AGENDA

A meeting of the Governing Body in public Date: 12 May 2016 Time: 10:00 – 12:30 Venue: St Laurence Centre, 37 Bromley Road, London SE6 2TS Chair: Dr Marc Rowland Enquiries to: Lesley Aitken Telephone: 020 7206 3360 Email: Lesley.aitken@nhs.net Voting Members Dr Marc Rowland Chair Lewisham CCG Dr David Abraham Senior Clinical Director Lewisham CCG Prof. Ami David MBE Registered Nurse Member Lewisham CCG Dr Charles Gostling Clinical Director Lewisham CCG Dr Mark Hamilton Secondary Care Doctor Lewisham CCG Dr Sebastian Kalwij Clinical Director Lewisham CCG Dr Faruk Majid Senior Clinical Director Lewisham CCG Dr Jacky McLeod Clinical Director Lewisham CCG Ms Rosemarie Ramsay MBE Lay Member Lewisham CCG Dr Angelika Razzaque Clinical Director Lewisham CCG Mr Tony Read Chief Financial Officer Lewisham CCG Mr Ray Warburton OBE Deputy Chair, Lay Member Lewisham CCG Mr Martin Wilkinson Chief Officer Lewisham CCG Non-Voting Members Ms Aileen Buckton Executive Director, Community Services, Lewisham Council Mr Nigel Bowness Chair Healthwatch Lewisham Dr Simon Parton Chair of Local Medical Council Dr Danny Ruta Public Health Director, Lewisham Council Quorum The Governing Body will be deemed quorate when a minimum of 7 members, 4 of which must be Clinical Directors, one must be either the Chief Officer or Chief Financial Officer and two must be independent members (Lay Members, Secondary Care Doctor or Registered Nurse). A member who is present at Governing Body meeting and is conflicted by a particular agenda item will not contribute to the quoracy of the meeting for the duration of that agenda item.  

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Order of Business

  Time Item Papers Presented by

1. 10:00 Welcome and introductions Chair

2. Apologies for absence

3. Declarations of Interest Members should discuss any potential conflicts of interest with the Chair prior to the meeting

Enc 1

Chair

4. To agree minutes of previous meeting To review the action log

Enc 2 Enc 2.1

Chair

5. Matters arising

6. Chair’s Report To receive and note for information

Enc 3 To follow

Dr Marc Rowland

7. Chief Officer’s Report To receive and note for information

Enc 4

Martin Wilkinson

8. Audit Committee Chair’s Report To receive and note for information from the meetings held on 29 March and 19 April 2016 Local Auditor Panel Chair’s Report To receive and note for information from meeting held on 19 April 2016

Enc 5 Enc 6

Ray Warburton Ray Warburton

9. Primary Care Joint Committee Chair’s Report To receive and note for information from the meeting held on 28 April 2016

Enc 7

Rosemarie Ramsay

10. Questions in relation to agenda items from members of the public

INTEGRATED GOVERNANCE 11. 10.30 Board Assurance Framework 2016/17

To receive and agree risks on the BAF Enc 8 To follow

Martin Wilkinson

12.

Integrated Governance Committee – Chair’s report from the meetings held on March and April

Enc 9 Martin Wilkinson

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2016 To receive and note for information

13. Integrated Performance Report Including Quality, Finance, QIPP and Performance To receive and endorse the reports

Enc 10

Dr Faruk Majid/ Tony Read

14. Operating Plan 2016/17

Enc 11 To Follow

Tony Read

15. Implementation of the Phase I Governance Review To approve the proposed approaches and revised terms of reference and Chair’s action to agree amendments to the CCG’s Constitution

Enc 12 Martin Wilkinson

STRATEGY AND PLANNING 16. 11:45 Strategy and Development Workshop – Chair’s

report from meeting held on 7 April 2016

Enc 13

Dr David Abraham

17. Equality and Diversity Report To receive and note the report

Enc 14

18. Potential Audit and Risk Management Issues

To identify any issues which the Governing Body consider would benefit further scrutiny by the Audit Committee

Chair

19. Any Other Business

20 12:20 Questions from members of the public

FOR INFORMATION ONLY

21. Approved Committee minutes for information only

Audit Committee (February and March 2016)

Delivery Committee (February and March

2016)

Strategy and Development ( February

Enc 15 Enc 16 Enc 17

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2016)

Clinical Strategy Committee (February 2016)

Primary Care Joint Committee (February 2016)

Enc18 Enc 19

22. 12:30 Date of next meeting: 21 July 2016 (please note change of date) – Civic Suite, Lewisham Town Hall

The Committee to agree that, if required, the public should be excluded from the meeting while the remaining business is under consideration, as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted. Managing Conflicts of Interest: Governing Body, committees, sub-committees and working groups

13. The chair of the Governing Body and chairs of committees, subcommittees and working groups will ensure that the relevant register of interest is reviewed at the beginning of every meeting, and updated as necessary.

14. The chair of the meeting has responsibility for deciding whether there is a conflict of interest and the appropriate course of corresponding action. In making such decisions, the chair may wish to consult the member of the governing body who has responsibility for issues relating to governance.

15. All decisions, and details of how any conflict of interest issue has been managed, should be recorded in the minutes of the meeting and published in the registers.

16. Where certain members of a decision-making body (be it the governing body, its committees or sub-committees, or a committee or sub-committee of the CCG) have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision-making itself (i.e., not have a vote).

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17. In any meeting where an individual is aware of an interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the chair, together with details of arrangements which have been confirmed by the governing body for the management of the conflict of interests or potential conflict of interests. Where no arrangements have been confirmed, the chair may require the individual to withdraw from the meeting or part of it. The new declaration should be made at the beginning of the meeting when the Register of Interests is reviewed and again at the beginning of the agenda item.

18. Where the chair of any meeting of the CCG, including committees, sub-committees, or the governing body, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the deputy chair will act as chair for the relevant part of the meeting. Where arrangements have been confirmed with the governing body for the management of the conflict of interests or potential conflicts of interests in relation to the chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the deputy chair may require the chair to withdraw from the meeting or part of it. Where there is no deputy chair, the members of the meeting will select one.

19. Where significant numbers of members of the governing body, committees, sub committees and working groups are required to withdraw from a meeting or part of it, owing to the arrangements agreed by the Governing Body for the management of conflicts of interest or potential conflicts of interest, the remaining chair will determine whether or not the discussion can proceed.

20. In making this decision the chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the CCG’s standing orders or the relevant terms of reference. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the governing body, committees, sub committees and working groups owing to the arrangements for managing conflicts of interest or potential conflicts of interest, the chair may invite on a temporary basis one or more of the following to make up the quorum so that the CCG can progress the item of business:

a. an individual GP or a non-GP partner from a member practice who is not conflicted

b. a member of the Lewisham Health and Wellbeing Board;

c. If quorum cannot be achieved by a) or b) (above) a member of a governing body of another clinical commissioning group.

21. These arrangements will be recorded in the minutes.

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GLOSSARY OF TERMS AAS Admission Avoidance Service ACRA Advisory Committee on Resource Allocation ADASS Association of Directors of Adult Social Services AEC Ambulatory Emergency Care A&E Accident and Emergency AfC Agenda for Change AHP Allied Health Professional AHSC Academic Health Science Centre AHSN Academic Health Science Network APMS Alternative Provider Medical Services AQP Any Qualified Provider ASTRO-PU Age, Sex, Temporary Resident Originated Prescribing Unit AWP Allocation Working Paper

BDA British Dental Association BMA British Medical Association BME Black and Minority Ethnic BNF British National Formulary BPPC Better Payment Practice Code

CAMHS Child and Adolescent Mental Health Services CAS Central Alert System C&B Choose & Book CBC Community Based Care

CBT Cognitive Behavioural Therapy CCG Clinical Commissioning Group CCNT Children’s Community Nursing Team CEMACH Confidential Enquiry into Maternal and Child Health CIO Chief Information Officer CIP Cost Improvement Programme CLG Clinical Leadership Group CNST Clinical Negligence Scheme for Trusts COPD Chronic Obstructive Pulmonary Disease CQRG Clinical Quality Review Group CRL Capital Resource Limit CPA Care Programme Approach CPD Continuing Professional Development CPN Community Psychiatric Nurse CPR Child Protection Register CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CRB Criminal Records Bureau CSU Commissioning Support Unit CSP Commissioning Strategy Plan CSR Comprehensive Spending Review CSS Commissioning Support Service CVD Cardiac Vascular Disease+ CYPPB Children and Young people Partnership Board

DAAT Drug & Alcohol Action Team DES Direct Enhanced Service DGH District General Hospital DH or DoH Department of Health DTC Delayed transfer of care

E&D Equality and Diversity ED Emergency Department EDS (NHS) Equality Delivery System EI Early Intervention EIA Equality Impact Assessment EIP Early Intervention in Psychosis EMIS Practice Information System ENT Ear, Nose and Throat EPP Expert Patient Programme EPR Electronic Patient Record EPRR Emergency Planning Response Register EPS Electronic Prescription Service ESR Electronic Staff Record EWTD European Working-Time Directive FCE Finished Consultant Episode FHS Family Health Services FIMS Financial Information Management System FLAG For Learning and Action Group FNP Family Nurse Partnership

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FOI Freedom of Information FOT Forecast Outturn FT Foundation Trust

GAD Government Actuary’s Department GDC General Dental Council GDS General Dental Services GMC General Medical Council GMS General Medical Services GOS General Ophthalmic Services GP General Practitioner GPI General Practitioner Interactive GPS Government Procurement Services GPSI or GPwSI General Practitioner with a special interest GPSoC General Practitioner Systems of Choice GSTT Guy’s & St. Thomas’s NHS Foundation Trust

HCA Health Care Assistant HCAI Healthcare-Associated Infection HCAIs Healthcare Acquired Infections HCAS High Cost Area Supplement HEMS Helicopter Emergency Medical Service HIA Health Impact Assessment HIEC Health Innovation and Education Cluster HMO Health Maintenance Organisation (USA) HoNOS Health of the

Nation Outcome Scales HRG Healthcare Resource Group HRG4 Healthcare Resource Group version 4 HSC Health and Social Care (Northern Ireland) HSJ Health Service Journal HTA Health Technology Assessment HV Health Visitors HWB Health and Wellbeing Board

IAPT Improving Access to Psychological Therapies (programme) IC Information Commissioner ICAS Independent Complaints Advocacy Service ICD International Classification of Diseases ICE Integrated Communication and Engagement ICO Integrated Care Organisation ICP Integrated Care Pathway ICT Information and Communication Technology ICU Intensive Care Unit I&E Income and Expenditure IFRS International Finance Reporting Standards IG Information Governance IMCA Independent Mental Capacity Advocate IM&T Information Management and Technology IP Information Prescriptions

IP Inpatient IPR Individual Performance Review IRP Independent Reconfiguration Panel IST Intensive Support Team

JCP Jobcentre Plus JHWS Joint Health and Wellbeing Strategy JNC Joint Negotiating Committee JSNA Joint Strategic Needs Assessment KPI key Performance Indicator KSF (NHS) Knowledge and Skills Framework

LA Local Authority LCFS Local Counter Fraud Specialist LDC Local Dental Committee LES Local Enhanced Services LETBs Local Education and Training Boards LGA Local Government Association LGT Lewisham & Greenwich NHS Trust LIFT Local Improvement Finance Trust LMC Local Medical Committee LSMS Local Security Management Specialist LOC Local Optical Committee LPC Local Pharmaceutical Committee LSP Local Strategic Partnership LSL Lambeth, Southwark & Lewisham

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LTC Long-Term Conditions

MCATS Musculoskeletal Community Assessment and Treatment Service MADEL Medical and Dental Education Levy Resignation Scheme MDT Multi Disciplinary Team MECS Minor Eye Condition Scheme MFF Market Forces Factor MHRA Medicines and Healthcare Products Regulatory Agency MMR Measles, Mumps, Rubella (vaccination) MPET Multi-Professional Education and Training MPIG Minimum Practice Income Guarantee MRI Magnetic Resonance Imaging MRSA Methicillin-Resistant Staphylococcus Aureus MSK Musculoskeletal

NCAS National Clinical Assessment Service Programme NCEPOD National Confidential Enquiry into Patient Outcome and Death NCVO National Council for Voluntary NTDA National Trust Development Authority NHS National Health Service NHSE NHS England NHS SBS NHS Shared Business Services NHSLA NHS Litigation Authority

OD Organisational Development OGC Office of Government Commerce OHSEL Our Healthier SE London OJEU Official Journal of the European Union ONS Office for National Statistics OOH Out of Hours OP Outpatient Assessment OSC (local authority) Overview and Scrutiny Committee PACS Picture Archiving and Communications System PAED Paediatric PALS Patient Advice and Liaison Service PASA Purchasing and Supplies Agency PBMA Programme Budgeting and Marginal Analysis PbR Payment by Results PDP Personal Development Plan PEG Public Engagement Group PHE Public Health England PHO Public Health Observatory PI Performance Indicator PMS Personal Medical Services PNA Pharmaceutical Needs Assessment POD Point of Access PPA Prescription Pricing Authority PPAG Patient and Public Advisory Group PPE Patient and Public Engagement PPG Patient Participation Group PPI Patient and Public Involvement

PPV Patient and Public Voice PRCC Principles and Rules for Cooperation and Competition PROM Patient-Reported Outcome Measure

QA Quality Assurance QALY Quality-Adjusted Life Year QIPP Quality Innovation Productivity and Prevention QMAS Quality Management and Analysis System QOF Quality and Outcomes Framework

RIO System Provider Serviced RO Responsible Officer RRL Revenue Resource Limited RTT Referral to Treatment

SAU Surgical Assessment Unit SBS (NHS) Shared Business Services SCG Specialised Commissioning Group SELDOC South East London Doctors on Call SFI Standing Financial Instructions SIRO Senior Information Responsible Officer SLA Service Level Agreement SLaM South London and Maudsley Mental Health Foundation Trust SMR Standardised Mortality Ratio SNOMED Systematised

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Nomenclature of Medicine SO Standing Order SOPHID Survey of Prevalent HIV Infections that are Diagnosed SRO Senior Responsible Officer SSBU Shared Service Business Unit STP Sustainability and Transformational Plan SUS Secondary User Services

TIA Trans Ischaemic Attack- Stroke Indicator TDA – Trust Development Authority TSA – Trust Special Administrator TUPE Transfer of Undertakings (Protection of Employment) Regulations 1981 UCC Urgent Care Centre UDA Units of Dental Activity

VCS Voluntary and Community Sector VFM Value for Money VPR Virtual Patient Record VSM Very Senior Managers VTE Venous Thromboembolism

WHO World Health Organization WIC Walk in Centre WTD Working-Time Directive WTR Working Time Regulations

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First name Surname Position within or relationship with the CCG or NHS England

Date Roles and responsibilities held within member practices

Directorships, including non-executive directorships, held in private companies or PLCs

Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and/or with NHS England

Shareholdings (more than 5%) of companies in the field of health and social care

Positions of authority in an organisation (eg charity or voluntary organisation) in the field of health and social care

Any connection with a voluntary or other organisation contracting for NHS services

Research funding/grants that may be received by the individual or any organisation you have an interest or role in

Other specific interests?

Any other role or relationship which the public could perceive would impair or otherwise influence your judgement or actions in your role within the CCG and/or NHS England

Marc Rowland Chair of the Govrning Body 19/06/15 Partner of Jenner PracticeMy Partner is a salaried GP at Deptford Surgery

None None Chair of London Clinical Commissioning Council None Small sum for GP research costs received by the practice annually. Variable, less than £5,00 over the past 5 years

None Professional Advisor to the Institute of Medical Education at the London Southbank University

Aileen Buckton Director of Adult Social Care 26/06/15 None None None None None Director of Adult Social Care Lead Commissioner for Joint Commissioned Services (Adult) - London Borough of Lewisham

None None None

Danny Ruta Director of Public Health, London Borough of Lewisham

18/06/15 None None None None Non-Exec Director Basketball Foundation None None None None

David Abraham Senior Clinical Director 18/06/15 GP Principal PMS Practice, Morden Hill Medical Practice.Wife is a practice nurse in Elm House Surgery, Beckenham

None None GP, South East London Doctors Co-operative (SELDOC)

None None None None Member of IFR panel and is remunerated for one session a month

Rosemarie Ramsay CCG Lay Member - Public Engagement

22/10/15 None None None None Chair - North Lewisham Stakeholders Group None None None None

Ray Warburton Vice Chair 18/06/15 None Director of Ray Warburton's Perspectives Limited

None None None None None None Member of the NHS Equality and Diversity Council

Faruk Majid Senior Clinical Director 18/06/15 Partner Hilly Fields Practice Lightmine Ltd (not active) None GP, South East London Doctors Co-operative (SELDOC)

None None None None None

Jacqueline McLeod Clinical Director 16/06/15 Salaried GP, The Vale Medical Centre, Forest Hill, SE23

None None None none GP Appraiser, NHS SE London, GP Triager Referral Support Scheme, BexleyHealth LTD

None None None

Angelika Razzaque Clinical Director 18/06/15 GP Partner, Queens Road Partnership Director of husbands company Adaptarose

None Self and husband shareholders in own company - Adaptarose

Vice Chair of Executive Committee of Primary Care Dermatology Society None None None None

Martin Wilkinson Chief Officer 18/06/15 None None None None None None None None None

Tony Read Chief Financial Officer 18/06/15 None None None None None None None None None

Ami David Board Member Nurse 21/08/14 None None Director Quest for Community Health specialising in risk management/project management to health care organisations (Private and NHS) & Royal Colleges.

Partner/close personal friends/business partner; co-director Prasand International Limited

None Visiting Professor of Nursing Leadership and Expert Practice London South Bank University.

Fellow Queens Nursing Institute.

Nurse Member Lewisham, Lambeth and Southwark CCG Governing Bodies

Director of Quest for Community Health specialising in risk management/project management to health care organisations (Private and NHS) & Royal Colleges.

Visiting Professor of Nursing Leadership and Expert Practice London South Bank University.

None None None

Simon Parton Board Member LMC Rep 02/07/14 GP Partner and member of SELDOC - practices in Neighbourhood 3 were registered as limited company

Director, MMP Oncology LTD. LTD company set up to support partners private oncology work in SW London; Dr Marina Parton (Partner) Co-Director of MMP Oncology Ltd

None None Chair, Lewisham Medical Committee None None None None

Nigel Bowness Interim Chair, Healthwatch Lewisham

12/11/15 None Chair of Leiwsham Homes Resident Scrutiny Committee

None None Director of The Crystal Coalition CIC (non profit organisation) Trustee of Healthwatch Bromley and Lewisham, None None Member of the Labour Party

Sebastian   Kalwij Clinical  Director 05/08/15 GP,  Amersham  Vale  Practice Director,  Dr  iSeb  Ltd None None None None None None NoneMark   Hamilton Secondary  Care  Doctor 02/04/16 None None None None Associate  Medical  Director,  Consultant  Anaesthetists  &  Intensivist  

St  Georgie's  NHS  FTNone None Board  Member  of

 Community  interest  company  -­‐  Evidence  Based  Perioperative  Medicine

Ad  hoc  advisory  work  for  North  East  Hants  &  Farnham  CCGMy  wife  is  a  local  salaried  GP  in  Epsom  and  a  clinical  lead  at  Surrey  Downs  CCG.    She  is  also  a  GP  tutor  for  KSS.

