint commissioning strategy there was little evidence and there are no Joint Commissioning Posts in place. • There is evidence to suggest that key stakeholders agree that the PCT is an effective partner in delivering health objectives with a survey score of 4.9 vs. 4.7. For both the Essex and Colchester LAAs key targets are in place for 2010/11. Responses to the PBC survey indicated that 44% have not agreed a commissioning plan with the PCT, which was higher than the SHA and national averages (of 38% and 36% respectively). However, the PCT explained that they had significantly improved on PBC commissioning plans (81% have agreed plans). Recommendations going forward: The PCT should enhance joint commissioning arrangements with the county council (e.g., shared posts and joint commissioning strategies), and move towards a joint commissioning unit

10. PCT's Self Assessment Competency 3: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health • Influence on local health opinions and aspirations • Public and patient engagement • Delivery of patient satisfaction • Rationale for scoring: • The PCT has a communications strategy in place which is linked to the strategic commitments and competencies, with a clear vision to ‘support the repositioning of the PCT as the leader of the local NHS and the champion of healthcare consumers’. There is a clear commitment to invest in social market, communication and better research, however this has not been implemented yet. There is evidence of an intention to actively promote health and wellbeing in innovative ways (e.g., KISS FM, commissioned to deliver health messages around dangers of smoking, drink awareness and safe sex, as well as other social marketing around childhood and flu immunisation). Feedback from key stakeholders indicate that stakeholders somewhat agree that the PCT proactively shapes local health opinions, with thePCT scoring 4.2 vs. 4.1 SHA average. Written responses were mixed, with some indicating that social marketing is weak across all sectors with little evidence of influence on local health opinions. • There is evidence to suggest that the PCT has a strategy in place that actively and continuously engages patients and the public in the commissioning and redesign of services, and that the PCT actively listens and responds to public and patients (e.g., Patient Commissioning Forums were established in January 2007). There is also evidence that the PCT engages with local engagement networks. LINKs is in the process of being established. Responses to the public perception survey suggest a lack of confidence of local people in their ability to influence local health care services. Only 21% of respondents agreed that they could influence decisions affecting the NHS services in their area, the fourth lowest score in the EoE. The PCT explained that it has been doing work on this matter (e.g., public and patients invited to appeal and board meetings) • There is evidence to suggest that the PCT actively reviews trends in patient feedback, and providers are required to provide patient experience data. There is evidence to suggest that the PCT uses views and trends highlighted by the PALS service, complaints, surveys, Patient Commissioning Forums and the Patient and Public Involvement Panel. The PCT also plans to roll out Local Incentive Schemes (currently in place for the acute provider) to providers in other sectors along with a pilot of ‘Net Builder’ patient satisfaction tracker systems in a wide range of providers. There is evidence that the local population agrees that the NHS actively promotes health and wellbeing in the area. Public perception survey indicates that 76% of respondents agree that the ‘NHS helps improve the health and wellbeing of me and my family’ which is similar to the EoE average. 87% of complaints received by the PCT are resolved within 25 working days Recommendations going forward: The PCT is heading in the right direction and should continue with its current plans

11. PCT's Self Assessment Competency 4: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Lead continuous and meaningful engagement of all clinicians to inform strategy and drive quality, service design and resource utilisation • Clinical engagement • Dissemination of information to support clinical decision making • Reputation as an active and effective partner • Rationale for scoring: • The panel found strong evidence that the PCT works with a range of clinicians, demonstrates active clinical leadership, and has established strong links between primary and secondary care. There is evidence that clinicians outside the PEC have made contributions to the SP (e.g., LT conditions strategic initiative developed with acute and primary care clinicians). The PCT explained that clinicians outside the PEC are involved through multiple methods (e.g., In diabetes, 80 nurses and doctors were involved, and acute and social were involved for DN specification). The PEC has a multi-professional membership, including PBC leads and nurses. There is also evidence to suggest that the PCT engages with a broad range of clinical groups (e.g., a pilot for clopidrogrel delivery in primary care involved ambulance personnel, an acute cardiac consultant, a pharmacist and the nursing and cardiac networks). There is evidence of a clear devolution of autonomy to clinicians. The PBC has been involved in driving forward initiatives (e.g., Step Care Model approach to improving community services). • The CS and self-assessment by the PCT also mentions ‘monthly information packs’ for PBC groups. Responses to the PBC survey indicate that PBC clinicians rate the quality or frequency of information lower than the national average. 25% rated the quality of information received by the PCT as ‘very good’ or ‘fairly good’ which was lower than the national average of 35%. Only 19% rated the frequency of information as ‘very good’ or ‘fairly good’ compared to a national average of 35% • The PCT described a monthly process sending data to PBC. The PCT is also providing support through educational programmes in Excel and SOLIS, and have provided evidence that PBC scores have improved. Responses to the key stakeholder survey indicate that key stakeholders somewhat agree that the PCT proactively engages clinicians to inform and drive strategy with a survey result of 4.3 against the SHA average of 4.2. Written responses were mixed • with some comments along the lines of ‘It does in general but on some developments their administrators do not involve the • clinicians nearly enough’. Recommendations going forward: The PCT should establish clinical benchmarking in quality reports and continue their communication efforts so that stakeholders recognize that clinicians are engaged in service redesign

