1. The Strategic Health Authority for London Planning 2007/8: PCT Operating Plans SHA Board Meeting 28 March 2007 Enclosure N Appendix 1

2. LOX-GNH077-20060208-DMPM 1 Contents TopicSlide Executive Summary-2 Description of risk ratings-3 PCT risk ratings (proposed)-4 Overview of risk ratings-5 Next Steps-6 Appendices Details of governance ratings-8-11 Details of quality and service -12-14 performance ratings, including health improvement ambition Glossary of terms-15

3. LOX-GNH077-20060208-DMPM 2 Executive summary The Board is asked to Sign off Operating Plans for 23 PCTs, subject to reconciliation with satisfactory and robust FIMS plans and to sign-off of the overall LDP by the DH Agree risk ratings (also subject to agreement of the above) Where plans are not agreed ensure that PCTs deliver robust and credible plans as a matter of urgency. Agree that delegated authority is provided to the SHA Chair and CE to sign off the remainder of the plans The PCTs have submitted Operating Plans in response to the DH Operating Framework and the SHAs Planning Guidance. The PCTs are planning to achieve all the key targets in 2007/8 and most of the other LDP targets. In aggregate PCT plans are broadly breakeven (after debt repayment and topslice). However, 8 individual plans require further work / discussion are not yet in a position to be signed off. The provisional risk ratings are set out in slides 4 & 5

4. LOX-GNH077-20060208-DMPM 3 Processes fail to sufficiently ensure good governance in key areas Persistent or deliberate failure to address other areas of governance Operating plans will be used to assess PCT risk rating in 3 areas Quality and outcomes GovernanceFinance 5 4 3 Meeting all key national targets and 85% of other targets within green tolerance Processes in place to ensure good governance or achievable action plans to address areas of concern Consistent good performance Reasonable surplus Achieving balance 2 Risk of failing to achieve 1 or more key national targets Risk of achieving below 85% of other targets within green tolerance Concern in 1 or more areas where insufficient remedial action is being taken to ensure good governance when necessary Small deficit Risk of not achieving balance High risk of failing to meet several of the national priorities or below 75% of other targets within green tolerance Significant deficit High risk of not achieving balance 1

5. LOX-GNH077-20060208-DMPM 4 Recommended risk ratings PCT Finance Quality & Service Targets Governance Status of plan Monitoring regime Surplus/ (deficit) £m, 2007/8 Barking and Dagenham PCT 4AgreedQuarterly6.0 Barnet PCT 2AgreedMonthly0 Bexley Care Trust 1Not yet agreedMonthlyNot yet agreed Brent Teaching PCT 2AgreedMonthly0 Bromley PCT 3AgreedQuarterly0 Camden PCT 3AgreedQuarterly0 City and Hackney Teaching PCT 4AgreedQuarterly1.0 Croydon PCT 3AgreedQuarterly0 Ealing PCT 3AgreedQuarterly0 Enfield PCT 1Not yet agreedMonthlyNot yet agreed Greenwich Teaching PCT 2AgreedMonthly0.1 Hammersmith and Fulham PCT 4AgreedQuarterly0 Haringey Teaching PCT 3AgreedQuarterly1.9 Harrow PCT 2AgreedMonthly0 Havering PCT 1Not yet agreedMonthly Not yet agreed Hillingdon PCT 1Not yet agreedMonthly Not yet agreed Hounslow PCT 1Not yet agreedMonthly Not yet agreed Islington PCT 2AgreedMonthly0 Kensington and Chelsea PCT 3TBCAgreedQuarterly0 Kingston PCT 1Not yet agreedMonthlyNot yet agreed Lambeth PCT 3AgreedQuarterly0 Lewisham PCT 2AgreedMonthly0 Newham PCT 2AgreedMonthly0 Redbridge PCT 4AgreedQuarterly2.0 Richmond and Twickenham PCT 3AgreedQuarterly1.2 Southwark PCT 2AgreedMonthly0 Sutton and Merton PCT 1Not yet agreedMonthlyNot yet agreed Tower Hamlets PCT 4AgreedQuarterly0 Waltham Forest PCT 2Not yet agreedMonthlyNot yet agreed Wandsworth PCT 4AgreedQuarterly2.1 Westminster PCT 4AgreedQuarterly3.0