Charles Gostling Clinical Director 08/10/15 GP Partner - Morden Hill Surgery None NoneGP , Lewisham Primary Care Partnership (N2)

Clinical Director South London Health Innovation Network (Academic health Science Network)

GP with Special Interest Lewisham and Greenwich NHS Trust

Member of DAFNE plus research collaborative None

Have given educational presentations on behalf of pharmaceutical industry - Novo Nordisk, Lilly, MSD, Sanofi-Aventis, Takeda

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Governing Body meeting

Minutes of the meeting of the Lewisham Clinical Commissioning Group (LCCG) Governing Body held on Thursday, 10 March 2016 at the St. Laurence Centre, 37 Bromley Road, London SE6 2TS

Mr Ray Warburton OBE Lay Deputy Chair, LCCG – Chair for this meeting Dr David Abraham Senior Clinical Director, LCCG Mr Nigel Bowness Chair, Healthwatch Lewisham Prof. Ami David MBE Nurse Member, LCCG Dr Charles Gostling Clinical Director, LCCG Dr Sebastian Kalwij Clinical Director, LCCG Dr Faruk Majid Senior Clinical Director, LCCG Dr Jacqueline McLeod Clinical Director, LCCG Ms Rosemarie Ramsay MBE Lay Member, LCCG Dr Angelika Razzaque Clinical Director, LCCG Mr Tony Read Chief Financial Officer, LCCG Dr Danny Ruta Public Health Director, LB Lewisham Mr Martin Wilkinson Chief Officer, LCCG In Attendance From Lewisham CCG, South East CSU, NHS England or London Borough of Lewisham: Ms Lesley Aitken Board Secretary (notes), LCCG Ms Sola Afuape Interim Head of Engagement, LCCG Mr Ian Brown NHS England Mr Clive Caseley Verve Communications Mr Mike Hellier Head of System Intelligence, LCCG Ms Valery Lawrence Communications Manager, SECSU Mr Charles Malcolm-Smith Associate Director, Strategy and Organisational Development Ms Susanna Masters Corporate Director, LCCG Ms Hannah Reeves PA to the Corporate Director, Commissioning Director, Nursing

and Quality Director, LCCG There were 5 members of the public present for the meeting. Apologies Ms Aileen Buckton Executive Director Community Services, LB Lewisham Dr Mark Hamilton Secondary Care Doctor, LCCG Dr Simon Parton LMC Chair Dr Marc Rowland Chair, LCCG LEW 16/23 Welcome and Announcements Mr Warburton welcomed all and informed the meeting that he would, in the absence of Dr Rowland, chair the Governing Body meeting. He welcomed Dr Charles Gostling the newly appointed Clinical Director to his first meeting. The CCG now had its full complement of Clinical Directors. Dr Mark Hamilton had been appointed as Secondary Care Doctor but was unable to attend the meeting due to prior commitments. Mr Warburton explained that questions would be taken from the public after the Primary Care Joint Committee Chair’s report and at the end of the agenda items.

Enclosure 2

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LEW 16/24 Declarations of Interest Ms Aitken had received Dr Gostling’s declaration of interest form, the register would be updated. There were no other new declarations of interest given at this point of the meeting.

LEW 16/25 Previous Minutes

The minutes of the previous meeting were taken as a true record. LEW 16/26 Action Log and Matters Arising

Updates were given on the open actions and the log was reviewed and revised. It was explained that the actions shown as amber are those which officers have proposed from their point of view were actioned and therefore closed. These could be challenged by Governing Body members. 132.2/16.04 The action attributed to Ms Buckton on the communication issue between housing and Neighbourhood Care Networks (NCNs) would be pursued. ACTION: Martin Wilkinson Mr Warburton requested that dates on when the action was completed to be shown on the action log.

LEW 16/27 Chair’s Report

The Chair’s report written by Dr Rowland was received and noted. Mr Warburton said that he was interested on further information on the link between primary and secondary care services in the Netherlands as mentioned in Dr Rowland’s report.

ACTION: Dr Marc Rowland 27.1 Chair’s actions

Annual Equalities Report – January 2015

Mr Wilkinson explained that the draft Annual Equalities report had been presented to the Governing Body on 14 January 2016 where further background to the proposed Equality Delivery System (EDS) gradings were requested before approval by Chair’s action. Background information on the EDS goals chosen, Goal 1 - Improving Outcomes, and Goal 2 – Access and Experience, had been given to Governing Body members. A meeting was held on 26 January to review the EDS process and gradings where it was agreed that revised gradings for Goals 1 & 2 were incorporated (Achieving for both Goals 1 & 2) into the report along with comments from the Governing Body. The report was completed by the statutory date of 31 January 2016 and made available on the CCG website.

Collaborative Framework between South East London CCGs The Framework had been considered at the Delivery Committee at its December 2015 meeting, comments taken at that meeting were agreed and incorporated and the Framework was signed off by the CCG Chief Officer and other SEL Chief Officers on 26 February 2016. This was in line with the delegated responsibility agreement given at the July Governing Body meeting. The Governing Body NOTED the Chair’s actions LEW 16/28 Chief Officer’s Report Mr Wilkinson gave the report and highlighted the following: 28.1 Our Healthier South East London Programme (OHSEL) – a full report was in the papers on the work progressing on each model of care and priorities for the coming months.

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South East London Committee in Common (CiC) 17 March 2016 – this is a meeting held to which public and residents are invited to attend. The membership of the meeting comprises three members from each of the six SEL CCGs. The Committee has a decision making role on issues related to OHSEL and other strategic matters which cross borough boundaries. At this first meeting there would be an update on progress on the orthopaedic planned care workstream. Copies of papers would be made available to all Governing Body members once available.

ACTION: Martin Wilkinson Regarding Maternity Prof David asked whether the CCG had considered being a pilot in line with the national review Better Births. Mr Wilkinson responded that conversations had not been held as yet but that there was a Maternity Network meeting being held 11 March 2016 at which this issue could be raised. In response to a question from Dr McLeod on how NHS 111 relates to mental health, Dr Abraham said that the programme board for NHS 111 was planning to look at the mental health interface in more specific terms. The Directory of Service (DoS) was not well developed for mental health and areas such as signposting crisis intervention help need improving, but that these and other matters were being taken forward. Responding to a question from Dr Razzaque on how the Adult Integrated Programme Board (AIPB) was improving their communication on what it was aiming to achieve, Mr Wilkinson said that communication was now across the board including staff, management, public and community groups and leading into practices. The CCG was looking at what outcomes to achieve especially in the Neighbourhood Care Networks (NCNs). It was recognised that the need to engage partnerships and the public was ongoing. The Joint Public Engagement Group (JPEG) had held early conversations on this area. Regarding the timescale to achieve the set of competencies to be developed on the different care navigator job descriptions and whether cultural competencies would be a key feature, Mr Wilkinson said that this was in hand and would feedback to Mr Bowness who had raised the question outside of the meeting.

ACTION: Martin Wilkinson 28.2 Responding to a question from Mr Warburton on the Junior Doctors Strike, Mr Wilkinson said that plans had been put in place in advance of the Junior Doctors strike and no particular problems or issues had been raised in Lewisham, though demand continues for A&E services. There were regular calls across partners with support care packages and discharge measures in place. Yesterday, Wednesday 9 March, services had been maintained but today was expected to be more problematic. Planning for the weekend was underway. Regarding the reduced budget for pharmacies Mr Wilkinson responded that the national contract for pharmacies was with NHS England (NHSE) but that the CCG continues to support enhanced work with them. The Governing Body NOTED the report LEW 16/29 Audit Committee Chair’s Report Mr Warburton gave the report from the meeting held on 2 February 2016 and highlighted the following:

Ms Shelagh Kirkland had been welcomed to the Committee as the newly appointed Independent Member; Ms Kirkland was a qualified accountant.

Internal Audit – their report on Workforce Management was received which had six recommendations raised, all of which were accepted by management. One of the recommendations was for the CCG to have a formal medium to long-term workforce plan in place.

Deep dives into the way corporate objectives are set out on the Board Assurance Framework (BAF) - Ms Braithwaite, Commissioning Director and Ms Browne, Nursing and Quality Director attended the meeting to describe how risks were identified and mitigated for NCNs and Primary Care. The Committee was assured that risk assurance processes were in place.

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Local Counter Fraud Service (TIAA) - a report was given which included how CCG staff were being trained in fraud awareness and described the challenge on keeping ahead of potential fraud. The FraudStop newsletter was presented.

The Committee NOTED the report

29.1 Lewisham CCG’s Local Auditor Panel and its Terms of Reference

Mr Warburton gave the report which explained that following the abolition of the Audit Commission it was now a legal requirement for CCGs to appointment their own external auditors from 2017/18 through a Local Auditor Panel. Draft Terms of Reference were given to be agreed in principle. The Panel would be the CCG Audit Committee members with the Chair of the Committee being the Chair of the Panel. It would be made clear when they were meeting as the Panel or as the Committee. The Panel would be accountable to the Governing Body. The appointment of the external auditors would be made; it was hoped, across the six CCGs, with the appointment to be made by December 2016. Mr Warburton added that minor adjustments to the Constitution would be made. Mr Wilkinson thanked Mr Warburton for the reports. The Committee NOTED the requirement to appoint the external auditor for financial year 2017/18 onwards and the next steps and AGREED in principle the Terms of Reference for the Local Auditor Panel, which identifies the members of the CCG Audit Committee as members of the Local Auditor Panel.

LEW 16/30 Finance and Investment Committee (FIC) Chair’s Report

Prof David, as Chair of the Finance and Investment Committee (FIC), presented the report from the meeting held on 19 January 2016. She reported that that the Committee had considered two business cases: 30.1 Service User Network (SUN) – the Committee considered the business case for a service user

network across Lambeth, Lewisham and Southwark which was an open access community based support group for people with a personality disorder. The business case was not approved and the committee had invited the commissioners to address the comments raised for future consideration.

30.2 OASIS service – this business case outlined the benefits to establishing an early detection and prevention service for young people of 14 to 35 at risk of mental health disorders, especially psychosis. The Committee did not approve the business case and have requested further information.

It has been agreed that the Strategy and Development Committee would discuss mental health strategic direction as part of a future workshop. The Finance and Investment Committee Terms of Reference would be discussed and agreed at their next meeting before coming back to the Governing Body in May for approval.

ACTION: Tony Read The Governing Body NOTED the report

LEW 16/31 Primary Care Joint Committee (PCJC) Chair’s Report Ms Ramsay gave the report as Chair of the PCJC. The report was from the meeting held on 11 February 2016 which was hosted by Lewisham. She highlighted the following:

Primary Care Medical Services Financial Report – at the end of December 2015 there had been a £219k overspend of which £414k was attributed to under deliverance QIPP offset by an underspend on seniority cost and a non-recurrent benefit from 2014/15 accruals.

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Lewisham Primary Care Programme Board – the PCJC ratified the amendment to the Primary Care Programme Board terms of reference.

Contract Variation – the PCJC approved the application for a single handed GP with a PMS contract to take on an additional partner.

Commissioning Intentions for Primary Care PMS Contracts – the commissioning intentions were agreed by NHS England and the CCG as Level two Joint Commissioners for primary care. The CCGs commissioning intentions demonstrated compliance with the national requirements.

Mr Wilkinson added that the local LMC were in formal discussion with the CCG and NHSE regarding local commissioning intentions for the PMS contract.

The Governing Body NOTED the report LEW 16/32 Questions for Members of the Public Q: Will the implementation of the Lewisham Devolution pilot have an impact on the Adult Integrated Care Programmes in areas such as estates? A: Mr Wilkinson responded that the work of the Integrated Programme was including a look at estates, workforce and reimbursement incentives. The development of a business case for the devolution pilot would consider the outputs of this work and develop the case for devolution by June 2016. More information would come back to the May meeting.

ACTION: Martin Wilkinson

LEW 16/33 Board Assurance Framework (BAF) 2015/16 Mr Wilkinson gave the report and highlighted the following:

There was one risk (risk 6a) with a residual risk score of Very High which related to the NHS Constitutional Commitment on waiting times for patients with cancers or suspected cancers. The Integrated Performance Report includes an exception report for cancer waiting times.

Further work was now underway to make the corporate objectives more focussed from which the risks would be identified for 2016/17.

The risk workshop was now scheduled for April 2016. The new BAF would come to the May meeting.

The Governing Body NOTED the report and APPROVED the Board Assurance Framework LEW 16/34 Delivery Committee Chair’s Report Mr Wilkinson gave the Chair’s report from the Delivery Committee meetings of 28 January and 25 February 2016. He highlighted the following:

An exception report on the recovery against the 62 day cancer wait was received. There had been significant progress with 84.6% of patients in December being treated. The 85% standard was expected to be achieved in March 2016 and held thereafter.

Dr Martin Baggaley, Medical Director of South London and Maudsley NHS Foundation Trust, had attended the January meeting to discuss the outcome of their CQC report which had been rated ‘good with some areas of improvement’. An internal review has been commissioned into the timeliness of responding to complaints received by the Trust.

The Committee had received updates on the development of the Operating Plan for 2016/17. One area discussed was an update on QIPP (Quality, Innovation, Productivity and Prevention) which showed further work was required on some plans and the pipeline to be discussed with Clinical Directors and reviewed though the RightCare benchmarking tool.

A focus was being kept on the National Constitutional Standards and KPIs. The slides on Planning 2016-17 and the key plans and assumptions were taken for information.

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Mr Wilkinson responding to a question from Mr Warburton said that RightCare was being reviewed for benchmarking for areas such as people with complex needs and specialities. The tool also provided case studies and was a way of judging with like. In response to a question from Dr McLeod on whether RightCare can be used to support outcomes against the constitutional standards such as cancer, Mr Wilkinson said that information was now being triangulated which could be used by RightCare and would help to identify where to focus. Following up on a further question from Dr McLeod on cancer outcomes in terms of early mortality, Mr Hellier said it was not yet known what was driving the outcomes regarding the cancer wait concerns and that work was underway with public health to identify.

The Governing Body NOTED the report LEW 16/35 Integrated Performance Report 35.1 Performance Mr Read gave the report which presented information by exception and focussed on the challenging issues. He highlighted the following:

Constitutional Standards: Referral to Treatment (RTT) current performance was 91.9% within 18 weeks for Lewisham patients

but year to date the performance was above the 92% standard. Scoping on the back log of patients has been undertaken and it was expected that next year there would be no backlog at LGT, albeit there may be issues at King’s.

A&E delivery had improved at LGT but was not at standard. A consultancy review by Transformation Nous, which was expanding on the One Version of Truth work in early 2015, had been conducted with agreement across the system on the key recommendations being sought. Action plans are being developed across Bexley, Greenwich and Lewisham CCGs and local System Resilience Group (SRG) partners which have identified that the way patients flow through the hospital to discharge had the key impact on emergency department performance on the Lewisham Hospital and Queen Elizabeth Hospital sites.

Cancer – December saw a significant increase in performance across the Trust. Against the 62 day standard trajectory the Trust recorded 84.6% against the standard of 85%. It was forecast that the standard would be achieved by year end. The tracking of patients in the system should reduce performance during February.

In response to a question from Prof David on a date for the CQC visit to the Trust in relation to community services, it was stated that CQC had previously visited the Trust but that the focus had been on the acute services it provided and a further date was not known. Regarding the amber staff vacancy rate Mr Read would look into this and discuss with Prof David outside of the meeting. This would also be discussed at Delivery Committee.

ACTION: Tony Read

In response to a question by Dr McLeod, Mr Read said that an investment had been made for 2015/16 to increase the capacity to respond to complaints especially into complex complaints. The CCG were expecting better results from the investment especially as Ms Browne, Nursing and Quality Director, and her team had also given support. Mr Wilkinson added that this matter had been discussed by the Delivery Committee and CQRG and that there had been an improvement since the report was issued. Dates were now being agreed with complainants for response to complex issues. This would be discussed further at the Delivery Committee with the report expected to include a trajectory of when improvement would be achieved.

ACTION: Martin Wilkinson

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Dr Majid added that one issue was the difficulty with the merger of the Patient Advice and Liaison Service (PALS) teams across the two hospitals. Lessons had been learned and there was now a clearer management process. It was now recognised that it was not good practice to extend the response time to complaints and backlog issues had been identified and dealt with, there was now a forward plan in place. Mr Warburton pointed out that there were issues with complaint responses across all the providers but this was not shown on the heat map, in response Mr Read agreed to split the patient experience data which included the complaints information.

ACTION: Tony Read

In response to a question from Dr Razzaque, Mr Hellier said that it was anticipated that King’s College Hospital would resume reporting on 18 weeks in March 2016 following an 11 month pause; these would be published in mid May 2016. Responding to Dr Razzaque asking if in relation to the prostrate cancer pathway and the MRI pre-biopsy across SE London, should there be more direct access to diagnostics from primary care; Mr Wilkinson said that the topic of diagnostics should be discussed more fully in a Clinical Director meeting and within SEL groups. Dr Abraham agreed that early access to diagnostics was good if it helped with a decision but that criteria needed to be developed for accessing. A joint group from LGT and Greenwich, Bexley and Lewisham GPs with management support, should address as a joint issue acknowledging that there were constraints within the two week wait system.

ACTION: Diana Braithwaite

Dr McLeod said that in relation to the Health Inequality Duty that the prostrate cancer pathway would affect the Black African and Caribbean population as rate of this cancer was higher in this group. Mr Wilkinson said that Clinical Directors should link with SEL groups to agree protocols.

ACTION: Diana Braithwaite

Dr Abraham added that LGT should give a breakdown of A&E attenders by protected characteristics. Mr Hellier responded that he would look at the data on attendees and report to the Delivery Committee.

ACTION: Mike Hellier

In response to a question raised by Mr Bowness on IAPT recover rates, Mr Wilkinson said that a national standardised tool was used whereby a questionnaire was completed before and after intervention. 35.2 Finance Mr Read gave the finance report for Month 10, period to 31 January 2016 and the full year forecast. He reported that at Month 10 the CCG was forecasting to deliver its planned surplus at year end. At Month 10 the CCG’s combined Revenue Resource Limits totalled £409.81m and that the CCG had received allocations for Overseas Visitors of £2.72m as host provider and from the Healthy London Partnership a non recurrent £810k. At Month 10 the underlying surplus position had slightly worsened and had dipped just below the 2% but the CCG was forecasting a breakeven position at year end against its planned surplus of £2.9m. The Better Practice Payment Code had exceeded the 95% target with the invoice from Lewisham Council now paid. Dr Razzaque asked whether the overspend of £113k on termination of pregnancies was due to the cuts in the sexual health budget. Mr Read responded that activity data could be looked at and he clarified that the sexual health contract was mainly through Public Health. Responding to a question from Dr McLeod about the combined acute and community budget and whether the intention was to spend more on community services, Mr Read said that the CCG has a block contract for community services with LGT and Guy’s & St. Thomas’ Trust (GSTT) and that the CCG therefore does not hold the underspend on community services but that the providers may. He agreed that community services should be developed to help support patients at

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home and avoid hospital stay. Dr Abraham added that a service was required where the right skills are provided in the right place for the patient. Dr Ruta explained that the overspend on terminations of pregnancies over the last 3-4 years could be a result of a reduction on the focus of teenage pregnancies by the partnership with family planning clinics being up to capacity. There was a reduction in grant funding for Public Health and that currently 40% of their funding was on sexual health services. There was an aim to rationalise services across London to make them more effective. Subsequent note; Dr Ruta at the end of the meeting, following an email exchange, stated that the problem for the sexual health services capacity was in the main because of population growth, rates had not changed much, in fact the rate of teenage pregnancies had decreased in 2014. The Governing Body NOTED the Integrated Performance Report LEW 16/36 Rapid Governance Review – Phase 1 Mr Wilkinson gave the report and explained that Phase 1 of the Governance Review was a rapid review of the decision making processes across the CCG’s committee structure which was undertaken during December 2015 and January 2016. The aim was to streamline the structure but not to lose assurance. Further phases of work would follow looking at the wider arrangements; this work was currently being scoped. The recommendations were grouped as:

That the CCG’s Governance structure was refreshed to make it a flatter structure with fewer layers of committees and groups to make decisions making it simpler, quicker and more transparent.

The Governing Body has a greater involvement in developing and overseeing the strategic direction of the CCG.

The Governing Body to agree to amendments to the Constitution and Committee Terms of Reference as required.

Indicating the Proposed Governance Structure Mr Wilkinson said that a change proposed was that an Integrated Governance Committee, which would replace the Delivery Committee with the incorporation of FLaG (For Learning Action Group) which was the CCG’s main vehicle for assurance and quality. There would be no change to the Audit Committee, Remuneration Committee, Finance and Investment Committee, Primary Care Joint Committee and Primary Care Programme Board It has been agreed that further work would be undertaken:

To ascertain if all work currently covered by FLaG could be covered by the Integrated Governance Committee. There would be further discussions on this at the March Delivery Committee.

On the Strategy and Development Committee, there would now be a Strategy and Development workshop open to all Governing Body members.

It was recognised that public engagement and equalities was a key function, therefore there was a proposal to develop a workshop for all Governing Body members to attend.

A change of timing for the Public Forum session held prior to the Governing Body meeting was recommended. From May 2016 Governing Body meeting the Public Forum session would be held at 9:30 to be attended by all Governing Body members followed by the in public formal meeting at 10:00 until 12:30, with 30 minutes (to 13:00) for Part II in confidence meeting if required. All revised committee Terms of Reference would come back to the May Governing Body meeting.

ACTION: Susanna Masters

Mr Wilkinson and Ms Masters were thanked for the useful piece of work. The Governing Body AGREED the recommendations of the Rapid Governance Review, AGREED the immediate action proposed and next steps required to implement the recommendations and AGREED the time change for the Governing Body meeting as proposed.