12. PCT's Self Assessment Competency 5: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements • Analytical skills and insights • Understanding of health needs trends • Use of health needs benchmarks • Rationale for scoring: • There is evidence to suggest that the PCT conducts regular needs assessments which result in clear conclusions and recommendations. The PCT applies a consistent methodology to identify and prioritize major health needs in the JSNA and also went beyond JSNA. JSNAs for Essex, Colchester and Tendring are in place identifying key health and social needs (both current and future) and the PCT has in addition produced an Annual Public Health Report. There is evidence to suggest that the PCT has a methodology in place to assess gaps in care across acute and primary care providers (e.g., the SP provides an in-depth analysis of the variation across GP practices in prescribing, disease prevalence and the GP need score, which indicates that practices with deprived populations tend to have the highest list sizes). The PCT does not have a systematic way to analyse progress sufficiently (e.g., diabetes) • The PCT demonstrates deep understanding of the major health needs of its local population, by providing a clear and succinct summary in the SP of conclusions drawn from the Health Needs Assessment conducted on NE Essex and the JSNA. The PCT also provides an overview of the key challenges faced by its local population in the SP, with clear benchmarking and analysis of trends in health needs. The PCT described how it assess in-depth unmet needs by ward/locality/MSOAs and targets services specifically. There is evidence to suggest that the PCT has gathered insights from the local population and clinicians to supplement the JSNA. • The JSNAs and APHR provide extensive benchmarking against national and SHA averages, with consistent comparison of performance across PCTs within Essex and the two LAs within NE Essex. LE, mortality rates, LT conditions and lifestyle choices are all benchmarked against national and SHA averages, and compared across LAs. The PCT has provided an analysis of the heterogeneity within PC in NE Essex on a wide range of metrics, such as obesity and smoking prevalence by GP practice. The LAA and SP set out targets against a number of metrics but do not systematically benchmark against national performance levels (e.g., smoking). There is some evidence to suggest that the PCT disseminates needs assessments (e.g., NE Essex HNA published on the PCT’s website, along with the SP). There is evidence that the PCT effectively shares data with providers and the public. Recommendations going forward: The PCT should continue to analyse progress in reducing health need gaps, systematically benchmark itself against national targets, and develop plans to improved performance on each target (including stretch targets)

13. PCT's Self Assessment Competency 6: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Prioritise investment according to local needs, service requirements and the values of the NHS • Predictive modelling skills and insights • Prioritisation of investment to improve population’s health • Incorporation of priorities into strategic investment plan • Rationale for scoring: • The PCT demonstrated modelling around activity. Although self-assessment by the PCT indicates that they have used best/worst case scenarios in financial planning, the financial section of the SP mentions scenario planning in reference to growth funds, but no further detail is provided. There is no evidence of sensitivity analysis by disease area. • The PCT does not outline the prioritisation criteria in submitted documents (including the SP) used in prioritising investment. The panel noted that modelling skills are developed, but that there is limited development of explicit prioritization criteria for new investments. Disinvestments have also not yet been quantified and identified in strategic plan. There is evidence of consultation with PEC clinicians when evaluating new investment proposals. • The SP states that a ‘full gateway process’ was introduced in 2007/08 to ensure that investment proposals are aligned with PCT priorities and objectives. This requires the completion of a full business case, with defined outputs, risks, sustainability and impact on providers. All investments are then tracked through to post implementation review to assess the value added. However, the process described is suggestive of a process for approving new business plans and investments, as opposed to real prioritisation of investment to target areas of greatest need and disinvestments. It is also unclear to what extent this prioritisation process has been effectively applied across strategic initiatives outlined in the SP. The PCT explained that they have not yet made decisions on disinvestments and recognized that more work needs to be done. Recommendations going forward: The PCT should establish more transparent and quantified criteria for prioritising investment, and should identify disinvestments required to make the plan future-proof