6. LOX-GNH077-20060208-DMPM 5 Overview of initial PCT ratings and implications for the monitoring regime Implications for monitoring regime PCTs FinanceQualityGovernance Ratings Low risk Barking and Dagenham* City and Hackney Hammersmith & Fulham Redbridge Tower Hamlets Wandsworth Westminster 4 Medium risk Bromley Camden Croydon Ealing Haringey Kensington & Chelsea Lambeth Richmond 2/3 Higher risk Bexley Enfield Havering Hillingdon Hounslow Kingston Sutton and Merton 1/2 Ideally the majority of PCTs would be in the low risk category. It is anticipated that this will be the trend, but the timing is of course dependent on future performance. NHS London will need to focus its support on the most challenged PCTs At the start of 07/8 around half the PCTs will be required to submit monthly monitoring reports (i.e. all higher risk PCTs and the medium risk PCTs rated a 2 on finance). As soon as confidence in 07/8 performance warrants it all the medium risk PCTs will be switched to quarterly reporting. The low risk PCTs will move to six-monthly reporting during 07/8, on a case by case basis. Brent Lewisham Waltham Forest Barnet Greenwich Harrow Islington Newham Southwark * At SHA discretion Barking & Dagenham PCT moved to low risk as its amber governance issue is on an LAA stretch target. N.B. These PCTs have ratings of 4 / green / green N.B. These PCTs have ratings of 2/3 or amber or amber N.B. These PCTs have ratings of 1/2 or red or red

7. LOX-GNH077-20060208-DMPM 6 The SHA is taking a number of steps to address emerging common themes What this entailsHow it will help Fitness for Purpose Development Plans PCTs are producing Development Plans to respond to the issues identified in the diagnostic assessment The Development Plans will address issues of capacity and capability to enable the PCTs to deliver their Operating Plans Step Programme work on 18 weeks The 18 week waiting time target for referral to treatment will require some coordination at SHA level The SHA will review plans, provide advice and coordinate the delivery of improved service pathways to achieve the waiting time targets Programme work on health improvement The SHA (inc. Regional Public Health and London Health Observatory) will review PCT action plans and support PCTs Targeted support, e.g. on smoking or GUM access, will be focussed on the key interventions at the most challenged organisations Benchmarking The SHA will provide information and some analytical support to PCTs and Trusts to benchmark their performance High quality benchmarking information will enable organisations to focus efforts on the areas likely to result in the greatest improvement

8. LOX-GNH077-20060208-DMPM 7 Appendices

9. LOX-GNH077-20060208-DMPM 8 Governance (top three) Clinical Governance - effective processes for monitoring (in qualitative and quantitative terms) the experience of the full spectrum of patients and other users of services commissioned by the PCT Clinical Governance - effectively monitoring and managing (a) the clinical and public health outcomes of its own provider arm, with clearly tracked, owned and understood metrics and a system of intervention; and (b) that its provider clinicians are appropriately qualified and trained; Delivery and Financial Governance - information systems are suitable for fulfilling its financial and clinical needs and the information is used for performance management. Governance ratings Governance n n n Key themes Red-rated PCTs; Bexley Brent Enfield Havering Hillingdon Hounslow Kingston Lewisham Sutton & Merton Waltham Forest

10. LOX-GNH077-20060208-DMPM 9 Board processes Member interests Member qualifications Non-executive skills and training Compliance with legal duties Compliance with NHS good practice Strategy and planning Contracts and SLAs agreed with providers Board satisfaction with operating plan assumptions Delivery Plans/processes to deliver operating plan Management capable of delivering operating plan Appropriate management and staff recruited Management and staff training and accountability Information systems suitability Financial governance Effective accounting and reporting arrangements Risk management and internal audit Probity and propriety Information systems suitability Clinical governance Monitoring and improvement of healthcare National core standards & targets Waltham Forest X City & Hackney X Lambeth Southwark Kingston X X X X X Source: Operating plan self certifications; Team analysis Barking & Dagenham Enfield X X XX Havering Newham X X Redbridge Tower Hamlets X Bexley X Croydon Greenwich Richmond & Twickenham Sutton & Merton X X Wandsworth Lewisham X X X Barnet X X Haringey Bromley Brent X Camden Ealing Hammersmith & Fulham Harrow Hillingdon X X Hounslow X XX X X Islington Kensington & Chelsea Westminster PCT governance risk ratings (1/2) X X Yes Not certified No but with plan Denotes highly weighted questions X X X X

11. LOX-GNH077-20060208-DMPM 10 Emergency planning Emergency governance Emergency resources Major Incident Plan Emergency exercises, training and testing Overall compliance Compliance with statutory duties Consideration of risks to statutory duties Review evidence of risk to statutory duties Relationship management Engagement of local authority and others Compliance with NHS London and DH requirements Response to all regulators and audits Relationship with providers Public patient involvement Source: Operating plan self certifications; Team analysis Overall risk rating (commissioner perspective)* Clinical governance (continued) Monitoring experience of services provided Monitoring experience of services commissioned Provider arm performance and staff Involvement of GP practices LAA target achievement Hounslow Kensington & Chelsea Hammersmith & Fulham Camden Westminster Newham X X Tower Hamlets X X X City & Hackney X Southwark Croydon X Kingston X X X Wandsworth Enfield Barking & Dagenham X Brent X X Harrow Hillingdon X X X Islington XX X Barnet Havering XXX Redbridge X X Waltham Forest XX Bexley X X Bromley Greenwich Richmond & Twickenham X Sutton & Merton X X Ealing Lewisham X X Haringey X X Lambeth PCT governance risk ratings (2/2) X XXXXX Yes Not certified No but with plan Denotes highly weighted questions X X