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LEW 16/37 Annual Report and Accounts 2015/16 Mr Read reported that the unaudited Annual Report and Accounts were due to be submitted to NHSE in draft form on 22 April and a final audited version by 27 May 2016. The Annual Report and Accounts would be presented to the CCG Annual General Meeting in September. Mr Read requested that the Governing Body agree the delegation of authority to the Audit Committee to approve the Annual Report and Accounts. Mr Warburton added that it was acknowledged that the timetable was tight for all the staff involved, but that lessons learned from last year resulted in preparation starting earlier this year. The Governing Body NOTED the timeline for the preparation and approval of the 2015/16 Annual Report and Accounts. AGREED the delegated authority to approve the 2015/16 Annual Report and Accounts to the Audit Committee and NOTED the management arrangements in place to prepare the content of the Annual Report and Accounts LEW 16/38 Policies for Approval 38.1 Safeguarding Through Commissioning Policy

Mr Wilkinson reported that the Governing Body was asked to approve a revised Safeguarding through Commissioning Policy pending comments from FLaG. The CCG’s arrangements for Safeguarding Children, Young People and Adults at risk had been assured as ‘Good’ by NHS England in its deep dive. Since the deep dive the Safeguarding through Commissioning Policy had been reviewed and updated to ensure that it was aligned with the Care Act (2015), the new London Multi-agency Adult Safeguarding Policy and Procedures and any other updates to national and local guidance. In response to a question from Mr Read on the point 5.2 ‘every health care provider commissioned by the CCG will be required to send a representative to the CCG Health Safeguarding Assurance Group’ Dr Majid responded that representatives attended from main trusts and private providers, representatives from voluntary organisations do not attend but there was attendance from the local authority who work with them. Prof David asked how the providers were reviewed; Dr Majid responded that the CCG reviews provider policies to ensure that they are being adhered to in areas such as safeguard training. The Health Safeguarding Assurance Group provides scrutiny. Mr Wilkinson added that it was not a contractual obligation to attend the meeting albeit that each organisation has a constitutional governance process related to safeguarding. Mr Hewett agreed to change the wording from require to send a representative to expected to send a representative to.

The Governing Body APPROVED the Safeguarding through Commissioning Policy subject to comment from FLaG which was being held the afternoon of 10 March and AGREED Chair’s action can be taken to approve the policy if significant changes are recommended by the Governing Body or FLaG on 10 March 2016.

38.2 SE London Treatment Access Policy (SEL TAP)

Mr Wilkinson presented the revised South East London Treatment Access Policy (SEL TAP) for 2016. The Governing Body was asked to delegate approval to the Delivery Committee. A question had been raised on this area at the Public Forum session around the evidence base for acupuncture services. Responding to a question from Dr McLeod regarding the proportion of IFRs (Individual Funding Request) funded, Mr Wilkinson said that policy was followed, the IFR panel was for appeals and that there was a triage process. A report on IFR panel activity was shared periodically through CCG commissioning structures. The Governing Body APPROVED delegation for approval of the SEL TAP to the Delivery Committee

LEW 16/39 Strategy and Development – Chair’s Report Dr Abraham gave the report and highlighted the following from the meeting held on 11 February 2016:

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Workshop - The meeting had been open to all Governing Body members and management and

held in a workshop format on the future role of commissioners in the 2020 vision for a whole system model of care. It had been a successful meeting and focussed on the way forward. The Strategy and Development Committee being more developmental was welcomed.

Estates and IM&T Strategies - the IM&T Strategy had been agreed. The interim Lewisham Estates Strategy (LES) had been presented which would support the CCG’s commissioning strategies, development of community based care and NCNs and the improvement in primary care. The next steps would include a review of GP premises and further development.

The Committee NOTED the report LEW 16/40 Potential Audit and Risk Management Issues Mr Warburton said that the Local Auditor Panel would be discussed at the Audit Committee on 29 March 2016. LEW 16/41 Any Other Business There was no other business at this stage of the meeting. LEW 16/42 Questions from Members of the Public Q. Understands that the budget falls outside of CCG remit in regard to teenage pregnancies and the

increase in sexual diseases but how was this referred on, by Health and Wellbeing Board, Overview and Scrutiny Committee or Secretary of State for redress?

A. Mr Wilkinson responded that this would be by the council through the Health and Wellbeing Board whose membership includes Public Health. The Director of Public Health was a member of the Health and Wellbeing Board for the Council along with Executive Director of Community Services, Ms Buckton and Dr Rowland for the CCG. The Council had previously made national representations on the public health budget.

LEW 16/43 Reports Taken for Information The approved minutes from the following meetings were taken for information:

Delivery Committee (December 2015 and January 2016) Strategy and Development Committee (December 2015) Primary Care Joint Committees (December 2015) Clinical Strategy Committee (20 August 2015)

LEW 16/44 Date of Next Meeting The next meeting of the Governing Body would be held on Thursday 12 May 2016, St. Laurence Centre, 37 Bromley Road, London SE6 2TS

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Minute Ref

Action Owner Agreed at meeting

Due Date Status Comments

28 Timescales to achieve the set of competencies to be developed on the different care navigator job descriptions and whether cultural competencies would be a key feature. Feedback would be given to Mr Bowness, who had raised the question, outside of the meeting.

Martin Wilkinson March 2016

Report expected June 2016

Open A report with key findings has been drafted and circulated to key stakeholders across South London. The report will include the developed competencies (JDs). A full report with findings and recommnedations will be circulated when completed.

35.1c Direct access to diagnostics from primary care to be discussed in a Clinical Directors meeting and within SEL Groups. Clinical Directors to link with SEL groups to agree protocols in regards the Health Inequality Duty in relation to the prostate cancer pathway and the high rate amongst Black African and Caribbean population.

Diana Braithwaite Diana Braithwaite

March 2016

May Clinical Directors meeting

Open On the forward planner for the May Clinical Directors meeting On the forward planner for the May Clinical Directors meeting

35.1d To look at the data regarding the breakdown of A&E attendees by protected characteristics.

Mike Hellier March 2016

May Integrated Governance Committee

Open On agenda for May Integrated Governance Committee meeting

14 Engagement plan for the Neighbourhood Care Networks and clarity on the Integrated Primary and Urgent Care service

Dr David Abraham January 2016

When completed

Open A Service Specification is being developed. A full Engagement and Communication pack

Governing Body meeting action log ENCLOSURE 2.1

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diagram to come back. will be circulated for information when finalised.

17.1 JPEG to look at the way in which the Adult Integrated Care Programme is engaging the public

Rosemarie Ramsay

January 2016

To be confirmed Open The current way JPEG is working with partners and the different Programme Boards is being reviewed to improve the effectiveness of sharing the experience and learning across Lewisham.

130.1 OHSEL - JPEG to look at the greater involvement of the council and voluntary organisations in co-ordination in the capture of local engagement data

Rosemarie Ramsay/Charles Malcolm-Smith

Nov 2015 Date of next meeting to be confirmed

Open JPEG is currently reviewing its remit. The CCG is working to support local voluntary groups to share engagement data by using ‘memberoo’ a digital engagement platform

132.2/ 16.04/16/26

In relation to communication between NCNs and housing associations the framework would be sent

Aileen Buckton Nov 2015 and Jan 2016

TBC Open Outstanding action

17 Lewisham Adult Integrated Care Programme – a report to come back with specific outcomes, measures of success and goals for 2016/17

Martin Wilkinson January 2016 and March 2016

May 2016 To be closed

Included in the Chief Officers report to the May 2016 meeting.

07/30 Finance and Investment Committee Terms of Reference to come to March meeting

Tony Read January 2016

May 2016 To be closed

FIC Terms of Reference are on the agenda for the May Governing

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Body 27 Further information on the link

between primary and secondary care services in the Netherlands mentioned in the Chair’s report to be provided to Mr Warburton outside of the meeting.

Dr Marc Rowland to Mr Warburton

March 2016

April 2016 To be closed

Information has been sent to Mr Warburton as requested

31 An update of the business case for the devolution pilot would come back to the meeting.

Martin Wilkinson March 2016

May Governing Body meeting

To be closed

Included in the Adult Integrated Care Programme item in the Chief Officers report.

36 Following the Governance Review all revised Terms of Reference would come back to the May meeting

Susanna Masters March 2016

May Governing Body meeting

To be closed

An agenda item for May Governing Body meeting

12 2016/17 Sustainability and Transformational Plan/CCG Medium Term Plan as a topic for a Governing Body workshop

Martin Wilkinson/Susanna Master

January 2016

April 2016 To be closed

Included in Strategy and Development Chair’s Report

35.1 Performance – To discuss the amber staff vacancy rate at LGT at the Delivery Committee and to Prof David outside of the meeting.

Tony Read March 2016

April Integrated Governance Committee meeting

To be closed

Included in the Integrated Governance Committee Chair’s report

35.1a An update report on responses to complaints to be taken to Delivery Committee to include a trajectory of when improvement would be made.

Alison Browne March 2016

28 April Integrated Committee meeting

To be closed

Included in the Integrated Governance Committee Chair’s report

ACTIONS CLOSED AT MARCH 2016 MEETING 03 The Governance Review to come

to the March meeting.

Martin Wilkinson/Susanna Masters

January 2016

March 2016 Action completed

Report came to the March Governing Body

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10 SE London CCG Collaborative Framework to be supported by Chair’s action and reported back to the meeting.

Martin Wilkinson January 2016

March 2016 Action completed 10 March 2016

This is referred to on the Chief Officer’s report in March 2016

128.2 A report on maternal deaths to be taken to FLaG and reported back to Part II Governing Body

Dr Faruk Majid/Alison Browne

Nov 2015 February 2016 FLaG meeting Part II Governing Body meeting

Action transferred to Part II Governing Body

The report is not yet published; to be considered by FLaG. This action is moved to Part II Governing Body

132.1

An action on how to tackle health inequalities would be taken back to the Adult Joint Strategic Commissioning Group.

Martin Wilkinson/Susanna Masters

Nov 2015

March 2016

Action completed 10 March 2016

Reported through the Corporate Objectives item which is on the March agenda.

134 A report on the impact of the council savings on health to come back to the meeting.

Aileen Buckton Nov 2015 February 2016 Action completed 13 January

The Adult Joint Commissioning Group discussed this item on 13 January

55 Further information on the time commitment for members of the Joint Committee for Primary Care Co-commissioning would be given when known.

Martin Wilkinson July 2015 & Jan 2016

June Remuneration Committee and

Action transferred to Part II Governing Body

A report to come to Part II Governing Body.

35.1b Complaint responses – the patient experience data which includes complaints information to be split.

Tony Read/Mike Hellier

March 2016

March 2016 Action completed March 2016

Complaints is now split out on the integrated governance dashboard

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Chief Officer’s Report Report for May 2016 meeting

1. Our Healthier South East London Programme (OHSEL) (January/February 2016 update) Local plans reflecting wider transformation in health and social care Our south east London strategy to improve and integrate health and care services is part of a bigger picture of change across NHS and social care systems. Recently published guidance outlines a new approach to planning the future of health and care services. NHS organisations are required to produce individual operational plans for 2016/17. In addition, every health and care system is, for the first time, working together to produce a Sustainability and Transformation Plan (STP) covering the period October 2016 – March 2021. This plan will identify how local services intend to become financially and clinically sustainable – ultimately delivering the NHS Five Year Forward View. To do this, health and care systems across the country have come together into 44 geographical ‘footprints’ with a local leader. The organisations in these areas will work together to narrow the gaps in the quality of care, health and wellbeing of different people, and in NHS finances. This process is important because it brings an end to health and social care services making plans in isolation. It requires organisations to work together to make sure services can deliver the best possible care now and for future generations. In south east London, a large amount of this work has already started as part of Our Healthier South East London. The new models of care at the centre of our strategy are the product of partnership working between clinicians, commissioners, social care leads from local councils, local hospitals, patients and members of the public. The STP for south east London is building on our strategy and helps us to make sure local plans fit with national activity. A first draft was submitted to NHS England in April, with a final version agreed by late June 2016, which will be considered by the Strategy and Development workshop, on behalf of the CCG, in June 2016. Elective Orthopaedic Care In March the south east London Committee in Common agreed that there was a sufficient case for making a change in how elective orthopaedic services are provided and that these proposals should progress towards an options appraisal. Following this the committee will agree the possible options that will be considered. If these options could result in a significant change to services, a public consultation would be necessary. The consultation could happen towards the end of 2016. We have been preparing for this possibility by planning how we would work with local people to get their views ahead of a formal consultation, if one is necessary. This ‘pre-consultation’ period is an opportunity to build on our previous engagement work and take a more in-depth look at how a consolidated service could be delivered. We will do this through a wide range of activities across all six boroughs once the possible options are agreed.

ENCLOSURE 4

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Primarily we will aim to hear from communities we think could be most affected by any potential service change – but we will share details of various opportunities for all local people to contribute. Patients and representatives from the voluntary and community sector also examined the ideas for improving orthopaedic care at the Planned Care Reference Group meeting. Attendees explored the clinical case for creating a consolidated orthopaedic service and had the opportunity to quiz orthopaedic surgeons from Guy’s and St Thomas’ Hospital and King’s College Hospital. The director of the South West London Elective Orthopaedic Centre also introduced how their model is improving the quality of care and patient experience. We heard people’s views on the criteria for an ‘options appraisal’ – a process which will help identify the most realistic ways of delivering the potential new model by considering things like effects on NHS staff, the patient experience and how much the changes could cost the NHS to implement. The message from patients was that finance should not trump quality for any new model of elective care. People also felt that pre and post-operative care and reasonable travel times were important. At our next session we plan to look at materials and process for a possible consultation, if one is required. During conversations with local people about our ideas for improving orthopaedic care, some people have expressed concerns about what the impact could be on orthopaedic services at their local hospital. Should our ideas to create elective centres go ahead, most patient care, including after care and follow up appointments, would continue to be provided at local hospitals. So, emergency orthopaedic surgery (at A&Es), outpatient and day case appointments would be provided from the same sites as today. Patients would only go to an elective orthopaedic centre for their planned surgery. Elective orthopaedic centres would be shared facilities which all surgeons would use to treat their patients. Information is available on the OHSEL website Q&A section and using social media such as Twitter (@ourhealthiersel). Maternity We want to do more to make sure women have a safe, personalised and positive experience of pregnancy, including pre-pregnancy health advice, antenatal care and postnatal support. The OHSEL work to date has involved a team of healthcare professionals including obstetricians, midwives, GPs, nurses, mental health specialists, patient representatives and health and social care managers using their experience to suggest a number of ways to improve maternity services, including:

better continuity of midwife-led care with a named midwife for each pregnant woman earlier risk assessment of pregnant women (10 weeks or less) – addressing the evidence

that late access can lead to poorer outcomes for mothers and babies better wellness advice for women delivered through Local Care Networks more midwife-led birthing units and births at home, as well as helping women and their

families make informed choices by providing more information about birthing options

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achieving the London Quality Standards for quality and safety - which include 24/7 consultant presence on labour wards.

More recently, our focus has turned to how these ideas can work in practice at local hospitals and community care services. We think that by working together to address the common issues facing women across south east London, we can deliver better care. A similar group of professionals – our South East London Maternity Network and Delivery Group – are now driving this work forward. Details of how the improvements can be implemented are expected to be finalised towards the end of the year. The initiatives we have come up with locally also reflect the findings in the recently published National Maternity Review. This highlighted the need to give women more personalised maternity care, choice and better communication to help them make informed decisions. The OHSEL website www.ourhealthiersel.nhs.uk has access to more information and opportunities to give us feedback on our ideas for improving maternity services. Patient voices Over the last seven months, the south east London CCGs and the OHSEL programme have been speaking to local people and communities about the challenges facing health and care services. We wanted to explain the problems that are facing the NHS and talk through our ideas of how they could be improved. To help us do this we published an Issues Paper in March 2015 – which set out the challenges and our initial ideas. Since its publication over 1,700 people across south east London giave their views about local services. We wanted to hear a diverse range of views and used a variety of methods including large scale events, focus groups, community meetings, surveys and working with local Healthwatch organisations. A number of themes came up repeatedly during our conversations, including:

continuity of care professional – people need contact with the same healthcare professional access and quality – everyone should have equal access to the same quality of services,

no matter where they live early diagnosis and prevention – supporting people to live healthier lives through education integration, co-ordination and communication – there needs to be better communication

between services with effective IT and data systems to support this person centred care – people want to be treated as individuals not conditions role of carers – this needs to be more strongly recognised and carers should be more

involved in discussions around treatment and care plans awareness of services – people need more information about what services are available

and how to navigate them. All of the feedback we received was extremely valuable and was analysed to help us to refine our ideas for improving services. You can now read the report to find out exactly what local people told us and how we have considered it when developing our plans on the OHSEL website publications (‘You Said We Did’).

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Cancer As the biggest cause of premature and avoidable death in London, we have made improving cancer services across south east London a priority. We know that we do not always diagnose cancer early enough and that some people with cancer wait longer than they should do for their treatment to start.

We want to focus on preventing cancer by helping people live healthier lifestyles. We also aim to increase screening rates so that we detect and diagnosis cancer earlier. This will save more lives and improve the quality of life for people diagnosed with cancer. We have taken the perspectives of clinicians, commissioners, social care leads and other experts, Healthwatch representatives, patients and members of the public to find ways to address these issues. One of the initiatives that we are focussing on is developing training and support for GPs, nurses in GP practices and other staff working in community and primary care. This will help them to better recognise signs and symptoms, ensuring that we can diagnose more patients at an earlier stage. It will increase screening rates and improve outcomes for patients, as well as help staff to provide better support to patients living with and beyond cancer. We are working with several important partners who are helping us to deliver this work including Macmillan Cancer Support, Cancer Research UK and Transforming Cancer Services London. More about our work to improve local cancer services and the two new cancer centres, which will offer first class facilities for local people, one at Guy’s Hospital and one at Queen Marys Hospital, Sidcup, is also available on the OHSEL website. 2. Adult Integrated Care Programme update Over the past month, the Adult Integrated Programme Board has been reviewing the programme priorities for 2016/17 and agreeing the specific activity that underpins them. For 16/17 the Board has agreed to focus on:

Developing the tools, systems and services to enable people to maintain and improve their own health and wellbeing, and to support independent living. This will include the development of signposting tools, specific prevention measures, improving digital access to information and advice, and remodelling of the Single Point of Access; Continuing the development of Neighbourhood Care Networks to support effective working across community health and care services, general practice, wider primary care and the voluntary sector. This will include consideration of what is needed to sustain effective networks into the future; Developing new models for the delivery of community health and care services and improving multidisciplinary working. This will focus on removing barriers and developing new approaches to improve patient experience and satisfaction. Continuing the redesign and development of admission avoidance and hospital discharge services. This will include the development of a rapid response service, ambulatory care unit, home ward and a community discharge and support team.

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Delivery against these priorities will be further supported by continuing our work to ensure that Lewisham has the right estate, IT and workforce in place to achieve a viable and sustainable health and care system. The Board has recognised the need to improve the communication, engagement and co-design with key stakeholders across the system and has committed to improving these aspects of the programme. The new programme plan for 16/17 is currently being finalised and more detail on planned activity will be communicated to the Governing Body in due course. As highlighted previously, Lewisham Council and Lewisham CCG have agreed to be a devolution pilot to assist with the wider understanding of how devolution to London might work. Lewisham is bringing forward a case for change, by June, to test and explore whether being given greater local freedoms in a few areas, including estates and workforce, could help deliver health and social care integration more quickly and/or more effectively across London. We are members of the London pilot sub-group and have been sharing experiences and ideas with others to help inform our case for change; the template for which was recently shared. Better Care Fund Plan The Lewisham Better Care Fund (BCF) Plan is an integral part of the delivery of Lewisham’s Adult Integrated Care Programme (AICP) and will contribute to the delivery of the AICP 2016/17 priority areas (see AICP update above). Lewisham’s BCF plan includes activity implemented in 2015/16 and sets out a number of new areas which will achieve a significant reduction in non-elective admissions to hospital, an improvement in timely discharge from hospital, better access, use and alignment of resources in the community, and an increased focus on prevention and early intervention. BCF funding in 2016/17 has also been allocated to IMT development and estates refurbishment to support new models and delivery of care. The Lewisham 2016/17 Better Care Fund (BCF) Plan has been signed off on behalf of the Health and Wellbeing Board by the Chair and Vice Chair (CCG Chair) of the board and was submitted to NHS England on 3 May 2016 for their review. Monitoring of the activity and performance supported through the BCF will be undertaken by the BCF s75 Management Group and progress regularly reported to the Health and Wellbeing Board. 3. London Borough of Lewisham National Obesity Pilot Status Building on existing activity within the borough to reduce obesity, which includes:

Working towards stage 3 UNICEF baby friendly status Developing a pathway for managing overweight and obese pregnant women Setting up a food partnership Signing up to the sustainable food cities Using participatory budgeting to allow local communities to fund their own healthy weight

initiatives Lewisham has been selected as a national obesity pilot, taking a whole system approach to tackling obesity. Lewisham will also be leading London boroughs in Jamie Oliver’s Sugar Smart Cities campaign.