14. PCT's Self Assessment Competency 7: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes • Knowledge of current and future provider capacity • Alignment of provider capacity with health needs projections • Creation of effective choices for patients • Rationale for scoring: • The PCT provides a very high level overview of the provider landscape, which lacks detail and comprehensive analysis of the cost and quality of providers to ensure that services are in place to meet the needs of providers. The PCT outlines the number of GPs in the area, as well as access times to primary care facilities, and a comparison across GP practices of performance against certain outcome metrics (such as obesity and smoking). However, there is no detail around the spend and quality in each of the provider segments, or indication of the number or range of providers outside of primary care. There is evidence that the PCT has used patient feedback to gain a richer understanding of commissioned services, with the establishment of Patient Commissioning Forums (which meet every 6 weeks) along with formal consultations such as the renal service ‘discovery day’ and the Patient and Public Involvement Panel. However, the PCT does not provide an overview of key messages, or of how specific feedback has been used to enrich their understanding of commissioned services. • Basic modelling assumptions used to feed into the baseline model include population growth trends, clinical prioritisation and maximum wait times. The baseline model is then adjusted for known strategic planning changes. The PCT has also provided an assessment of the impact of lifestyle factors (such as smoking or obesity) on programme budget category, which it states will result in an estimation of utilisation growth between 2008 and 2015, and will then be compared to population growth. However, the PCT has not yet comprehensibly identified market gaps. Activity projections were also not clearly quantified in the SP, and so could not be linked to the activity or revenue projections in the FP. • The panel acknowledges that the PCT has made positive progress on patient choice (e.g., has improved to be the 22nd highest out of 152 in the Extended Choice Network) and the PCT clearly is very keen to see that extended. The PCT outlines its strategy for creating more choice in the SP, including: public information, such as the development of a PCT directory of hospital and primary care services that will contain information around quality; public campaigns around the launch of Free Choice in NE Essex in April 2009; and effective use of Choose and Book (target of 100% referrals through Choose and Book in 5 years time). The PCT has self-assessed choice as an area of strength with references to their position as the 22nd highest user of the Extended Choice Network out of 152 PCTs and high utilisation of Choose and Book. Recommendations going forward: The panel thinks that the appointment of the new director post will make a great difference. The panel encourages the PCT to continue with its intended plans, and is convinced that the PCT will make rapid progress.

15. PCT's Self Assessment Competency 8: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration • Identification of improvement opportunities’ • Implementation of improvement initiatives • Collection of real time quality and outcome information • Rationale for scoring: • While the PCT provides benchmarking of performance against SHA and national best practice (across quality metrics/health outcomes and operational milestones), it is unclear to what extent benchmarking has been incorporated into clinical redesign initiatives. The PCT has provided two pathway redesign initiatives, one for the ENT pathway, and one for the Step Care Model, neither of which has a clear process map identifying the specific interventions required at each point in the pathway, or clear criteria for moving patients along the pathway. Both pathway redesign initiatives were developed in conjunction with clinicians and clinical network groups, and patients were involved. The PBC survey indicates that a significantly higher than average proportion of respondents (67% vs. a SHA average of 26%) indicate that none of the business cases for redesign have been accepted by the PCT, suggesting that this is an area in need of further development. The panel noted that the PCT has carried out some benchmarking, but not yet sufficient. • The PCT has a performance framework in place to monitor performance with the use of balanced scorecards to identify areas in need of improvement. Both of the pathway redesign initiatives provided clearly identify the need that is being addressed, as well as clear objectives, targets and resources required. The PCT provided evidence of progress in ENT and LT conditions pathways. • There is evidence to suggest that the board regularly monitors provider performance reports. Balanced scorecards tracking national health measures were not available for review. Provider contracts clearly specify the need for monitoring and reporting of quality outcomes. The PCT explained that acute and provider arm reports are discussed. The PCT provided near real time information examples (e.g., OOH GUM, acute patient experience), but could further improve this practice. Recommendations going forward: The PCT should use more near real time data and measuring progress in drivers of performance