12. LOX-GNH077-20060208-DMPM 11 Quality & Service Targets A number of targets are subject to revision as part of the national LDP phase 3 process, and therefore the assessments are subject to amendment when the final LDP is signed-off by the DH in April / May. All PCTs are intending to deliver the 18 week referrals to treatment milestones All PCTs are intending to achieve the key targets, with he exception of 5 PCTs on the all age all cause mortality target Quality and Service Targets risk ratings n Quality & Service Targets n n Key themes Red-rated PCTs; None Amber Enfield To be confirmed (following discussions with the DH on the sign-off of one key target) Kensington and Chelsea

13. LOX-GNH077-20060208-DMPM 12 Quality and service target ratings PCTRisk rating % other national targets PCT plans to achieve National key target breaches Barking and Dagenham PCT – 100 Barnet PCT– 95 Brent Teaching PCT– 90 Bromley PCT- 95 Camden PCT- 90 City and Hackney Teaching PCT- 95 Croydon PCT- 90 Ealing PCT -86 Enfield PCT–62 Greenwich Teaching PCT- 81 Hammersmith and Fulham PCT– 95 Haringey Teaching PCT – 86 Harrow PCT– 95 Havering PCT – 90 Hillingdon PCT-90 Hounslow PCT–81 Islington PCT–81 Kensington and Chelsea PCT All age all cause mortality is subject to DH agreement100 Kingston PCT 76 Lewisham PCT - 81 Redbridge PCT -86 Richmond and Twickenham PCT–76 Southwark PCT -86 Sutton and Merton PCT –86 Tower Hamlets PCT-90 Waltham Forest PCT –86 Wandsworth PCT–90 Westminster PCT–95 Lambeth PCT – 81 Newham PCT – 86 Bexley Care Trust - 81

14. LOX-GNH077-20060208-DMPM 13 PCTs in a sustainable finance position and / or with significant growth have defined local priorities and action plans. NHS London will be monitoring delivery against these plans. There are three PCTs in this category: Barking and Dagenham City and Hackney Tower Hamlets Health Improvement Ambition n n PCTs in financial balance were also asked to review progress on TB and HIV in the London guidance of December 2006. There are six additional PCTs in this category which was made on the basis of M11 (forecast outturn): Hammersmith and Fulham Kensington and Chelsea Lambeth Redbridge Wandsworth Westminster Barking and Dagenham City and Hackney Tower Hamlets LOCAL HEALTH PRIORITIES LONDON PRIORITIES

15. LOX-GNH077-20060208-DMPM 14 Glossary of terms Risk rating NHS London assesses the risks in each PCTs Operating Plan and assigns a risk rating in three areas: financial performance, quality and outcomes and governance. NHS London will use the risk ratings to guide the intensity of its monitoring and signal to the PCT its degree of concern with the specific issues identified and evaluated in the Operating Plan review. Finance rating The risk that the PCT will end the year in deficit (refer to slide 3 for meaning of the finance ratings and to the PCT Commissioning Regime for the methodology for calculating the ratings) Governance rating The risk posed by the PCTs governance systems and processes (a summary of the results of the governance self certification questionnaires is set out in slides 8- 10, the methodology for calculating the ratings is set out in the PCT Commissioning Regime) Quality rating The risk that the PCT and its commissioned services will not deliver national, London-wide and local quality and outcomes targets (the targets and the methodology for calculating the ratings are set out in the PCT Commissioning Regime) Operating plan Sets out how the PCT plans to achieve the health outcome and financial goals for the year. In future years will be based on its Commissioning Strategy Plan. It includes targets, financial and activity schedules and action plans. Developed annually. Monitoring regime As part of the PCT Commissioning Regime, intervention is also underpinned by the Regimes overall principles: (1) self- governance, (2) risk-based, proportionate approach, (3) trust, (4) transparency, (5) minimal information requirements and (6) developmental CIPs Cost Improvement Programmes, initiatives developed each year by service providers to improve efficiency DP Development Plan - describes the organisational capabilities needed to deliver the Commissioning Strategy Plan, the current capability gaps and how they will be filled, for 2007/8 this will be the Fitness for Purpose Development Plan Contingency Resource retained to mitigate in-year financial pressures, DH guidance is that this should be 0.5% of turnover as an absolute minimum FIMS Financial Information Management Systems, a system of financial plans and monthly reporting against them London Planning Guidance Guidance issued to PCTs and Trusts by NHS London each year to inform the planning process, including confirmation of the targets to be delivered in the following year and of the financial planning assumptions to be used by organisations in producing their annual and operating plans Demand management Action being take by PCTs to ensure that services respond most appropriately to need including being located in the most appropriate places to provide quality, personalised care. Strategic context is set by the Our Health, Our Care, Our Say White Paper