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A restricted planning policy on hot food takeaways facilities near schools within the borough has already been implemented and as a national pilot restrictions and flexibilities will be identified which if applied or enforced locally could better tackle obesity.

4. Provision of GP IT and CCG IT

Following a re-tendering exercise for a new provider of GP IT and CCG IT in NHS Lewisham CCG alongside colleagues at Greenwich, Lambeth, Lewisham and Southwark CCGs, it has been announced that North East London Commissioning Support Unit (NEL CSU) has been named as the preferred bidder. The tender process included the involvement of a multi-disciplinary panel who helped to evaluate the bid and sat on the decision making panel. A provider was wanted that was focussed on high quality service provision and customer service and NEL CSU clearly demonstrated those qualities during the procurement process. The NEL CSU is expected to take over the running of both services from the current provider from 1 August 2016. 5. Healthwatch

Lewisham Council has awarded the new Healthwatch contract to Healthwatch Bromley and Lewisham. An open tendering process was initiated in December 2015, tenders were evaluated in January and the decision to award the contract to Healthwatch Bromley and Lewisham was made in February 2016. The contract, which started on 1 April 2016, is for an initial period of two years, with an option to extend the contract for a further year. The scope of the contract has been extended to include the provision of the NHS Complaints Advocacy Service. By combining the two contracts, the Council aims to achieve efficiencies and improved outcomes. 6. Integrated Urgent Care update Work on the Integrated Urgent Care Service (111) procurement has continued over recent months. The service specification and KPIs for the new service have been signed off by all six CCGs (Finance and Investment Committee for Lewisham CCG). The updated service specification included feedback from CCGs, NHS England and the inclusion of recent service developments such as the out of hour’s dental nurse triage service. The Procurement Panel is in place and roles and responsibilities have been confirmed to the Panel. The procurement documents were due to be published at the end of April, however, this remains subject to addressing a number of subsequent queries raised by NHS England. Due to the contractual differences in GPOOHs (GP Out of Hours) services across SEL, it had always been stressed that the Integrated Urgent Care (IUC) Service model would focus initially on functional integration across providers once the service was procured and to service go live. It was proposed that as contracts came up for renewal contractual integration would be considered where this was appropriate. NHS England is now looking for contractual integration of providers within the Integrated Urgent Care Service to occur at a quicker rate. They have therefore asked for some particular areas to be addressed prior to signing off the procurement process. These include a more detailed description of functional integration with GP Out of Hours Services and over what

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timeframe Further updates will be brought to the Governing Body as the process proceeds towards procurement. 7. Improving SLaM’s Place of Safety Provision The South London and Maudsley NHS Foundation Trust (SLaM) is proposing to develop a purpose built, central place of safety, based on the Maudsley Hospital site, to receive children, young people and adults who are detained by the Police under Section 136 of the Mental Health Act (MHA). A place of safety, as defined in the MHA, can be any facility which is willing to receive the detained person temporarily. These places are usually in mental health hospitals and in extreme cases in police custody suites. The new Central Place of Safety, to cover Lewisham, Lambeth, Southwark and Croydon, would have the capacity to assess up to six people at any one time in an environment suitable for people of all ages and levels of distress. Currently the local Place of Safety is the Ladywell Unit at Lewisham Hospital. Currently the four Section 136 suites are not fit for purpose as they are too small and can only accommodate one patient at a time. This was confirmed through the recent CQC inspection of SLaM services. These are staffed as part of the Psychiatric Intensive Care Unit (PICU) provision therefore there is no dedicated staffing. If the Place of Safety (POS) is in use this means drawing staff from the PICU wards, clearly this is problematic if PICU is busy and often results in high levels of agency staff potentially making both services unsafe. If a very disturbed patient damages a Section 136 suite, the service can be out of action for days, this causes significant problems for the police. The proposed new service will have a dedicated highly skilled staff team with a high level of medical input making the service much safer and higher quality. The proposal has been supported by the CCG on quality and safety grounds subject to ongoing engagement on operational details with partners as proposals move to implementation. The proposal was presented by SLaM to a Joint Overview and Scrutiny Committee covering Lambeth, Southwark, Lewisham and Croydon on 26 April 2016. As well as raising a number of questions, they asked for further engagement and consultation activities to be concluded. 8. Junior Doctors Strike Tuesday 26th and Wednesday 27th April 2016 saw the first a national strike of Junior Doctors, where cover in Emergency Departments (ED) was withdrawn. The CCGs responsibility as commissioners is to ensure continuity of care for our population. In response commissioners working with local GPs and Trust colleagues in the Emergency Department, piloted GP/ENP triaging for the first time in the Urgent Care Centre (UCC) over the strike period and the following 2 days. In addition, on Friday 22nd April 2016 the CCG issued a scheme to all GP practices to commission additional urgent GP capacity over the period. The scheme compromises of two components;

1. From the 26th April to the 29th April 2016 GP practices held a number of appointments for the UCC/ED to redirect patients to using the Clinical GP practice by pass numbers.

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2. On Thursday 28th April and 29th April 2016 GP practices provided additional urgent GP appointments.

For Lewisham & Greenwich Trust the performance against the 4 hour target at each site improved;

University Hospital Lewisham: Performance improved for the two days of the strike to 98.91% on the Tuesday and 99.24% on Wednesday. Attendances to the UCC and ED department were circa 20% lower. Both the pilot and increased urgent GP appointment capacity will have contributed to the improved performance. However, when attendances returned to expected levels the average performance remained at a higher level of 93.58%.

Queen Elizabeth Hospital: The performance against the 4 hour target at QEH is on an upward trend with no significant changes to performance or the number of attendances at the UCC and ED departments over the two days of the Junior Doctors strike. Performance for the two days was 87.23% on the Tuesday and 84.36% on Wednesday and a weekly average of 88.32%.

9. CCG Stakeholder Survey At the end of April the CCG received its report for the annual stakeholder survey. It forms part of our annual assurance process with NHS England and is carried out independently by Ipsos Mori. The survey collected feedback from our main stakeholders, including the CCG membership, provider trusts, local authority, local Healthwatch and Health and Wellbeing Board members. The overall results are very positive, showing high levels of satisfaction with our engagement, involvement of stakeholders in commissioning decisions, the leadership of the CCG, monitoring the quality of services, and in our plans and priorities. They show also that we compare very favourably with similar CCGs and nationally. Although much improved from 2015, regular involvement with our member practices in the management of the CCG’s finances is still our main development area. Martin Wilkinson Chief Officer – Lewisham CCG 5 May 2016

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Report from the Chair of the Audit Committee

Date of Meetings reported: 29 March 2016 and 19 April 2016 Author: Ray Warburton, Chair of the Audit Committee

Governing Body meeting on 12th May 2016 Meeting held on 29 March 2016 Main issues discussed The Audit Committee discussed the timelines for receiving the draft Annual Report and draft Annual Accounts before the next meeting of the Committee on 19 April 2016. It noted that it would be asked to approve the draft Annual Report and draft Annual Accounts on behalf of the Governing Body, so that they could be submitted to NHS England by 22 April 2016. The Committee, as a key part its assurance work, received a deep dive on the CCG’s development corporate objective; Planning and Control – Engagement and Equalities. The draft Internal Audit work plan for 2016/17 was presented by the CCG’s Internal Auditors, KPMG. The Internal Auditors also reported on the findings from their in-year review of Information Governance. The Committee considered the results of a self-assessment exercise, carried out for it by the Internal Auditors, KPMG. The CCG’s External Auditors presented the Audit Plan for 2015/16 which set out the proposed work to address the risks identified to the audit of the 2015/16 financial statements and to reach the Value for Money (VfM) Conclusion. The Local Counter Fraud Service, provided by TIAA, presented a progress report and its draft work plan for 2016/17. The Committee noted the Terms of Reference and the steps now required to set up the CCG’s Local Auditor Panel, and noted that the Department of Health has published guidance on the Local Procurement of External Auditors for NHS Trusts and CCGs, with NHS England monitoring progress. Key achievements The Committee approved the process for discussing and approving the draft Annual Report and draft Annual Accounts for 2015/16. The Committee made a number of positive suggestions for how the Board Assurance Framework can better describe the risks to engagement and their mitigation. In particular, all protected characteristics should be covered and, if risks are identified, there should be relevant actions to deal with them.

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The Committee approved the Internal Audit plan for 2016/17. There will be reviews of the following emerging areas: the Sustainability and Transformation Plan; Safeguarding adults; Better Care Fund governance; Co-commissioning governance; plus reviews of the following core operations: financial management; information governance; and risk manager. The Committee approved the Counter Fraud work plan for 2016/17. The key risk areas are commissioning; continuing health care; prescribing; integrated working; and other internal risks Key challenges addressed The design and operation of key Information Governance controls was assessed as ‘Partial Assurance with improvements required (amber/red). This rating showed that there was still work to do to demonstrate the minimum Level 2 compliance across all requirements by March 2016. All recommendations are now built into the CCG’s Information Governance work plan. The Chief Financial Officer reported that policies and procedures have since been updated and agreed by the Information Governance Steering Group. The Committee commented on the bunching of Internal Audit reviews towards the end of the year, with work on some reviews spilling over into 2016/17. One explanation was stretched management capacity. It was agreed that in future, efforts would be made to complete reviews in-year. Key risks (include assurances received positive and negative) The self-assessment highlighted the learning and development needs of Committee members, and the need for succession planning given the time-limited nature of members’ appointments. The Committee commended the training provided by the CCG’s Counter Fraud Specialist but asked that its effectiveness is further evaluated. How did the meeting help address inequalities and fairness? During the deep dive discussion of engagement and equality, better ways of engaging with a fuller range of local communities were suggested. Meeting on 19 April 2016 Main issues discussed The Committee considered how to progress the main learning points to arise from the recent self-assessment, carried out for it by the CCG’s Internal Auditors, KPMG. The Committee received the draft Annual Report and draft Annual Accounts for 2015/16.

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It also received a Local Security Management Service progress report and a draft work plan for 2016/17. Key achievements The Committee recognised the need for its members, both individually and collectively, to be as skilled, equipped and up-to-date as possible, in order to carry out their Audit Committee functions effectively. A number of possibilities were identified, which will be pursued with management. In behalf of the Governing Body, the Audit Committee scrutinised and then approved both the draft Annual Report and draft Accounts, subject to a number of changes being made and approval under Chair’s action. The Committee praised officials for all their good and hard work, against very tight deadlines. Both the draft Annual Report and draft Annual Accounts were submitted in time to NHS England and the CCG’s External Auditors on 22 April 2016. The Committee also confirmed the accounting policies that underpin the draft Annual Accounts; and confirmed that the draft Annual Report and draft Annual Accounts were compliant with the requirements of the National Health Service Act 2006. The Committee was pleased to hear that the draft Head of Internal Audit Opinion for 2015/16 was ‘Significant with minor improvements and that assurance can be given on the overall adequacy and effectiveness of the CCG’s framework of governance, risk management and control’. The Audit Committee also approved the Local Counter Security Management Service work plan for 2016/17. Key challenges addressed The Committee noted an instance of non-compliance with HMRC’s VAT regulations, including the under-declared VAT value, interest charges and corrective action taken, and noted the penalties and penalty suspension. Key risks (include assurances received positive and negative) The Committee expressed the view that at Governing Body meetings, the Audit Committee and other CCG meetings, there needs to be more specific monitoring and assurance on community-based care and the Adult Integrated Care Programme. The Committee agreed with the Chief Financial Officer that there is a need to be better at holding providers to account on their responsibilities in security management through the CCG’s contracting arrangements. The Committee felt that aspects of the work on local security management in 2015/16 had lacked impetus. How did the meeting help address inequalities and fairness? A number of suggestions were made by Committee Members to improve the content of the Annual Report with respect to equality and diversity.

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The Committee was pleased that the Internal Auditors will review its low risk assessment for Equality and Diversity in its work plan.

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Report from the Chair of the Local Auditor Panel Date of Meetings reported: 19 April 2016

Author: Ray Warburton, Chair of the Local Auditor Panel Governing Body meeting on 12th May 2016

Main issues discussed The Panel received and noted the Terms of Reference, approved in principal by the Governing Body on 10 March 2016. The Panel noted guidance published by the Department of Health on the Local Procurement of External Auditors for NHS Trusts and CCGs, with NHS England monitoring progress. The Panel discussed the process it is likely follow in helping the CCG appoint its External Auditor for April 2017, and possible co-operation with the other south east London CCGs. Key achievements The meeting on 19 April was the first meeting of the Panel. The Panel confirmed that’s its role is to advise the Governing Body on the selection and appointment of the external auditor, and it will report to either Part I or, for commercially sensitive matters, Part II of the Governing Body meeting. Key challenges addressed The Chief Financial Officer will liaise with his opposite numbers in south-east London to consider an effective way forward so that the CCG’s External Auditor for 2017/18 and beyond can be confirmed by the end of 2016. Key risks (include assurances received positive and negative) Good progress will need to be maintained so that the key milestones are achieved. How did the meeting help address inequalities and fairness? The procurement will be carried out fairly. Ray Warburton 4 May 2016

Enclosure 6

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Governing Body meeting on 12th May 2016

Report from Rosemarie Ramsay MBE, CCG Lay Member and Chair of the Primary Care Joint Committee

Date of Meeting reported: 28th April 2016 Author: Diana Braithwaite, Director of Commissioning & Primary Care

Primary Care Joint Committee with NHS England was held in common with other South East London Primary Care Joint Committee’s covering the other South East London CCGs.

1. Primary Care Medical Services Financial Report At Month 11 there is an overspend of £233k (0.7%) of which £506k is attributable to the under-delivered QIPP – offset by an underspend on seniority costs and a non-recurrent benefit from 2014/15 accruals. The underspend on seniority costs is due to contractual changes emanating from a phased reduction in seniority payments over six years, which has been reinvested in core services effective from October 2015. The other causes of the overspend are due to QOF (£123k). The forecast year end outturn variance based on Month 11 is an overspend of £300k (0.8%) which comprises of £551k QIPP savings under-achievement, an overspend on QOF (£145k) offset by an underspend on seniority cost (£110k) and a non-recurrent prior year accruals (£364k). Lewisham’s weighted population has increased by 0.2% year on year from April 2014 to April 2015.There has been a considerable growth of 2.2% (6,515 weighted population) for the 4 quarters to 1st January 2016. The PCJC noted the report.

2. Performance & Quality Report The PCPB received and noted the new style Performance & Quality Report. The new report draws on the following available data sets;

National GP Patient Survey Care Quality Commission (CQC) reports; Quality & Outcomes Framework (QOF); and Friends and Family returns

3. Primary Care Transformation Fund (PCTF) The PCJC agreed to delegate the review and endorsement of schemes to be submitted to the PCTF to the Primary Care Programme Board (PCPB) – subject to the decision being made by voting members, in accordance with the Terms of Reference for the PCPB. A report on the process and outcome of the considerations will be brought back to the 29th June PCJC.

4. Personal Medical Services (PMS) Review PCJC noted the status of PMS contract reviews in South East London. Subsequently, if NHS England and South East London CCGs are in a position to progress their negotiations before the next PCPB on 29th June 2016, it was agreed the PCJC delegate the review and endorsement of final PMS commissioning intentions to the PCPB. This would be subject to the decision being made by the voting members, in accordance with the Terms of Reference for the PCPB.

5. Standing Operating Procedures for Primary Care Contracts

The PCJC agreed the approach subject to any material changes that may occur following other CCG or London LMCs inputs.

ENCLOSURE 7

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6. Local Improvement Scheme The PCJC approved the Supporting Practice Engagement in Clinical Commissioning Local Improvement Scheme (LIS) 2016/17.

7. Further information Full meeting papers for the Primary Care Joint Committee held on the 28th April 2016 are available at: http://www.lewishamccg.nhs.uk/about-us/how-we-work/PublishingImages/Pages/Primary-Care-Joint-Committee/SEL%20PCJC%20meeting%2020160428.pdf

8. Date of next meeting

The Primary Care Joint Committee in public will be on 29th June 2016. 5th May 2016

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ENCLOSURE 9

Governing Body meeting on 12th May 2016 Report from the Chair of the Integrated Governance Committee Date of Meeting Reported: 24th March 2016 and 28th April 2016 Author: Martin Wilkinson 1. Main Issues Discussed

1.1 Terms of Reference and ways of working - the Committee has discussed and agreed the new Terms of Reference and the ways of working for the Integrated Governance Committee, which now incorporates the functions previously undertaken by FLAG. It was agreed that a further review was required of the Committee’s membership to strengthen the Independent Governing Body representation in order to increase scrutiny and assurance; this is to be part of a wider CCG review of the effective deployment of the Governing Body’s Independent Members. Also, it was agreed a that ‘stock take’ would be undertaken in six months’ time on how effectively the Committee was operating.

1.2 Corporate Objectives - the Committee received an update of the work in progress by the CCG’s Executive Team - to define more clearly the specific priority actions for the developmental objectives for 2016/17, to identify associated risks and to align clinical and staff capacity appropriately.

1.3 Information Governance Toolkit self-assessment – the Committee reviewed the preliminary assessment of the Information Governance Toolkit and delegated final sign off by the SIRO. It was reported that the overall assessment for the IG Toolkit was 82% in 2015/16; a reduction from 85% in 2014/15.

1.4 Review of 2015/16 QIPP Schemes concluded that there had been too many fragmented schemes set up, and that the plans to reduce non-elective activity had not been delivered. However the prescribing, mental health and Referral Support Service schemes had performed well.

1.5 Operating Plan 2016/17– the Committee received an update on the Operating Plan submission on 11th April. Also, an update was provided on the contract negotiations, noting that contracts have been agreed with SLaM, Guy’s and St Thomas’ (GSTT) and King’s. The Lewisham and Greenwich Trust (LGT) contract had been through a mediation process to attempt to resolve the outstanding issues, as the contract had not been agreed.

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1.6 NHS Constitutional Standards - The CCG remained on track to deliver against most standards, or against agreed recovery plans and performance improvement trajectories where standards were not met last year, with the following exceptions:

- A&E: Lewisham and Greenwich Trust’s overall performance delivered 83.7% in February 2016, which is below the trajectory. The rolling year position still shows a marked improvement from the previous year.

- RTT: The 18 week standard remained marginally below the target at 91.7% in February, although year to date performance is above the 92% RTT standard. LGT has developed a specialty plan to address specific issues in Trauma and orthopaedics and ENT.

1.7 Quality – in April, the Integrated Governance Committee focused on the quality of commissioned services delivered by the acute and community providers. The Adult Community Services Dashboard was reviewed and additional information was requested to enhance this Dashboard. It was highlighted that:

the LGT’s staff vacancy RAG rating of red was due to the stepped increase in the staffing establishment as a result of implementing ‘Safer Staffing’ last year. This required Trusts to increase their ratio of nurses to patients. Midwifery Services had achieved this ratio already. The positive trend in sickness rate for LGT was noted and that the current sickness rate was below 5%

LGT had improved the management of complaints. The response rate for complaints had improved to 81% of complaints being replied to within the agreed timescale (January 2016); this stepped improvement had been supported by the CCG investing additional resources. It was recognised, however, that this improvement would need to be sustained, and there remained complaints’ timeless problems at GST and Kings, which are being monitored by the Clinical Quality Review Groups (CQRGs)

the significant improvement in leg ulcer healing rates – see ‘Key Achievement’ below

Never Events – there is an action plan in place to address the high number of Never Events at GST, which is being monitored by the host commissioner, Lambeth CCG.

1.8 Treatment Access Policy (TAP) – the final version of the TAP was agreed, with minor amendments.

1.9 Learning and Development – this is a new standing agenda item for the Committee to reflect on any learning gained from the work of the Committee.

2. Key achievements

2.1 The CCG has delivered its planned year-end financial targets and delivered all statutory financial duties in 2015/16.

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2.2 Community Health Services have seen a significant improvement in the leg ulcer healing rates of 24 weeks from 12% in September 2015 to 86% in February 2016.

2.3 Cancer Waits - February 2016 data shows that 90% of Lewisham patients were treated within 62 days from GP referral to treatment target (up from 82.4% in Jan 16); the rating is now green.

2.4 There has been significant improvement against the A&E 4 hour standard at Lewisham and Greenwich Trust, compared to last year.

3. Key challenges addressed

3.1 The focus of providers is on sustaining improvements to the Cancer 62 day waiting standard, together with A&E 4 hour waits and associated risks as part of Operating Plan discussions.

3.2 Sustaining quality improvements in Community Health Services by undertaking a

more detailed review of the learning from COPD at the next Integrated Governance Committee.