16. PCT's Self Assessment Competency 9: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Secure procurement skills that ensure robust and viable contracts • Understanding of providers economics • Negotiation of contracts around defined variables • Creation of robust contracts based on outcomes • Rationale for scoring: • There is limited evidence to suggest that the PCT has an in-depth understanding of provider economics or provider market dynamics. The SP provides very little detail around the financial performance, relative costs or utilization of its various providers. There is evidence to suggest that the PCT considers patient experience data for its providers as evidenced by the inclusion of clauses in provider contracts specifying the need for the provision of patient experience data. Although the SP identifies procurement as an area of improvement, the PCT has made some progress in outlining a draft procurement strategy. The SP has outlined the current procurement principles which will inform the market management and procurement strategy. The PCT explained that it has a formal procurement strategy in place. • Negotiation variables are clearly identified in both the submitted contracts (CHUFT and the Provider Arm of North East Essex PCT) with consistent application of cost, clinical indicators, quality and service targets across both contracts provided. (e.g., the CHUFT contract contained negotiation variables on cost, quality, clinical indicators (such as stroke and chemotherapy) and service targets (such as waiting time targets). The PCT's self-assessment suggests that specialist legal advice is sometimes used during the negotiation process. The PCT explains that it has a formal negotiation strategy and how it manages the cost/ quality trade-off. • One acute care contract was provided in the documentation (relating to CHUFT), which contained quality standards and outcome measures, a clear dispute resolution and arbitration process, detailed service specifications and specified improvement to patient pathways. Relevant SP initiatives on patient experience, safety and emergency responses could be linked to the contract outcomes. The CHUFT contract had been prepared and signed off in February 2008. There is evidence that the CHUFT contract contains break clauses linked to quality variables such as underperformance or non-compliance with quality standards. The PCT has robust contracts based on outcomes and is looking at incentivizing and commissioning for quality, but this is not yet in place Recommendations going forward: The PCT should ensure that the newly appointedDirector of Commercial services will ensure that quality, in particular, is embedded into contracts. The panel is convinced that the PCT will improve fast.

17. PCT's Self Assessment Competency 10: Panel assessment • Panel Assessment • Competency • Measure • Level 1 • Level 2 • Level 3 • Level 4 • Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money • Use of real time performance information • Implementation of regular provider performance discussions • Resolution of ongoing contractual issues • Rationale for scoring: • The panel agrees with the PCT’s self assessment • There is evidence to suggest that the board regularly monitors provider performance reports. The monthly finance and performance committee meetings discuss high level performances such as performance against 18 weeks (July 2008) and MRSA (June 2008). Balanced scorecards tracking national health measures were not available for review. The board explained that they received monthly reports. • There is evidence to suggest that the board regularly reviews the performance of the major acute provider. The PCT explained that they have monthly reviews for primary care and community care, and not yet in dentistry. • Both the CHUFT and the Provider Arm of the PCT contracts contain dispute, breach and termination clauses. Both contracts clearly state situations under which intervention would be required. Both contracts contain detailed procedures relating to disputes and the level of investigation/remedial action that would be carried out in such a situation. For example the CHUFT contract clearly outlines the steps that would be taken in a dispute situation and how the dispute would be investigated and actioned. Recommendations going forward: The PCT should consider establishing a mid-year performance review for general practice contracts and a regular performance review for dental providers