4. Key risks (include assurances received positive and negative)

4.1 A&E: Lewisham and Greenwich Trust will not recover sustainable performance to standard, as planned in 2015/16.

4.2 Despite significant improvement at LGT, there remain delivery challenges around the 62 day wait cancer standard at GSTT and Kings, and risks to the Referral to Treatment Standard, given that King’s has yet to resume reporting. Data should be available for the next Governing Body Meeting.

5. How did the meeting promote quality and safety?

5.1 Through the review of quality reports on a three monthly rolling cycle and by linking quality to financial and other performance metrics.

6. How did the meeting help address inequalities and fairness?

6.1 Delivery of the NHS Constitutional Standards reduces the risk of unequal access to services

Chair of the Integrated Governance Committee Martin Wilkinson 04 May 2016

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A meeting of the Governing Body 12th May 2016

ENCLOSURE 10

Integrated Performance Report M12 2015-16

RESPONSIBLE LEAD: Tony Read, Chief Financial Officer

AUTHOR: Tony Read, Chief Financial Officer Mike Hellier, Head of System Intelligence Paul McAuliffe Head of Financial Management and Planning

RECOMMENDATIONS: The Governing Body invited to note the Integrated Performance Report (encompassing Quality, Performance (to M11) , Finance (M12), QIPP (M12) and Activity (M11). The Report includes:

A summary integrated performance heat map at Appendix 1 An exception report for A&E 4 hour standard at Appendix 2 – NB Cancer Waits 62

Days have delivered the standard in February 2016, so key remaining issues are covered in this cover sheet.

A summary finance report for Month 12 is in this cover sheet.

SUMMARY Quality Performance on responsiveness to complaints continues to be below standard across providers. Performance at Lewisham and Greenwich Trust has improved to 81% of complaints being replied by agreed timescales in January 2016. This is a considerable improvement and moves this from red to an amber rating, but is still short of the LGT plan of 95%. A recovery plan including action plan has been developed and was presented to the Clinical Quality Review Group on 18th February 2016. It should be noted that the measure has changed from responses within xx days to responses within timescales agreed with the complainant. The National Staff survey 2015 was published in February 2016. It shows an overall improvement in staff engagement from 2014 across all providers. For instance, 73% report that the care of service users is my top prioirity at Lewisham and Greenwich NHS Trust, which is higher than 68% in 2014 However, staff reported that they are working longer hours across all providers, and the percentage saying this has increased by 4-5% since the last survey and now stands in the

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range 75% to 79%. The percentage of staff across all South East London acute hospital providers reporting that they experience discrimination at work has fallen (by 4% to 8%), but is still higher than the national average of 10% with a range of 12% to 14% Lewisham and Greenwich NHS Trust has reviewed the staff survey and is developing a refreshed action plan. This will be presented to LGT’s Trust Board and the LGT CQRG. The Care Quality Commission has reported on its review of Guys and St Thomas NHS Foundation Trust with the Trust receiving an overall Good Rating. An action plan has been developed to address the issues raised and the requires improvement for the safety domain. NHS Constitutional Standards In terms of NHS Performance Indicators, the key exceptions are: the A&E 4 hour standard with the London Ambulance Service standard for reaching

Category 1 (potentially life threatened) patients within 8 minutes the Cancer Waiting Times relating to GP Referral to Treatment within 62 days. For

February 2016 this standard was passed for Lewisham people, although there are still issues that need to be resolved with patients referred to tertiary serfvices largely at Guys and St Thomas. There is an emerging issue in the past quarter on the 31 day standard from decision to treat to treatment.

In February 2016 less than 92% of Lewisham patients were on an incomplete pathway under 18 weeks on the Referral to Treatment 18 weeks measure – Lewisham and Greenwich NHS Trust delivered the standard overall.

A&E 4 hour standard Lewisham and Greenwich NHS Trust delivered 83.7%in February 2016. The rolling year position shows a marked improvement from the previous year. An independent review by Transformation Nous extending the One Version of the Truth work in early 2015 has been conducted with agreement across the system on implementation of the key recommendations being discussed. A draft System Resilience Plan has been presented to the System Resilience Executive. The risk register has been updated to show a current risk score of 15 (3I x 5L) against Q6b “There is a risk that the CCG does not commission local health services that meet the NHS Constitution commitments on waiting times for patients at A&E” to reflect that the A&E standard will not be delivered at 95% for 2015/16. Discussion and agreement on the recovery trajectory for 2016-17 are not yet finalised.

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Cancer Waits 62 Days from GP Referral to Treatment February 2016 data shows that 90% of Lewisham patients are treated within 62 days of referral; which is a green rating (see graph below for trend).

There has been a focus on the Patient Tracking List and weekly review at Lewisham and Greenwich Trust over the last three months. While this weekly data is not yet fully validated and is Trust specific, the Trust in March 16 is broadly in line with its Cancer Waiting Time 62 day plan and the backlog reduction plan for those without a Decision to Treat. The next two graphs summarise the position against the trajectories set.

05

101520253035404550556065707580859095

Apr-­‐15 May-­‐15 Jun-­‐15 Jul-­‐15 Aug-­‐15 Sep-­‐15 Oct-­‐15 Nov-­‐15 Dec-­‐15 Jan-­‐16 Feb-­‐16 Mar-­‐16

Cancer  first  treatment  62  days,  GP  referral

Actual

Recovery  Trajectory

Target

40.0%

50.0%

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70.0%

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90.0%

100.0%

Cancer  waits  weekly  data  -­‐ LGT

0

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40

60

80

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Patients  with  no  DTT  over  62  days

Patients  with  no  DTTover  62  Days

Plan

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The Trust planned to reduce the number of patients over 62 days with a decision to treat to 1 patient, but is in fact at 4 to 5 patients over the last few weeks, which is slightly less than the starting position of 6. Lewisham patients are also treated at GSTT and Kings. The percentage of patients treated over the last 4 weeks overall at the two Trusts are: Kings 95 patients treated with 85.2% within 62 days GSTT 116 patients treated with 62.0% within 62 days. It will, therefore, remain challenging for the CCG position to be consistently meeting the standard, since around half of Lewisham patients are treated at GSTT. Inter trust transfer issues are deing dealt with at South East London level via 62 day working group. Referral to Treatment (RTT) On 18 weeks, the standard is reported on the incomplete treatment standard only as per NHSEngland guidance (revised in 2015). February 2016 performance is 91.7% within 18 weeks for Lewisham patients, which is marginally under the standard, but year to date performance is above the 92% standard. Lewisham and Greenwich NHS Trust has met the standard (92.3%), while Guys and St Thomas NHS Foundation Trust achieved 92.2%. Lewisham and Greenwich NHS Trust has developed a specialty plan, especially for Trauma and Orthopaedics and ENT. The CCG has provided funds for additional elective work in Q4 and is working with the Trust to understand the degree to which backlogs will be cleared before 2016-17. NHS England is requiring all Trusts to validate the incomplete list during Q4 and NHS England funding of £54k for LGT has been received by the CCG in Month 11. There is a risk rating system for Trusts, which indicate the degree of forward risk to achieving the standard. Lewisham and Greenwich Trust has been reviewed as medium risk over the last four months; there are issues in the number of weeks (too many) it will take to clear the existing incomplete (waiting) list and those patients waiting over 18 weeks already This forward risk has risen in the last two months, although the Trust has met the standard all the way through 2015-16 to date.. The gap between weekly and monthly reporting has been improved in mid January 2016. Kings College Hospitals has not yet resumed reporting, so a comprehensive report for NHS Lewisham CCG patients will not be available until two to three months after the resumption of reporting. The current planned date for resuming reporting is March 2016 and this will be published in May 2016. The effect of this will be reported to the Governing Body in July 2016

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Improving Access to Psychological Therapies (IAPT) standards

The Q4 IAPT service report indicates that all standards, including the waiting time standards for 6 and 18 weeks, except for recovery rate. This stood at 44.3% against a 50% standard and the plan is that it will take until Q4 2016-17 for this standard to be met.

Dementia Diagnosis Rate In February 2016 NHS Lewisham CCG practices achieved the required standard at 70.4% against a standard of 67% and this is also an improvement from previous months.

Transforming Care (Learning Disabilities - Winterbourne View) There are two main standards to be delivered:

1. Discharge over half of the patients who were in inpatient care pre April 2014 to be in more appropriate settings by the end of 2015-16. Lewisham started with 7 people as inpatients pre April 2014, of which only 2 remain as inpatients.

2. There is a London plan for a 13 per cent reduction of current inpatients. For the post April 2014 admissions, Lewisham had 3 people as inpatients of which there are now 2 in inpatient care.

Finance At Month 12 the CCG has delivered its planned surplus for the full year. The underlying I&E position of the CCG, at 1.94%, has performed marginally (£400k) below the target of 2%. The CCG has exceeded the Better Paymemnts Practice code target of 95% by achieving 97.2%.

Measure    Plan  /  Target   Actual   Variance   RAG  

 Planned  Surplus     £7.6m   £7.6m   £0.0m   G  

 Acute  Expenditure     £223.7m   £224.0m   £0.3m   G  

 Total  Expenditure     £402.3m   £402.2m   £(0.1m)   G  

 QIPP  Delivery     £7.4m   £7.4m   Nil   G  

 Underlying  Position  (2%)     £8.2m   £7.8m  (1.94%)   £(0.4m)   A  

 Better  Practice  Payments  Code     95.0%   97.2%   2.2%   G  

 Cash  Drawdown   £402.8m   £402.7m   £0.01m   G    Maximum  cash  balance  at  31  March    2016     £0.1m   N/A   G  

NHS Clinical Commissioning Groups have a number of financial duties under the NHS Act 2006 (as amended). The CCG has achieved a surplus of £7.6m against the I&E target, staying within the revenue resource limit set and within the limit set for Running Costs.

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The CCG’s performance against those duties was as follows:

Financial  duty   Target   Performance  

Favourable/  (Adverse)  Variance   RAG  

Expenditure  not  to  exceed  income   412.4   404.7   7.6   Achieved  

Capital  resource  use  does  not  exceed  the  amount  specified  in  Directions   0.0   0.0   0.0  

Achieved  

Revenue  resource  use  does  not  exceed  the  amount  specified  in  Directions   409.9   402.2   7.6  

Achieved  

Capital  resource  use  on  specified  matter(s)  does  not  exceed  the  amount  specified  in  Directions   0.0   0.0   0.0  

Achieved  

Revenue  resource  use  on  specified  matter(s)  does  not  exceed  the  amount  specified  in  Directions   0.0   0.0   0.0  

Achieved  

Revenue  administration  resource  use  does  not  exceed  the  amount  specified  in  Directions   6.9   6.1   0.7  

Achieved  

Activity Emergency activity is reported as over plan and elective under plan at LGT. QIPP QIPP schemes have delivered in terms of new activities that are designed to reduce emergency admissions. The shortfall against expected financial savings in relation to emergency activity is caused by the extraordinary increase in emergency activity experienced at LGT, against which the CCG has utilised reserves. Better Care Fund Q3 London Borough of Lewisham (LBL) and NHS Lewisham CCG submitted the quarterly return. It was confirmed that national conditions have been met, except the following, which is in progress. 5) Is a joint approach to assessments and care planning taking place and where funding is being used for integrated packages of care, is there an accountable professional? Joint assessments and care plans are being developed in the Neighbourhood Community Teams. Multi disciplinary meetings ensure the engagement in care plans of primary care, mental health and the voluntary and community sector. The aim remains for joint assessments and care plans to be fully integrated to address physical and mental health and social care needs. The key metrics for Emergency Admissions (4.6% above plan) and Delayed Transfers of Care – Days Delayed for LBL - (59.7% above plan) for Q3.

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CORPORATE AND STRATEGIC OBJECTIVES Delivery of the CCG’s standards for quality, outcomes, NHS constitutional commitments and expenditure plans will assist the Trust in meeting its operating plan, corporate objectives and statutory duties. The corporate objectives specifically target recovery actions to improve the underperforming top performance measures

CONSULTATION HISTORY: Intregrated Governance Committee (previously Delivery Committee).

PUBLIC ENGAGEMENT None The integrated performance report is routinely reported in summary to the Governing Body in public

HEALTH INEQUALITY DUTY The failure to achieve access standards for, in particular, RTT, A&E 4 hour waits and some cancer treatments could potentially contribute to inequitable access to healthcare and poorer or differential outcomes. Significant additional resource has been targeted to improve performance against these targets in 2014/15 and 2015/16. PUBLIC SECTOR EQUALITY DUTY This report does not specifically address the public sector equality duty. The CCG’s quality, outcome and financial objectives are designed to support the delivery of the duty.

STAKEHOLDER INVOLVEMENT To be communicated to the GP Membership

RESPONSIBLE LEAD CONTACT: Name: Tony Read E-Mail: tonyread@nhs.net Telephone: 0203 049 3833

AUTHOR CONTACT: Name: Mike Hellier Email: Mike.Hellier@nhs.net Telephone: 0207 206 3322 Name: Paul McAuliffe Email: p.mcauliffe@nhs.net Telephone: 0207 206 3200 Ext 26509  

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                            Appendix  1  

   

Integrated  Performance  ReportOverview  Integrated  Performance  Heat  Map

Performance  Acute

Recovery  performance  

on  track

Performance  Other

Recovery  Performance  on  Track

Finance QIPP£

Activity.v.  plan  *

Current Forecast Current Current Forecast Current Current

Patient  safety  

A&E  4  hoursIAPT  entering  treatement  

Planned  surplus  forecast  

Emergency  admissions

Emergency  Admissions

Patient  experience  

 18  weeks  RTT

incomplete

 IAPT    RecoveryRate

Acute  expenditure  forecast

RSS  Outpatients  

First  Outpatients

Staff  engagement  

Cancer  waiting  times  2  

week  waits

IAPT  6  week  from  referral  to  treatment

Total  expenditure  forecast

Urgent  Care  Strategy  

A&E  attendances

CQC  Registration  &  Inspection

CQC  Registration  &  Inspection

Cancer  waiting  times  62  days  

Dementia  Diagnosis  Rate

QIPP  Delivery  forecast    

KPIsElective  

Admissions

Complaints  timeliness

Diagnostics  6  weeks

Transforming  Care  

Winterbourne  

Risk  Adjusted  Surplus  forecast  

Mental  Health

Health  Visitors  TBD

Underlying  Position  (2%)  

forecastPrescribing  

LAS  Red  1  Better  Practice  Payments  

Other  

BCF  MetricsCash  

Drawdown  Balance  

Quality  

 Key:    Movement  from  previous  month                      Positive                    Negative                            

Appendix  1  

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Appendix  2    A&E  4  Hour  Waiting  Time  Standard    

   Performance:    February  2016  performance  has  become  more  challenged  than  in  2015.    The  flu  and  respiratory  reporting  has  risen  in  February  and  March  2016,  which  is  later  than  in  the  previous  year.          System  Resilience  Plan  2016-­‐17  Draft    Following  the  Transformation  Nous  and  a  review  of  2015-­‐16,  including  winter  and  Easter  the  following  main  priorities  are  included  in  the  draft  plan  Systems  Resilience  Plan:.    

:Improving  Discharge:  both  for  complex  patients  and  to  bring  simple  discharges  earlier  in  the  day  

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Jan15

Feb15

Mar15

Apr15

May15

Jun15

Jul  15 Aug15

Sep15

Oct15

Nov15

Dec15

Jan16

Feb16

A&E  Performance  LGT  &  UHL

LGT

UHL

Standard

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Delivering  Improvements  to  the  emergency  care  pathway:  both    flow  to  community  capacity  and  medical    model,  including  ambulatory  care.  

Admission  avoidance  through  the  non-­‐elective  'front  door'  service   Increasing  'home    first'  capacity  to  reduce  acute  days  lost  for  patients  waiting  for  social  care  assessment  and  intervention.        

   

As  these  are  largely  about  patient    flow,  no  extra  capacity  is  planned  currently,  but  this  is  dependent  on  the  outcome  of  activity  plans  and  the  linked    demand  and  capacity  planning,  including  escalation  capacity..    

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Date: 03/05/2016. Version: 3.0.

 

 

 

 

 

Integrated Governance Committee (the Committee) brings together the systems and processes by which NHS Lewisham CCG leads, directs and controls its functions in order to achieve organisational objectives and quality of commissioned services, and by which NHS Lewisham CCG relates to patients and carers, the wider community and partner organisations.

The Integrated Governance Committee is a standing Committee of NHS Lewisham CCG, which exists to oversee the delivery of the CCG’s Operational Plan including the implementation of change and the realisation of benefits.

Oversee the delivery of the CCG’s Operational Plan and associated work Encourage a culture of openness and transparency in its reporting and learning and development

To monitor performance against the Operating Plan commitments and targets for: o Quality – covering the three domains of safety, effectiveness and patient experience o Health outcomes – national and local; including meeting the Public Sector Equality Duty o NHS Constitution Standards o Key performance indicators – national and local o Corporate objectives o Activity o Expenditure

To agree and monitor mitigation and recovery plans when delivery is off track

To consider the linkages between performance in terms of quality, outcomes, standards, activity

and expenditure

To identify and address any barriers to delivery

To identify, assess and monitor risks to ensure that in year risks to the delivery of the operating plan are effectively mitigated and brought to the attention of the Governing Body

To review key reports from priority commissioning areas

To identify, escalate, monitor and learn from patient feedback, patient safety and quality incidents and issues. To agree and oversee implementation of mechanisms for sharing learning with providers and to inform future commissioning plans

DRAFT  TERMS  OF  REFERENCE  

NHS  LEWISHAM  CLINICAL  COMMISSIONING  GROUP  

 Integrated  Governance  Committee  

 1. Introduction

 

2. Purpose

 

3. Areas of Focus

 

Enclosure 12 A

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Date: 03/05/2016. Version: 3.0.

Where deep-seated barriers to delivery are identified, which cannot be resolved through routine

corrective action, refer exploration and resolution to the Clinical Directors Committee or Strategy and Development Workshop as appropriate.

To oversee the development, implementation and monitoring of the CCG’s annual Quality Innovative, Productivity and Prevention (QIPP) programme

To track benefits realisation plans following the CCG’s investment decisions

To provide assurance to the Governing Body that the CCG has sufficient grip to deliver its Operational Plan

To ratify clinical policies, protocols, procedures and guidance in accordance with national and local best practice requirements

The Committee will contribute to the CCG’s compliance with the national CCG Assurance Framework.

The Committee will meet on a monthly basis, with meeting dates coordinated to achieve best fit with the availability of timely performance information. Additional meetings may be held if required, for example to review Serious Incidents and emerging clinical risks.

The Committee will be accountable to the Governing Body through distribution of its minutes and work plan in addition to the production of a report detailing its activities at least annually.

The Chair of the CCG is an ex-officio member of this Committee and sub groups with full voting rights.

Core members Chief Officer (Chair of the Committee) 1 Senior Clinical Director – with a lead role for quality (deputy Chair) 2 Clinical Directors Chief Financial Officer Commissioning Director (or deputy) Director of Nursing and Quality (or deputy) Head of Joint Commissioning (or deputy) Lay Member (finance and audit) Representative from Lewisham Public Health In Attendance as required Corporate Director Assistant Director of Nursing and Quality Designated Nurse (Safeguarding & LAC)

5. Meeting Schedule

 

6. Accountability

 

7. Committee Membership

 

4. NHSE CCG Assurance Framework

 

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System Intelligence Manager Head of Public Engagement Medicines Management Advisor Healthwatch Lewisham CCG’s System Resilience Lead Senior Contract Manager(s) of acute, community and/or mental health The Committee is authorised to co-opt other non-voting members as appropriate to its work.

The following members must attend for the Committee to be quorate.

1 Senior Clinical Director 1 Clinical Director Chief Officer or nominated deputy 1 further Director The Chair of the GB and any of the elected Senior Clinical Directors and Clinical Directors present will count towards the meeting being quorate

Committee Members will follow the code of conduct contained in the CCG’s constitution.

The Committee is authorised to establish sub-committees and working groups as required to deliver its terms of reference.

Standing sub groups of the Integrated Governance Committee will be:

Individual Funding Request Panels Prescribing and Medicines Management Group Information Governance Steering Group Urgent Care Network System Resilience Group Health Safeguarding Group

The Integrated Governance Committee is authorised by the Governing Body to:

investigate any activity within its terms of reference. seek any information it requires from any employee or provider of services commissioned by NHS

Lewisham CCG and employees are directed to co-operate with any request made by the Committee Obtain outside legal, clinical or other independent professional advice and to secure the attendance

of external experts and advisors with relevant experience and expertise if it considers this necessary.

The Committee will maintain clear records for the purpose of effective communication, openness and transparency of the process and for accountability.