18. A • DRAFT panel assessment Governance: Panel assessment on Strategy Overall recommendation on governance: The PCT must prioritize initiatives to a central few that can be linked to financial investments. Please refer to headline recommendation 2 and 3 • Assessment • Measure • Red • Amber • Green • Vision and objectives • Initiatives to ensure delivery of strategic objectives • Consistency of financial plan with the strategy • Board challenge and ownership of the strategic plan • Achievement of milestones to date Rationale for rating: Visions and objectives: The PCT’s vision is ambitious, but does not yet point to a specific strategy (this still in evolution) and might not be realistic (targets are not consistently set, and the impact of initiatives has not been modelled through). The vision is not underpinned by aligned, coherent concrete objectives. The vision is fully in line with Darzi, national priorities and “Towards the Best Together”. Initiatives to ensure delivery: The PCT has 9 strategic commitments with 65 initiatives. The panel is concerned that 65 initiatives are not sufficiently prioritized, and not aligned with key priorities. While some targets seem overambitious (e.g., childhood obesity), others are under-ambitious (e.g., smoking cessation), and others are not yet defined. Metrics are not consistent, and many lack baselines and targets. Timelines have been defined, but accountabilities and resources have not. Investments are identified in the SP, but are not detailed in the financial template. No disinvestments or productivity savings have been identified. Risks have been identified in the SP, but are not quantified in the financial template. There has been full and ongoing engagement with the public, clinicians, patients, and the local partners. Consistency FP and SP: The panel is concerned that the FP has not yet fully aligned with the strategic financial plan: for example, surpluses are not invested appropriately (the PCT plans to only draw down 50% of the SHA deposit), and there are unallocated investments in the plan (e.g., “other commissioning spend” is increasing by £25m). The PCT recognizes this as an area that needs further work, and has started to draw up detailed business plans. Please refer further to headline recommendation 3. Board challenge and ownership: The Board has been involved in the SP, but the NEDs disagreed on top priorities during the panel day Achievements of milestones: The PCT has a history of achievements Recommendations going forward: please refer to headline recommendations 2 and3

19. A • DRAFT panel assessment Governance: Panel assessment on Finance • Measure • Red • Amber • Green • Sustainable financial position • Historical financial management • Robustness of planning assumptions Rationale for rating: Sustainable financial position: The PCT is projecting in every year over the next 5 years a break even position. No turn around plan is required. Historic financial management: The PCT has a small surplus in 07/08 of £0.2m (within the 0.5% SHA expectations). For 05/06 (a deficit of £4.3m) and 06/07 (a surplus of £0.9m) the year end outturn was >0.5% above or below plan in one of the two years. The PCT has metrics in place to trace financial performance. Robustness of planning assumptions: Basic assumptions in the plan are clear, apart from assumptions around incidence levels. Assumptions could not all be linked to activity or revenues in the financial template. The panel is also concerned that the PCT’s top priorities are currently not sufficiently financed. Recommendations going forward: please refer to headline recommendation 3

20. G • DRAFT panel assessment Governance: Panel assessment on Board • Assessment • Measure • Red • Amber • Green • Organisation • Risk • Information • Performance • Delegation • Board interaction Rationale for rating: Organisation: The PCT has a well defined organisational structure, roles and accountabilities. The PCT has started to identify gaps in the organisation, has plans to restructure the organisation (e.g., a new AD for communications), and has currently set aside £0.5m for OD, which is likely to increase once planning is completed. It has just finished consultation on its new structure, and has potential to move to green. Risks: The PCT has received an ALE rating of 3 Information: There is evidence that the Board receives performance information, and provider performance reports are consistent and actionable. Performance: The PCT reviews performance information for acute, community care and has plans to put it in place for primary care. The PCT is underperforming on 3/43 existing national targets, and 3 out of 13 new national targets. It is one of the top 2 PCTs in EoE Delegation: The PCT has a robust governance arrangement in place for PBC, and has given it a lot of thought. Board interaction: There has been Board interaction, but the panel thinks that the Board could have provided more challenge in terms of prioritizing initiatives, investments and disinvestments. Recommendations going forward: The PCT should finalize its consultation on the new organisational structure

21. Potential for Improvement Commentary • PCT trajectory • The PCT has a strong history of performance, with a strong and effective Board. The panel has every confidence that the PCT will move forward and reach level 3 in a year’s time, but it must focus its strategy for the benefit of the PCT, its public and its partners. • Areas for organisational development • The PCT should reflect on its organisational structure, and ensure that the strategic function is able to pull together the full range of the PCT’s functions to provide a strategic view.