8. Quorum Rules and Responsibilities of Members

 

9. Subgroups

 

11. Reporting Arrangements

 

10. Authority

 

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The Committee will provide a Committee Chair’s report of its meetings to the CCG Governing Body and the minutes of each Committee meeting will also be provided for information. The Committee may require exception reports to be prepared if it is not assured that the safety, effectiveness and patient experience of the services commissioned by the CCG at least meet minimum standards and show continual quality improvement to achieve the highest possible standards. The Committee may refer issues to the Clinical Directors Committee or the Strategy and Development workshop for further consideration where appropriate. The Corporate Risk Register will also provide the vehicle for escalation to the Governing Body. .

As part of the reporting process to the Governing Body

Terms of Reference will be reviewed annually.

The Committee will be supported by the Corporate Director of the CCG, who will be responsible for:

overseeing of Governing Body and Committee agendas, minimising the duplication of discussion and decision-making

assisting those chairing the Governing Body and Committee with preparation for meetings bringing together in accessible form the reports and information necessary to the support discussion

and decision-making of the Governing Body and the Committee producing and distributing minutes within five working days of meetings tracking progress on actions, identifying and rectifying any lapses in communication.

Meeting dates will be agreed on an annual basis and will not be changed without the permission of the Chair.

Agendas for the meeting will be distributed no less than seven days before the meeting. Papers for the meeting will be distributed no less than seven days before the meeting.

Any exceptions to this will require written notification to the chair, and subsequent agreement on distribution arrangements.

Version Control

Version: Date Changes made 1.0 14/04/2016 Initial Document prepared by David Cotter (SECSU) 2.0 19/04/2016 Susanna Masters, Corporate Director – presented to Integrated

Governance Committee  on 28th April 2016 3.0 03/05/2016 Susanna Masters, Corporate Director – incorporating changes from

the Integrated Governance Committee meeting on 28th April 2016: The purpose to include learning and development (Section 2) The areas of focus – to expand Quality to cover the three domains

13. Monitoring adherence to the Terms of Reference

 

14. Review

 

15. Resources and support

 

12. Escalation  

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and include Corporate Objectives (Section 3) compliance with the national CCG Assurance Framework (section

4) Committee Membership – to exclude Public Health as part of the

core membership; identification of a deputy chair (Section 7) New section on Authority (Section 10) New section on Escalation (Section 12)

 

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TERMS  OF  REFERENCE  NHS  LEWISHAM  CLINICAL  COMMISSIONING  GROUP  

Strategy  and  Development  Workshop    1. Introduction The Strategy and Development Workshop is a standing Committee of Lewisham CCG, which exists to consider strategic context and risks, exploring options and developing a collective view on the CCGs strategic direction and priorities. The format of each meeting will be a developmental workshop. The Workshop will make recommendations on the CCG’s strategic direction for commissioning and develop formal Strategic, Integrated and Operational plans for approval by the Governing Body. It will also develop and maintain the CCG’s formal position in relation to strategic change in the wider health and care economy. 2. Purpose

a) Make recommendations to the Governing Body on the CCG’s strategic direction for

commissioning to best meet population health needs b) Develop strategic, integrated and operational plans in line with the CCG’s strategic direction

and NHS England guidelines

c) Oversee the development, implementation and monitoring of the CCG’s Organisational Development Plan

d) Consider and address major strategic quality themes

e) Consider and make recommendations on major investment/reconfiguration decisions

Ensure effective engagement and consultation is in place with patients, public, clinicians, London Borough of Lewisham and south east London CCGs

 f) Provide feedback and assurance to the CCG Governing Body that equalities responsibilities

are being carried out in the best way and meet legal duties placed on the CCG  

g) Agree and monitor strategies and plans for research and innovation and environmental sustainability and organisational development.

3. Areas of Focus a) Set and maintain the CCG’s strategic direction for commissioning to best meet population

health needs: Ensure effective participation in the development of the Lewisham health and wellbeing strategy, in conjunction with the Health and Wellbeing Board

Take account of population health needs, as described in the JSNA and informed by member practice and other stakeholder input

Take account of the current performance of the Lewisham health system and its relative position in London and with peers across England

Make recommendations on long-term commissioning priorities for health

Enclosure 12 B

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Make recommendations on medium-term objectives in terms of health outcomes, ensuring a clear framework of metrics exists to enable the CCG to set out and track achievement of its commissioning ambition in quantifiable terms

Review priorities and outcomes periodically and recommend adjustments if needed

b) Develop strategic, integrated and operational plans in line with the CCG’s strategic direction and NHS England guidelines:

Develop and maintain a rolling high-level plan for execution of the CCG’s commissioning strategy

Develop formal strategic plans in line with the CCG’s strategic direction and NHS England guidance

Oversee the development of annual (Integrated, Operational) plans and set the strategic framework within which investment and cost reduction measures are considered

Make prioritisation recommendations for investment and disinvestment within available budgets and ensuring best alignment with the CCG’s strategic direction

c) Oversee the development, implementation and monitoring of the CCG’s Organisational

Development Plan: Ensure that the CCG has a strategy and plan for organisational development Oversee the annual Board self-assessment Review key stakeholders and staff survey

d) Consider and address major strategic quality themes:

Review major national policy proposals and requirements around patient safety and clinical quality and determine how they should be best be addressed within the CCG’s strategic agenda

Consider quality themes of a strategic nature, whether proposed by CCG Groups or referred from the Integrated Governance Committee as deep-seated delivery issues

e) Consider and make recommendations on major investment/reconfiguration decisions:

Consider formal businesses for major investments and make recommendations for decision to the Governing Body

Review the implications of major changes in the local provider market and proposals for reconfiguration, and determine what outcome would best facilitate delivery of the CCG’s strategic ambition and to take into account patient experience and the impact on the local population.

Determine the parameters within which delegated individuals can negotiate in reconfiguration discussions on the CCG’s behalf

Make recommendations to the Governing Body on major reconfiguration decisions f) Provide feedback and assurance to the CCG Governing Body that equalities responsibilities

are being carried out in the best way and meets legal duties placed on the CCG by contributing to: • the delivery of annual equality objectives • the achievement and reporting of the CCG Public Sector Equality Duty Approve annual equalities objectives Approve the annual Equality Delivery System assessment

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Ensure effective engagement and consultation is in place with patients, public, clinicians, London Borough of Lewisham and other CCGs and commissioning organisations, in south east London, London-wide, and national where applicable.

Ensure the effective working of joint arrangements in relation to the South London strategy committees

Determine what level and quality of engagement with stakeholders the CCG should aim for in the development of its strategy and plans and seek evidence of compliance

Set standards for the level and quality of engagement with stakeholders which is expected by the CCG in relation to investment and reconfiguration proposals and seek evidence of compliance

f) Agree and monitor strategies and plans for research and innovation, environmental

sustainability and organisational development.

Ensure that the CCG has strategies and plans for research and innovation Ensure that the CCG has strategies and plans for environmental sustainability Ensure that the CCG has a strategy and plan for organisational development

The Committee will contribute to the CCG’s compliance with the national CCG Assurance Framework. 5. Meeting Schedule

The Strategy and Development Committee will meet as a minimum on a bi-monthly basis. with dates co-ordinated to achieve best fit with meetings of the South London joint clinical strategy committees. 6. Accountability

The Committee will be accountable to the Governing Body through the distribution of its minutes and work plan in addition to the production of a report detailing its activities at least annually.

The Committee will have access to regular CCG performance reports, strategies and plans. 7. Committee Membership

A Senior Clinical Director will Chair the Strategy and Development Workshop. Membership may only be changed with the permission of the Governing Body.

Core Members two Senior Clinical Directors (one to chair) four Clinical Directors the Chair of the Governing Body; two lay members Independent Nurse Member Secondary care consultant the Chief Officer the Chief Financial Officer;

The above roles are voting members and the Chair has the casting vote. Additionally, the following appointments on an advisory (non-voting) capacity will be invited to attend in a non-voting capacity:

4. NHSE CCG Assurance Framework  

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In attendance Senior Management Team Public Health Local Authority Healthwatch Lewisham Local Medical Committee

Other representatives may be asked to attend in accordance with the needs of the Agenda.

8. Quorum Rules and Responsibilities of Members

The Committee will be quorate when a minimum of 7 members is present, 4 of which must be clinical directors, one must be either the Chief Officer or Chief Financial Officer and two must be independent members (lay members or Secondary Care Doctor or Registered Nurse).

Committee Members will follow the code of conduct contained in the CCG’s constitution.

9. Subgroups The Strategy and Development Workshop is authorised to establish sub groups and working groups as required to deliver its terms of reference.

10. Reporting Arrangements

The Committee will provide a regular report of its meetings to the CCG Governing Body. 11. Monitoring adherence to the Terms of Reference

As part of the reporting process to the Governing Body

12. Review

Terms of Reference will be reviewed annually.

13. Resources and support The Committee will be supported by a Director of the CCG, who will be responsible for: overseeing of Governing Body and committee agendas, minimising the duplication of

discussion and decision-making assisting those chairing the Governing Body and committee with preparation for meetings bringing together in accessible form the reports and information necessary to the support

discussion and decision-making of the Governing Body and its committees producing and distributing minutes within five working days of meetings tracking progress on actions, identifying and rectifying any lapses in communication.

Meeting dates will be agreed on an annual basis and will not be changed without the permission of the chair. Agendas for the meeting will be distributed no less than seven days before the meeting. Papers for the meeting will be distributed no less than seven days before the meeting. Any exceptions to this will require written notification to the chair, and subsequent agreement on distribution arrangements.  

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TERMS  OF  REFERENCE  NHS  LEWISHAM  CLINICAL  COMMISSIONING  GROUP  

Public  Engagement  and  Equality  Forum   1. Introduction The Public Engagement and Equality Forum is a standing Committee of NHS Lewisham CCG. The format of each meeting will be generally a developmental workshop. The Public Engagement and Equal i ty Forum (the Committee) exists to ensure the Lewisham Clinical Commissioning Group (CCG) has the mind-set, the structures and processes in place to achieve a high level and quality of patient and public engagement and that its approach to engagement promotes equality and diversity and the reduction of health Inequalities 2. Purpose

a) Provide feedback and assurance to the CCG Governing Body that patient and public

engagement is being carried out in the best way and meets the legal duties placed on the CCG.

b) Ensure that information drawn from engagement is taken account of and demonst rated

in the development of CCG strategy and plans.

c) Develop and monitor an annual plan to improve engagement over the year in line with the Public Engagement Strategy.

d) Develop public engagement so that it is both deeper and wider in its scope, providing and maintaining

a timely, accurate and complete view of reported patient experience in Lewisham.

e) Provide feedback and assurance to the CCG Governing Body that equalities responsibilities are being carried out in the best way and meets legal duties placed on the CCG

3. Areas of Focus

a) Provide feedback and assurance to the CCG Governing Body and Committees that patient and public engagement is being carried out in the best way and meets legal duties placed on the CCG:

Provide assurance on the duty to consult obligation

Provide feedback which focuses specifically on the Outcomes Framework domain of patient experience and associated guidance

b) Ensure that information drawn from engagement and equalities assessment is taken account

of in the development of CCG strategy and plans;

Determine the structure of engagement to provide input into planning (April)

Oversee the engagement exercise (May to September)

c) Develop and monitor an annual engagement plan to improve engagement over the year in line with the CCG’s public engagement strategy;

Enclosure 12 C

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Ensure local alignment of engagement plans to maximise collect ive impact, such as engagement overseen by the Health and Wellbeing Board and engagement plans of Lewisham & Greenwich NHS Trust and other local partners, by linking to the Lewisham Joint Public Engagement Group (JPEG)

d) Develop public engagement so that it is both deeper and wider in its scope, providing and maintaining

a timely, accurate and complete view of public feedback and reported patient experience in Lewisham, and that is reflective of the diverse population in Lewisham, and endeavours to reach those groups that may be ‘seldom heard’.

e) Develop and review key measures from patient experience, e.g. national surveys, Lewisham Healthwatch database patterns, changes in choices by patients. These should align to the Outcomes Framework Patient Experience dimensions.

f) Develop feedback mechanisms from clinicians' one-to-one discussions with patients (based on increasing shared decision making between them) and the patient participation groups.

g) Provide feedback and assurance to the CCG Governing Body that equalities responsibilities are being carried out in the best way and meets legal duties placed on the CCG, by contributing to:

the delivery of annual equality objectives the achievement and reporting of the CCG Public Sector Equality Duty

The Committee will contribute to the CCG’s compliance with the national CCG Assurance Framework. 5. Meeting Schedule

Meetings will take place as a minimum on a bi-monthly basis but may be held more often as considered necessary to the meet the requirements of the CCG. 6. Accountability

The Group will provide minutes of its meetings to the Governing Body. Governance support will ensure any insights and suggested actions are communicated to other Committees as appropriate. 7. Committee Membership

The Chair of the CCG is an ex-officio member of this Committee with full voting rights.

The Lay Member with responsibility for Public Engagement will be the Chair of the Public Engagement and Equal i ty Forum Core members CCG Governing Body Lay Member with responsibility for engagement ( C h a i r ) 2 CCG Clinical Directors (one to act as Deputy Chair) Corporate Director Deputy Director (Strategy & Organisational Development) Head of Communications & Engagement (deputy: Engagement Officer) Healthwatch representative In Attendance

4. NHSE CCG Assurance Framework

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All members of the Governing Body and the Senior Management will be invited to attend the Public Engagement and Equality Forum. CCG’s Communications and Engagement Lead CCG’s Equality and Diversity Lead In order to conduct its business, the committee may agree for a sub-group to meet where decisions or assurance requirements fall outside the normal meeting schedule.

8. Quorum Rules and Responsibilities of Members

A quorum will be over 50% of members including one CCG Governing Body member. Committee Members will follow the code of conduct contained in the CCG’s constitution. 9. Reporting Arrangements

The Committee will provide a regular report of its meetings to the Governing Body 10. Monitoring adherence to the Terms of Reference

As part of the reporting process to the Governing Body

11. Review

Terms of Reference will be reviewed annually.

12. Resources and support The Committee will be supported by the CCG Deputy Director (Strategy & Organisational Development), who will be responsible for:

development of group agendas, minimising the duplication of discussion and decision- making

assisting the PEEF Chair with preparation for meetings bringing together in accessible reports and information necessary to the support

discussion and decision-making of the group producing and distributing minutes within seven working days of meetings tracking progress on actions and plans, identifying and rectifying any lapses in communication .

Meeting dates will be agreed on an annual basis and will not be changed without the permission of the chair. Agendas, minutes and papers for the meeting will be distributed no less than seven days before the meeting. Papers for the meeting will be distributed no less than seven days before the meeting. Any exceptions to this will require written notification to the chair, and subsequent agreement on distribution arrangements

Version Control

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Version:   Date   Changes  made  

1.1 28 May 2015 Sections 3 c) and 6 2.0   21st  April  2016   Initial  Document  prepared  by  David  Cotter  (SECSU)  

3.0   3rd  May  2016   Susanna  Masters,  Corporate  Director  -­‐  incorporating  changes  to  reflect  role  regarding  Public  Sector  Equality  Duty  

3.1   4th  May  2016   Deputy  Director  (Strategy  &  Organisational  Development),  incorporating  comments  received  from  clinical  director  and  lay  member  leads  for  public  engagement    

 

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Date: 03/05/2016 Version: 4.0 Status: Draft Approvals: None

NHS LEWISHAM CLINICAL COMMISSIONING GROUP Audit Committee

TERMS OF REFERENCE Version 4.0

 1. Introduction  

1.1 The Audit Committee (the Committee) is established in accordance with the Lewisham Clinical Commissioning Group’s (CCG) Constitution, Standing Orders and Scheme of Delegation. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the CCG’s Constitution and Standing Orders.

 2. Purpose  

2.1 The Committee provides the CCG’s Governing Body with an independent and objective view of the CCG’s financial and control systems, financial and business information and compliance with laws, regulations and directions governing the CCG in so far as they relate to quality, finance, control systems and risk management. The Governing Body has approved and keeps under review the terms of reference for the Audit Committee.

 2.2 The Committee shall critically review the clinical commissioning group’s quality

and financial reporting and internal control systems and ensure an appropriate relationship with both internal and external auditors is maintained.

 3. Areas of Focus  

3.1 Integrated governance, risk management and internal control  

3.1.1The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities that support the achievement of the CCG’s objectives, including core business services provided to the CCG (for example commissioning support services).

 3.1.2 Its work will dovetail with that of any Committee(s), which the CCG has

established to seek assurance that robust clinical quality is in place. In particular, the Committee will review the adequacy and effectiveness of:

• All risk and control related disclosure statements (in particular the Annual

Governance Statement), together with any appropriate independent assurances, prior to endorsement by the CCG.

 • The underlying assurance processes that indicate the degree of

achievement of CCG objectives the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

Enclosure 12 D

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• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

 • The arrangements for and effectiveness of Internal and External Audit.

 • The policies and procedures for and effectiveness of all work related to

fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud and Security Management Services.

 • The arrangements for and effectiveness of services provided by

Commissioning Support providers, including Internal Audit arrangements and alignment with CCG audit plans.

 

3.1.3 In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

 3.1.4This will be evidenced through the Committee’s use of an effective

assurance framework to guide its work and that of the audit and assurance functions that report to it.

 3.2 Internal audit

 3.2.1 The Committee shall ensure that there is an effective internal audit function

that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Accountable Officer and CCG. This will be achieved by:

• Consideration of the provision of the internal audit service, the cost of

the audit and any questions of resignation and dismissal.  

• Review and approval of the internal audit strategic and operational plans and more detailed programmes of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the assurance framework.

 • Considering the major findings of internal audit work (and

management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources.

 • Ensuring that the internal audit function is adequately resourced and

has appropriate standing within the clinical commissioning group.  

• An annual review of the effectiveness of internal audit.

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• Receiving Head of Internal Audit opinions  

3.3 External audit  

3.3.1 The Committee shall review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:

• Agreement of fees

 • Consideration of the performance of the external auditors, as far as the

rules governing the appointment permit.  

• Discussion and agreement with the external auditors, before the audit commences, on the nature and scope of the audit as set out in the annual plan, and ensuring co-ordination, as appropriate, with other external auditors in the local health economy.

 • Discussion with the external auditors of their local evaluation of audit

risks and assessment of the clinical commissioning group and associated impact on the audit fee.

 • Review of all external audit reports, including the report to those

charged with governance, agreement of the annual audit letter before submission to the CCG and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.

 3.3.2 The Committee shall fulfil the role of an Independent Auditor Panel, as described in the Local Audit and Accountability Act 2014

 

3.4 Counter fraud  

3.4.1 The Committee shall satisfy itself that the CCG has adequate arrangements in place for countering fraud. This will be achieved by:

 • Approving the counter fraud work plans and programme. • Reviewing the progress against the counter fraud plan and outcomes of

counter fraud work • Reviewing the effectiveness of the counter fraud service. • Reviewing the CCG’s assessments against NHS Protect’s qualitative

assessments. • Receiving the counter fraud, anti-bribery and other relevant policies • Receiving the counter fraud annual report.

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3.5 Financial management and reporting  

3.5.1The Audit Committee shall monitor the integrity of the financial statements of the clinical commissioning group and any formal announcements relating to the CCG’s financial performance.

 3.5.2The Committee shall ensure that the systems for financial reporting to the

CCG, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the CCG. This will include:

• Reviewing proposed changes to the CCG’s prime financial policies • Reviewing reported losses and special payments • Authorising the write off of debts • Reviewing all instances where requirements of prime financial policies

have been formally waived.  

3.5.3 The Audit Committee shall review the annual report and financial statements before submission to the Governing Body and the CCG, focusing particularly on:

• The wording in the Annual Governance Statement and other disclosures relevant to the terms of reference of the Committee;

 • Changes in, and compliance with, accounting policies, practices and

estimation techniques;  

• Unadjusted mis-statements in the financial statements;  

• Significant judgements in preparing of the financial statements;  

• Significant adjustments resulting from the audit;  

• Letter of representation; and  

• Qualitative aspects of financial reporting.  

 3.6 Management

 3.6.1The Committee shall request and review reports and positive assurances from

directors and managers on the overall arrangements for governance, risk management and internal control.

 3.6.2 The Committee may also request specific reports from individual functions

within the clinical commissioning group as they may be appropriate to the overall arrangements.

 

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3.7 Other assurance functions

3.7.1The Audit Committee shall review the findings of other significant assurance functions, both internal and external, including quality, and consider the implications for the governance of the CCG.

 3.7.2These will include, but will not be limited to, any reviews by Department of

Health arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission and NHS Litigation Authority) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).

3.7.3 The Committee will contribute to the CCG’s compliance with the

national CCG Assurance Framework.

6. Meeting Schedule  6.1 The Committee will meet sufficiently to fulfil its work plan or no fewer than four

times per year as a minimum. The Governing Body reserves the right to call a meeting at any time (with appropriate notice) if an urgent matter arises.

 6.2 The external auditors or Head of Internal Audit may also request a meeting if they

consider that one is necessary.  6.3 A notice period of at least 14 days shall be given before the Committee meets.

The Agenda and supporting papers will be circulated 7 days prior to the meeting.  7. Accountability  7.1 The Committee will be accountable to the Governing Body through the

distribution of its minutes and work plan in addition to the production of a report detailing its activities at least annually.

 7.2 The Committee will have access to regular CCG performance and quality reports,

strategies and plans.  8. Committee Membership  8.1 The Committee shall be appointed by the CCG as set out in the CCG’s

constitution.  8.2 Members:

• Chair – the lay member of the Governing Body who was has qualifications, expertise or experience in financial management and audit matters;

• The lay member of the Governing Body appointed as lead on patient and public participation matters,

• Senior Clinical Director with lead for quality  

• Secondary Care Consultant Governing Body member  

• Registered Nurse Governing Body member  

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8.3 The provisions for appointment and tenure of the members of the Committee are defined in the Standing Orders relating to these posts in the CCG Constitution.

8.4 In the event of the Chair of the Audit Committee being unable to attend all or part of a meeting, he or she will nominate a replacement from within the membership to deputise for that meeting

 

8.5 Individuals in regular attendance but who are not members of the Committee include the CCG’s Accountable Officer, Chief Financial Officer and representatives from internal and external audit services.

 

8.6 At least once a year the Committee will meet privately with the external and internal auditors without any director or senior officer present.

 

8.7 Representatives from Local Counter Fraud Services and NHS Protect may be invited to attend meetings and will normally attend at least one meeting each year

 

8.8 Regardless of attendance, external audit, internal audit, local counter fraud and local security management providers will have full and unrestricted rights of access to the Audit Committee.

 

8.9 The Accountable Officer will be invited to attend and discuss, at least annually with the Committee, the process for assurance that supports the Annual Governance Statement. He or she will also normally attend when the Committee considers the draft internal audit plan and the annual accounts.

 

8.10 Any other directors (or similar) may be invited to attend, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that director.

 

8.11 The Chair of the Governing Body may attend any meeting each year in order to form a view on, and understanding of, the Committee’s operations. However the Chair of the Governing Body may not be a member of the Audit Committee.

 

8.12 The Audit Committee may recruit or co-opt additional members that are independent of the CCG Governing Body.

   9. Quorum Rules and Responsibilities of Members  9.1 The meeting will be quorate when three members are present; at least one of

which must be a lay member.  9.2 The Committee shall conduct its business in accordance with national guidance,

relevant codes of practice including the Nolan Principles and the Conflict of Interest policy. Members should make every effort to attend Committee meetings.

 10. Reporting Arrangements  10.1 The Committee Chair shall report formally to the CCG Governing Body on its

proceedings after each meeting on all matters within its duties and responsibilities. The Chair of the Committee shall draw to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or require executive action. The Committee shall make recommendations to the Governing Body on any area within its remit where action or improvement is needed.

10.2 Items that are confidential or commercially confidential and any associated

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minutes will be reported to the Governing Body not in public.  

11. Monitoring adherence to the Terms of Reference  

11.1 The Group will report to the CCG Governing Body annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Assurance Framework, the completeness and effectiveness of risk management in the organisation and the integration of governance arrangements.

 12. Review

 12.1 These Terms of Reference will be reviewed on an annual basis or sooner if

required with recommendations made to the CCG Governing Group for approval.  

12.2 Any resulting changes to the terms of reference will be approved by the Governing Body.

   

13. Resources and support  

 13.1 The Committee will be supported by a Director of the CCG, who will be

responsible for:  

 • overseeing of Committee agendas, minimising the duplication of discussion

and decision-making • assisting those chairing the Committee with preparation for meetings • bringing together in accessible form the reports and information necessary to

the support discussion and decision-making of the Committee • producing and distributing minutes within five working days of meetings • tracking progress on actions, identifying and rectifying any lapses in

communication.  

13.2 Meeting dates will be agreed on an annual basis and will not be changed without the permission of the Chair.

 13.3 Agendas for the meeting will be distributed no less than seven days before the

meeting.  

13.4 Papers for the meeting will be distributed no less than five days before the meeting.

 32.5 Any exceptions to this will require written notification to the Chair, and

subsequent agreement on distribution arrangements.

     

Version Control Version: Date Changes made 2.0 Feb 2014 Approved by GB

2.1 09/10/2014 Minor changes made for consistent formatting. Added version control box.

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2.2 09/01/2014 Additions to 3.1.2; 3.2.1; 3.4.1; 3.5.2

2.3 4/11/2014 Paragraphs 3.1.1 and 3.2.1 minor changes to wording. Para 6.11 “ex officio” deleted. New paragraphs 6.12, 3.3.2 and 8.2

3.0 13/11/2014 Approved by GB

4.0 03/05/2016 Section 3.7.3 added reference to the CCG’s Assurance Framework Paragraph 8.11 amended to clarify position of the Chair of the Governing Body

 

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 TERMS  OF  REFERENCE  

NHS  LEWISHAM  CLINICAL  COMMISSIONING  GROUP  Finance  and  Investment  Committee  

 1. Introduction  

The Finance and Investment Committee is established as a standing Committee of NHS Lewisham CCG.  

2. Purpose  

2.1 The purpose of the Committee is 2.1.1 to maintain a detailed overview of the CCG’s assets and resources in relation to the

achievement of financial targets and business objectives and the financial stability of the CCG. This will include:-

 • scrutiny and approval of business cases • oversight of the capital programme • oversight of the use of non-recurring budgets, reserves and contingencies • reviewing financial planning assumptions • considering financial risk evaluation, measurement and management •

2.1.2 provide oversight over the CCG’s major procurements  

2.2 As a Committee of the CCG Governing Body it will:  

• Make decisions within the scheme of delegation • Advise and make recommendations to the Governing Body, including investment

decisions that exceed delegated limits Routinely conduct business in confidence, unless expressly stated as public.

   

3 Areas of Focus  

3.1 Business Cases  

• To perform a preliminary review of proposed major investments. • To establish the overall controls which govern business case investments and to approve

the CCG’s Business Case Procedure. • In accordance with the Business Case Procedure and Scheme of Delegation rigorously

review and approve business cases. • To ensure that robust processes are followed, evaluating, scrutinising and monitoring

investments so that benefits realisation can be confirmed. • To ensure testing of all relevant options for larger business cases prior to detailed workup • To focus on financial metrics within cases e.g. payback periods, rate of return.

 3.2 Capital Programme oversight

 

 • To oversee the development and management of the rolling capital programme including

scrutiny of the prioritisation process, forecasting and remedial action  

3.3 Oversight of Non Recurring Budgets

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 • To oversee use of non-recurring budgets not delegated in the CCG budget for specific

purposes  

3.4 Financial Planning Assumptions  

• To consider the Financial Strategy, ensuring that the financial objectives are consistent with the strategic direction and quality and performance priorities.

• To review the long term financial model • To review key medium term planning assumptions

 3.5 Financial Risk Management  

• To review financial risk and advise the Audit Committee and Governing Body accordingly:

• Review and evaluation of key financial risks (e.g. tariff changes, commissioning intentions, achievement of savings, control of recruitment costs, underlying activity levels

• Deep dive into risk management processes around significant evaluated risks linking to Assurance Framework providing assurance around active financial risk management (Note: the formal link between the finance risk register and Corporate Risk Register will be through the Integrated Governance Committee)

3.6 Scrutiny over major procurements

To receive assurance that appropriate procurement routes are considered and selected

Review procurement related risk Monitor procurement process

   

4.1  The Committee will contribute to the CCG’s compliance with the national CCG Assurance Framework.

5 Delegated Authority  

5.1 The Governing Body delegates the above functions to the Committee. The Governing Body also delegates decisions not of a significant nature. In practice what is significant will depend on the judgement of members but committees must refer the following types of issue to the Governing Body.

 Any matter which will:

• Change the strategic direction of the CCG. • Conflict with statutory obligations. • Contravene national policy decisions or governmental directives. • Have significant revenue, capital or cash implications. • Have significant governance implications. • Be likely to arouse significant public or media interest.

5.2 In recognition of 4.1 above the Committee will not make decisions contrary to the

strategic direction of the CCG or agreements made by the CCG at the Strategic Committee in Common for Decision Making. Any such matters will be referred to the Governing Body.

 5.3 The Committee will be expected to take decisions in its areas of responsibility unless

4. NHSE CCG Assurance Framework [New Section]

 

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there are wider implications for the CCG, requiring the matter to be referred to the Governing Body

 5.4 The Governing Body delegates to the Committee the specific function of reviewing and

approving business cases for capital and revenue investment falling within the following categories:

• Business cases with an anticipated annual revenue spend of up to £500,000 per

annum (the highest annual cost). For business cases with an anticipated annual revenue spend in excess of £500,000 the Committee will make recommendations to the Governing Body

• Business cases requiring capital investment up to the value of the CCG’s capital resource limit.

• The Committee is authorised to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience if it considers this necessary

 6 Meeting Schedule  

The Finance and Investment Committee will meet at least 6 times per annum. Meetings may be held more regularly or scheduled as the need arises. 7 Accountability  

The Committee will be accountable to the Governing Body.  

8 Committee Membership  

The Chair of the Finance and Investment Committee will be an independent member of the Governing Body  

The Chair of the CCG is an ex-officio member of this Committee with full voting rights.  

Core members Lay Member for Governance Lay Member for Public Engagement Registered Nurse Member Secondary Care Doctor Member Senior Clinical Directors Chief Officer Chief Financial Officer  

In attendance Head of Finance Management and/or clinical leads as required

 9 Quorum Rules and Responsibilities of Members  

9.1 The following members must attend for the Committee to be quorate:  

At least 2 independent members of the Governing Body of which 1 must be a lay member and 1 a clinician and at least one of either the Chief Officer or Chief Financial Officer

   

9.2 Committee Members will follow the code of conduct contained in the CCG’s constitution. 9.3 The CCG’s Conflicts of Interest policy will be strictly applied

 

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10 Subgroups  

The Finance and Investment Committee is authorised to establish sub-committees and working groups as required to deliver its terms of reference.

 11 Reporting Arrangements  

The majority of Committee business is either confidential or commercially sensitive at the time of decision making. The Committee will routinely report to Part II of the Governing Body. Summary notes, outlining major decisions, will be produced for Part I of the Governing Body meeting held in public, where there is no confidentiality or commercial restriction.

 12 Confidentiality  

12.1 The business and records of the Finance and Investment Committee are confidential by default except where specific confidentiality requirements are deemed not to exist.

 12.2 Confidential minutes shall be maintained, where necessary, for considerations of

confidentiality, including commercial confidentiality. Matters must be treated as entirely confidential by the Committee. Confidential minutes shall be maintained for considerations of confidentiality, including commercial confidentiality.

Matters specifically agreed to be confidential by the Committee must be treated

as entirely confidential. They must be minuted and reported to the Governing Body separately. In addition, All Committee business must be kept confidential until reported to the Governing Body or otherwise concluded, unless the Committee agrees otherwise.

 12.3 Summary reports, outlining major decisions and key messages, will be produced for

Governing Body meetings. Confidential reports will be presented to Part II Governing Body meetings. Non confidential reports will be presented to Part I Governing Body meetings held in public.

 13 Monitoring adherence to the Terms of Reference  

As part of the reporting process to the Governing Body  14 Review  

Terms of reference will be reviewed annually.  15 Resources and support

   15.1 The committee will be supported by a Director of the CCG, who will be responsible for:  

• overseeing of Governing Body and committee agendas, minimising the duplication of discussion and decision-making

• assisting those chairing the Governing Body and committees with preparation for meetings

• bringing together in accessible form the reports and information necessary to the support discussion and decision-making of the Governing Body and its committees

• producing and distributing minutes within five working days of meetings • tracking progress on actions, identifying and rectifying any lapses in communication.

 15.2 Meeting dates will be agreed in advance.  

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15.3 Agendas for the meeting will be distributed no less than seven days before the meeting  15.4 Papers for the meeting will be distributed no less than seven days before the meeting.  15.5 A n y exceptions to this will require written notification to the chair, and subsequent

agreement on distribution arrangements.

Version Control Version: Date Changes made 0.5 15/09/14 Approved by Governing Body

1.0 11/03/2016

Revised to incorporate agreed changes by the Governing Body on 14th January 2016 –    

To  oversee the implementation of major procurements and associated procurement processes (para 2.1)

To revise the delegated authority in terms of £500,000 per annum for revenue expenditure (para 5.4)

To strengthen confidentiality of business (para 12) 1.1 03/05/2016 Revised to clarify interface with other Committees (para 5.2)

 

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Lewisham  CCG  

Draft  Constitution  April  2016  

Summary  of  Changes  

 

 

Change   Location   Commentary  Changes  to  version  number   Title  Page  and  All  Footers   Not  material  Changes  to  Production  Date   Title  Page  and  All  Footers   Not  material  Contents  Page  Updated   Contents  Page   Not  updated  for  last  set  of  

changes  Minor  spelling  mistakes  and  formatting  errors  corrected  

Throughout  document   Not  material  

All  instances  of  NHS  Commissioning  Board  changed  to  NHS  England  

Throughout  document   The  NHS  Commissioning  Board  became  NHS  England  on  1  April  2013  

Additional  sentence  added  to  Foreword  to  reflect  further  changes  made  in  this  iteration.  

Page  4    

Delivery  Committee  changed  to  Integrated  Governance  Committee  

Paragraph  5.2.4    

Changed  all  reference  to  “Clinical  Directors  Committee”,  “Clinical  Directors  Committee  (Executive  Committee)”  and  “Executive  Committee”  to  “Clinical  Directors  Committee  (Executive  Committee)”  for  consistency  

Throughout  document   Not  material  

Paragraph  6.11  added  to  clarify  that  the  Chair  is  an  ex-­‐officio  member  of  all  committees  except  the  Audit  Committee  

Page  24    

Paragraph  3.1.3    box    has  been    removed  

Page  42   Information  is  out  of  date  

Appendix  7  NHS  Constitution  key  principles  updated  

Page  83   NHSE  principles  updated  in  July  2015    

Enclosure 12 F

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Governing Body 12th May 2016 Report from the Chair of the Strategy & Development Workshop Date of Meeting(s) Reported: 7th April 2016 Author: Dr David Abraham 1. Main Issues Discussed

The aims of the first Strategy and Development Workshop were to:

agree the Operating Plan Framework 2016/17.

develop an understanding of the financial challenges faced by the CCG in the next two years.

develop a common view of key priorities, and to agree the priority actions in order to make a difference.

2. Operating Plan Framework 2016/17

An overview was given of the key planning assumptions upon which the Operating Plan had been based. It was noted that the financial and activity assumptions were not significantly different from the information previously presented to the Governing Body Meeting on 16th March 2016.

Following discussion, the Strategy and Development workshop agreed the key planning assumptions for the Operating Plan Submission on 11 April.

3. Financial Challenges

A summary of the financial challenges faced by the CCG was presented. A deteriorated financial position was forecast from 2016/17onwards, due to many factors including changes in national allocations to CCGs, requirements for surplus and non-recurrent allocations.

However, there remained potential opportunities to improve ways of commissioning services. For example, Lewisham CCG had significantly higher numbers of emergency admissions compared to similar/’like’ CCGs. The most recent benchmarking information from the National Rightcare Programme, confirmed that the CCG’s focus should remain on reducing avoidable emergency admissions. Also, it was highlighted that a large proportion of acute expenditure was on planned outpatient attendances.

ENCLOSURE 13

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4. Priority actions to make a difference

The Strategy and Development Workshop session considered how commissioners could reduce and sustain a reduction in emergency admissions working with the current providers during the next two years. The key themes that emerged from these discussions were: Community health care providers - take forward case management, learning

from the Buurtzorg model, to be co-produced with the public and providers; improve the quality of nursing care and professional communication within the broader context of multi-disciplinary team working and workforce development;

GP providers – a continued focus on chronic disease management, self care and self-management for people with LTC; improve GP’s access through a variety of modalities - access by telephone, face to face and virtual; greater use and the development of the wider primary care workforce to free up time for GPs to provide more holistic, personalised care.

Mental health providers - mental health to be woven through all commissioned services and to be a core part of the Adult Integrated Care Programme to deliver parity of esteem; continue to improve, support and care for dementia and psychological support services, which are wider that of IAPT; future plans required for adult inpatient beds

A general observation was made that greater clarity was needed about the Adult Integrated Care Vision for 2020, and the phased implementation to reach this vision. . The Strategy and Development Workshop concluded that the CCG’s main focus should be on developing community based care in 2016/17. It was agreed that the CCG’s Executive Team should ensure that clinical and staff capacity is aligned to deliver the developmental Corporate Objectives which will contribute to taking community based care forward.

5. How did the meeting promote quality and safety?

It was concluded that the re-procurement of Community Health Services would not guarantee the quality improvements that the Members and the public wished to see. It was proposed that the CCG’s use the freedoms within the current contract framework to support and sustain different ways of working and to improve consistency of quality. This will be supported by moving to an outcome based specification and contract with aligned incentives and penalties.

6. How did the meeting help address inequalities and fairness?

It was agreed that mental health and wellbeing should be woven more tightly into all commissioned services to deliver parity of esteem and to be a core component of the Adult Integrated Care Programme.

Dr David Abraham 03 May 2015

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A meeting of the Governing Body 12th May 2016

Enc 14 EDS2 (Equality Delivery System2) –

Completion of EDS2 2015 and EDS2 Summary Report for 2015

CLINICAL LEAD: Dr David Abraham MANAGERIAL LEAD: Charles Malcolm- Smith

Senior Clinical Director Deputy Director (Strategy & Organisational Development)

AUTHORS: Valerie Richards

Equality & Diversity Lead, South East Commissioning Support Unit

RECOMMENDATIONS: The management team is asked to:

Note the report on the completion of the EDS2 2015 process and approve the EDS2 Summary Report to enable it to be published on the CCG website and the NHS England EDS2 Dashboard.

KEY ISSUES: 1. Background 1. Background and purpose

1.1 The EDS2 is an equality performance tool that all CCGs and Providers are required (by NHS

England) to use. The EDS is a vehicle for dialogue which brings together the evidence and perspectives of all stakeholders, including the views of local people, to find areas of potential improvement across the 4 goals – in particular improvements relevant to those who share one or more protected characteristic. The EDS process can only be complete when external stakeholders have had an opportunity to give their opinion on the performance of their CCG. This report provides an update on the completion of Equality Delivery System2 (EDS) process for 2015

2 Completion of Equality Delivery System2 (EDS) process for 2015 2.1 The EDS2 process for 2015 started in April 2015 below are highlights of events for each Goal:

Fig. 1 Lewisham CCG 2015 Equality Delivery System (EDS) Events

EDS2 Goal

Event

1 – Better Health Outcomes

External Stakeholder Panel Event to review evidence and agree EDS Grading – 18 September 2015

2 – Improved patient access and experience

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3 – A representative and supported workforce

Staff Survey – May 2015 Independent review of the Staff Survey responses – December 2015

4 – Inclusive leadership

Independent Review of evidence – 12 April 2016

2.2 The EDS2 Grading agreed for each Goal is outlined in Fig 2 below Fig. 2 Lewisham CCG 2015 Equality Delivery System (EDS) Grading

EDS2 Goal

Grading achieved 2015

1 – Better Health Outcomes

ACHIEVING

2 – Improved patient access and experience

ACHIEVING

3 – A representative and supported workforce

DEVELOPING

4 – Inclusive leadership

DEVELOPING

2.3 The EDS2 Grading for Goal 1 and 2 in 2015 is ‘ACHIEVING’. This means the CCG’s

commissioning of the three services reviewed resulted in people from many of the protected groups having good access and experience of the services compared to people overall, but there is still more to be done to ensure that all protected groups have good access and experiences.

2.4 The CCG grade for EDS2 Goal 3 was agreed as ‘DEVELOPING’. This grade took into account the

results of the Staff Survey which demonstrated that the data available to the CCG supplied data for most of the protected characteristics therefore, overall most staff members from most protected groups fare as well as the overall workforce. However, the results of the independent review of the Staff Survey results highlighted areas that require improvement. An action plan has been prepared and is being monitored by the Equality & Diversity Steering Group.

2.5 The CCG grade for Goal 4 was assessed by an Independent Review as DEVELOPING which

means that more emphasis can be made on Lewisham CCG leading the way on commissioning inclusive health services which meet the specific and general health needs of all people in Lewisham, in particular by focusing on getting services right for those who experience the greatest need and barriers due to sharing one or more protected characteristic. An action plan for improvements in Goal 4 will be developed.

2.6 An EDS2 Summary report with details of the process and evidence reviewed can be found at

Appendix 1. This report needs to be approved by the CCG Governing Body, for publication on the CCG website and the link to the report put on the NHS England EDS2 Dashboard.

3 How does the CCG EDS2 2015 performance compare with 2014?

3.1 In 2014 the overall EDS2 grading for the CCG was DEVELOPING because Developing was awarded for 3 out of the 4 Goals. See Fig 3 below for more details.

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Fig.3 Lewisham CCG 2014 Equality Delivery System (EDS) Grading

EDS2 Goal

Grading achieved 2014

1 – Better Health Outcomes

DEVELOPING

2 – Improved patient access and experience

DEVELOPING

3 – A representative and supported workforce

ACHIEVING

4 – Inclusive leadership

DEVELOPING

3.2 In 2015 there has been improvement in the performance for Goals 1 and 2 with each being

awarded the ACHIEVING grade. 3.3 However, the performance for Goal 3 was downgraded to DEVELOPING in 2015, mainly due to

the results of the independent review of the Staff Survey results. This is being addressed by an action plan.

3.4 In 2015 the result for Goal 4 remained at DEVELOPING even though improvement was noted by

the Independent Reviewer regarding an increase in Governing Body members taking part in the process and improvement in the quality and equality content of some of the reports reviewed.

CORPORATE AND STRATEGIC OBJECTIVES The EDS and its assessment processes support the CCG in meeting its statutory equality and diversity responsibilities.

CONSULTATION HISTORY: The Governing Body previously considered the gradings for goals 1 and 2 at its January 2016 meeting, confirmed at its meeting in March 2016. Governing Body members were requested to complete and submit examples of demonstrating their commitment to equalities inside / outside the CCG in October 2015.

PUBLIC ENGAGEMENT: A stakeholder workshop was held in September 2015 to determine the gradings for Goals 1 and 2.

HEALTH INEQUALITY DUTY: The purpose of EDS2 Goals 1 and 2 is to help organisations to understand if the services they have commissioned are providing better health outcomes and improved patient access and experience. The key question of EDS2 is “How well do people from protected groups fare compared with people overall?” Therefore, when Lewisham CCG carries out the EDS2 it is an opportunity to analyse performance, identify any gaps or areas that require improvement and identify any high risk areas priorities for setting objectives. PUBLIC SECTOR EQUALITY DUTY: The EDS was created by the NHS in response to the

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Equality Act 2010 and if completed well it helps NHS organisations to meet the general and specific duties of the Act. This is because in collecting evidence and engaging with stakeholders the CCG is able to:

Demonstrate how it is meeting the three aims of the general duty to: Eliminate unlawful discrimination or any other conduct prohibited by or under the Act Advance equality of opportunity between persons who share a protected characteristic and

persons who do not share it. Foster good relations between people who share a relevant protected characteristic and

people who do not share it.

Meet the specific duties by using the evidence to inform the Annual Equality Report and to create Equality Objectives.

This report is the first of a range of reports that will set out the EDS process during 2016 and request input, guidance and feedback from the SMT.

RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Charles Malcolm-Smith E-Mail: Charles.malcolm-smith@nhs.net

AUTHOR CONTACT: Name: Valerie Richards E-Mail: valerierichards@nhs.net

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Equality Delivery System for the NHS EDS2 Summary ReportImplementation of the Equality Delivery System – EDS2 is a requirement on both NHS commissioners and NHS providers. Organisations are encouraged to follow the implementation of EDS2 in accordance with the ‘9 Steps for EDS2 Implementation’ as outlined in the 2013 EDS2 guidance document. The document can be found at: http://www.england.nhs.uk/wp-content/uploads/2013/11/eds-nov131.pdf

This EDS2 Summary Report is designed to give an overview of the organisation’s most recent EDS2 implementation. It is recommended that once completed, this Summary Report is published on the organisation’s website.

Headline good practice examples of EDS2 outcomes (for patients/community/workforce):

Level of stakeholder involvement in EDS2 grading and subsequent actions:

Organisation’s EDS2 lead (name/email):

Organisation’s Board lead for EDS2:

NHS organisation name: Organisation’s Equality Objectives (including duration period):

Publication Gateway Reference Number: 03247Page 95 of 179

Date of EDS2 grading Date of next EDS2 grading

Goal Outcome Grade and reasons for ratingOutcome links to an Equality

Objective

Bett

er h

ealt

h ou

tcom

es

1.1

Services are commissioned, procured, designed and delivered to meet the health needs of local communities  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

1.2

Individual people’s health needs are assessed and met in appropriate and effective ways  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

1.3

Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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Goal Outcome Grade and reasons for ratingOutcome links to an Equality

ObjectiveBe

tter

hea

lth

outc

omes

, con

tinu

ed

1.4

When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

1.5

Screening, vaccination and other health promotion services reach and benefit all local communities  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

Impr

oved

pa

tien

t ac

cess

an

d ex

peri

ence

2.1

People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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Goal Outcome Grade and reasons for ratingOutcome links to an Equality

ObjectiveIm

prov

ed p

atie

nt a

cces

s an

d ex

peri

ence 2.2

People are informed and supported to be as involved as they wish to be in decisions about!their care  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

2.3

People report positive experiences of the NHS  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

2.4

People’s complaints about services are handled respectfully and efficiently  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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Goal Outcome Grade and reasons for ratingOutcome links to an Equality

ObjectiveA

rep

rese

ntat

ive

and

supp

orte

d w

orkf

orce 3.1

Fair NHS recruitment and selection processes lead to a more representative workforce at all levels  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

3.2

The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

3.3

Training and development opportunities are taken up and positively evaluated by all staff  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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Goal Outcome Grade and reasons for ratingOutcome links to an Equality

ObjectiveA

rep

rese

ntat

ive

and

supp

orte

d w

orkf

orce 3.4

When at work, staff are free from abuse, harassment, bullying and violence from any source  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

3.5

Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

3.6

Staff report positive experiences of their membership of the workforce  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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Goal Outcome Grade and reasons for ratingOutcome links to an Equality

ObjectiveIn

clus

ive

lead

ersh

ip

4.1

Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

4.2

Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

4.3

Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination  Grade

Undeveloped

Developing

Achieving

Excelling

 Which protected characteristics fare well

Age

Disability

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race

Religion or belief

Sex

Sexual orientation

  Evidence drawn upon for rating

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AUDIT COMMITTEE

Minutes of the meeting held 2 February 2016

Room 1 Cantilever House

PRESENT Ray Warburton OBE (RW) Lay Deputy Chair (Chair), LCCG Prof Ami David MBE (AD) Registered Nurse Member, LCCG Shelagh Kirkland (SK) Independent Member, LCCG Dr Faruk Majid (FM) Senior Clinical Director, LCCG Rosemarie Ramsay (RR) Lay Member, LCCG IN ATTENDANCE Lesley Aitken (LA) Board Secretary (minutes), LCCG Melanie Alflatt (MA) Local Counter Fraud Specialist, TIAA Ali Azam (AA) Manager, Internal Audit, KPMG Diana Braithwaite (DB) Commissioning Director, LCCG (for item 16/06) Alison Browne (AB) Nursing and Quality Director, LCCG (for item 16/06) Matt Dean (MD) Audit Manager, External Audit, Grant Thornton Sarah Ironmonger (SI) Engagement Lead, External Audit, Grant Thornton Fleur Nieboer (FN) Director, Internal Audit, KPMG Tony Read (TR) Chief Financial Officer, LCCG Martin Wilkinson (MW) Chief Officer, LCCG APOLOGIES None for this meeting AC16/01 Welcome and introductions RW welcomed all to the meeting and introductions were made. A welcome was given in particular to Shelagh Kirkland (SK) who was newly appointed to the post of Independent Member of the Audit Committee who brings to the Committee her particular experience as a chartered accountant. Sarah Ironmonger (SI) was also welcomed as an External Audit representative on the Committee replacing Sue Exton. AC16/02 Declarations of Interest There were no interests declared which would knowingly affect the business of the meeting. A declaration of interest form would be sent to SK. Due to a potential conflict of interest the Internal and External Auditor attendees would leave the meeting for the Local Auditor Panel item.

Enclosure 15

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AC16/03 Minutes of the last meeting The minutes of the meeting held on 6 October 2015 were agreed as a correct record AC16/04 Matters arising 04.1 Action Log The action log was updated and revised. 04.2 Any matters not covered on the action log None received at this point on the meeting. 04.3 Glossary of Terms The glossary was received, any additions to be sent to Ms Aitken (LA). AC16/05 Internal Audit 05.1 Progress Report FN gave the report and confirmed that the Workforce Management – design of arrangements review had been completed and the fieldwork for the reports for Information Governance, Management of CSU and Workforce Management; test of operations had commenced. The Better Care Fund Governance Terms of Reference (TORs) had been agreed but the timing of the review was yet to be finalised. The previously agreed review of Procurement, because of the lack of a clinical case study, has been replaced by a Data Storage and Security review of Joint Commissioning. TR explained that the competitive process had been delayed therefore the body of evidence for the procurement review was limited. The risk of how secure and protected the PID (Person Identifiable Data) was at Adult Joint Commissioning had been highlighted because of Information Governance work. The procurement review would be undertaken later in the year. FN reported that since the last Audit Committee six recommendations had been raised from the workforce management review. There were three recommendations outstanding from the Risk Management report, of these one medium priority was not yet due and two low recommendations were overdue. The KPIs were on track. The Annual Plan for 2016/17 would come to the March meeting. The Technical Update was noted. Responding to RW on why the reports were bunched at the end of the March, FN said that there had been a delay due to not being able to obtain all the information required from the CSU. TR added that the Information Governance toolkit would be going to the March Delivery Committee. The draft Internal Audit Plan 2016/17 would come to the March Audit Committee meeting which would look at the phasing of reports.

ACTION: Internal Audit

In response to a question from AD, TR said that the review of data storage would look at the design of the arrangements for keeping data safe and that there was a fraud investigation underway on client groups where data currently sat.

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In response to a comment by RW, that it was unfortunate that there was not enough core activity to undertake the review of procurement, TR said that the core business was community healthcare which was predominately through the healthcare provider which doesn’t include competitive procurement, it had been proposed to undertake the review around urgent care centre but this has now been paused. TR explained that after scoping the procurement review it was decided that there were not enough examples. FN added that last year IA did a review of Conflicts of Interest which looked at procurement. TR continued that a paper had gone to the Finance and Investment Committee on Community Services which detailed how the service had not gone out to competitive tender. RW said that the draft Internal Audit Plan which was coming to the March meeting should include activity around procurement. Referring to the Technical Update and the national tariff update and 2016-17 draft prices, TR stated that each year there was a consultation around PbR (Payment by Results) and the CCG was working with the draft prices for contract negotiations. 05.2 Results of the Audit Committee’s Self-Assessment AA said that the results of the Audit Committee’s self assessment would come to the March meeting. The results were dependent on various bodies giving their returns, as not all of these had been received the analysis was not yet completed. Once completed this could be shared by email before the next meeting.

ACTION: Internal Audit 05.3 Draft HoIA Opinion FN reported that the TDA has requested the draft HOIA Opinion by 22 February. A Significant Assurance with improvements was forecast. More medium term risks had been raised this year than last but that this was expected as the first two years of the CCG there had been core internal assurance, now more areas were being found with less significant assurance. 05.4 Internal Audit Reviews

Workforce Control Process AA reported that the workforce arrangements have been reviewed and that an overall assessment of ‘partial assurance with improvement required’ had been given. The review had raised five medium priority and one low priority recommendation. IA looked at three areas; workforce management, workforce planning and recruiting and workforce reporting of which each element had aspects that could be improved. Workforce planning – found that there were short term plans in place for staffing but no formal plans in place for medium or long term. Recruitment – there were processes in place for permanent staff with guidance and documentation though some areas could be improved. For interim staff all processes were on a short term basis with no medium or long term plans in place. Workforce Management Report – the CSU produces the report for the CCG which was found to be produced for the CCG as a whole and not by department. Regarding the amber recommendations AA stated that:

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1. Workforce Planning – it was recommended that the CCG set up a workforce plan which aligns with the Strategic Plan, to be reviewed and updated annually.

2. Employment checks – that the CCG’s employment policy, though set by the CSU, the CCG should ensure that it was updated annually and to take in the points raised by the review.

3. Content of the Workforce Report – that the content of the workforce reports should be expanded to incorporate the points raised by the review.

4. Tracking of actions – that actions arising from the review of workforce management should be given a deadline and delegated a responsible officer.

5. Temporary Recruitment Request Form (TRRF) – to be standardised to provide better information.

All recommendations had been accepted by management. TR said that controls were important and agreed that the CCG does not have a formalised medium term process for interims. He reminded the Committee that last year MW consulted staff on a new staffing structure which took into account the needs of the organisation. MW added that the CCG would plan for commissioning for outcomes in future in liaison with CSU staff. RW said that it was a good report and acknowledged the full support of the management. TR confirmed that staff turnover was low, staff numbers were low and with less staff it meant there was less opportunity internally for progression, which was the main reason staff left the CCG. MW added that there had been independent work undertaken following the staff survey on retention and equalities. Exit interviews were undertaken. FM stated that the community workforce planning for Neighbourhood Care Networks (NCNs) should be considered with NHSE. MW added that the Organisational Development Plan was a roadmap for commissioning intentions and that we need skilled staff in the provider organisations. How to know what skills and competencies for staff would be needed would need to known for future market development. The Committee NOTED the reports AC16/06 Board Assurance Framework 06.1 Deep Dive – Neighbourhood Care Networks and Primary Care DB and AB joined the meeting to present the reports. RW requested in future that there be a written report in the set of papers, if necessary management could help the authors. RW continued that at the Delivery Committee the risk to achieving the RTT and Cancer constitutional standards was highlighted. The Q6 risk ‘operational grip – delivers the operational plan, including the NHS Constitutional Standards’ has now been broken down into four risk areas to be tracked separately. Referring to the Referral Support Service (RSS) and public engagement risk DB stated that the RSS was launched in July 2014 and that patient surveys were conducted until March 2015. DB highlighted the following in the report and provided responses:

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1. Satisfaction was noted as 90% not 85% as indicated in the assurance column which indicated the BAF had been out of date.

2. It was not mentioned in the BAF that the survey was introduced to 20% of the practices only.

It was reported in July 2015 that concerns had been raised by a member of the public at the Governing Body and also by the CCG’s Public Engagement Group (PEG) about patient feedback on RSS. A risk was then raised on the BAF.

A dedicated interim Primary Care Engagement Manager had been appointed in November with one of the key tasks being to address and evaluate patient feedback on RSS. A Patient Evaluation Report on RSS had been completed and was shared with the meeting.

Bexley Health Ltd are required as part of the contract for the pilot to send out patient surveys to 20% of referrals received by GPs each month, which contains 12 questions.

The review by KPMG suggests that the BAF was not kept up to date. However, this is a misinterpretation of the information contained in BAF. The figure of 85% relates to the target for the number of patients rating their experience as excellent. The table in the report presented shows that the target set was delivered and at no time during the period (July 2014 to March 2015) was the monthly figure ever 90%.

On reviewing the patient surveys and the RSS patient evaluation report none had rated the service as poor; 95% expressed the view that the RSS had improved their experience of the referral booking service.

As a part of the QIPP monitoring reports on RSS are taken to the Delivery Committee by exception.

Patient Engagement Plan (Evaluation Report) was to test patient engagement and feedback on RSS and how this might be improved within the scope of the contract. The patient engagement report interviewed 42 patients from four practices reflective of the four neighbourhoods. The key recommendation is that the percentage of questionnaires is increased to 30% with a return rate of 25%.

Choose and Book was now at 63% with a forecast to reach the target of 75% by March 2016.

Lessons learned should include that the CCG should develop a better understanding and definition of why it believed something was a risk, and how much information should be included on the BAF MS Excel spread sheet – recognising that the system would be changing.

In response to a question on whether the CCG were appropriately focussing on long terms risks, DB responded that the risks were generated as a result of the corporate objectives each year. The key risks in her opinion for the future were; (i) co-commissioning and moving to level 3 (delegation); and (ii) the primary care provider contract and what would happen after the initial two years. Discussions are being held and the CCG Primary Care Strategy is being refreshed. SK asked what the number of complaints had been following 29,000 referrals through RSS. DB responded that there had only been one written complaint last year and that was when the national booking system had gone down in the summer and the CCG temporarily suspended RSS as a consequence. This was also included as a risk on the BAF and mitigations were put in place. In response to AD’s comment on level 3 delegation, DB responded that the Commissioning Intentions were being recommended for approval to the Primary Care Joint Committee (PCJC) on the 11th February. Level 3 delegation had been discussed at the Finance and Investment Committee and the Strategy and Development Committee.

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TR added that the level of details required by the Governing Body and Audit Committee was normally within the BAF process which would give the level of assurance to mitigate risks. How to test and challenge recommendations from IA would be discussed at the Risk Management Group (RMG).

ACTION: Martin Wilkinson

The Chair commended and thanked DB for an exemplary report with almost no notice.

Neighbourhood Care Networks: DB reported that the NCN risk reflects the corporate objectives and an update on this developmental objective was reported to the Strategy & Development Committee in October 2015. DB advised the board that although she was the overall owner of the risk there were a number of workstreams with delivery that sat across the whole system. DB added that there was an Integrated Care Board in place which consisted of four different organisations with a shared risk register. AB provided an overview of the Enhanced Care and support work stream. The redesign and specification of four integral services had been audited which raised issues around provider capacity and capability to delivering the service/s. The Out of Hospital wards and the Admissions Avoidance Service was being redesigned, which would include processes to prevent patients coming into hospital. MW added that the Adult Care Integrated Programme linked enhanced care with NCNs in relation to risk stratification. He explained that enhanced care was when a crisis has been reached or there was a fast deterioration. There was now a definition of Neighbourhood Care Network which had been developed by the CCG, GP Federations, LGT and the Local Authority. There had been an issue with scope creep of the specification. Following the IA review a lessons learned report had been developed which would feed into the specification and would link with conversations regarding QIPP, admissions avoidance and supported discharge. AB reported that there were pilots in progress looking at where the savings would go which included QIPP. In response to a comment from RW on the link between assurance gaps to actions, and that these were now better thought through, MW stated that at the beginning of the year the corporate objectives were not known but that there was now a clearer roadmap into 2016/17 and 2017/18 which gave clarity on risks and vision. He acknowledged that the Governing Body had less sight of NCNs than the Membership. DB added that the Risk Management Group (RMG) reviewed all risks and implications on the corporate objectives. MW acknowledged that it had not been articulated where this sat in relation to Governing Body informing management on their risk appetite. The CCG needs all its partners on board to support the Adult Integrated Care Programme. AD said she was encouraged by the progress made, but that there was a need to look at all the approaches and not to create silos. RW said that assurance was demonstrated that processes were working well.

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The Committee NOTED the report 06.2 Current Improvements – verbal It was noted that a new risk management system, Datix, was being introduced which would improve the format of the BAF. The Committee NOTED the report AC16/07 Service Auditor Report (SAR) Interim Report TR gave the report which highlighted the arrangements for the South East CSU support arrangements for the current year. The timetable and deadline for 2015/16 year-end SAR was taken for information. The SAR report provided assurance to CCGs that its internal controls are effective. Deloitte are the Service Auditors. The reporting period for year-end Service Auditor reporting has moved to 29 February 2016 with a bridging letter covering the period 1 March 2016 to 31 March 2016, this would give greater confidence to the Audit Committee and External Audit that reports would come through in better time for the Annual Report and Accounts reporting. This would allow for a little time if anything significant had happened which needed further discussion. The Committee RECEIVED the South East CSU Service Auditor Report and NOTED the timetable for October 2015 to March 2016 and the arrangements for the reporting gap. AC16/07 Local Counter Fraud Specialist (LCFS) 07.1 MA presented the LCFS Progress Report which included the progress of the counter fraud work to date against the Fraud Risk Assessment, the counter fraud plan, the Fraud Stop Newsletter, the summary of the feedback from the fraud and bribery awareness training and the NHS Protect Circular on FAQ’s regarding complaints with NHS Standards fro Commissioners. This was the fourth report from TIAA for 2015/16, the report set out the work carried out since the last Audit Committee meeting against the LCFS work plan. MA reported that TIAA had completed the Fraud Risk Assessment for the CCG, and that results were being discussed with CCG management. The Counter Fraud Annual Plan for 2016/17 would be informed by the outcomes of the Fraud Risk Assessment. The latest edition of Fraudstop! had been sent to all CCG staff, via email, intranet and through a staff briefing. It was suggested that a copy should go onto GPi to raise awareness to GPs and colleagues. A copy was presented in the report for the Audit Committee’s information. The Antifraud and Bribery policies are to be aligned and would be presented at the next Audit Committee meeting for approval. There had been three mandatory training sessions for CCG on Fraud and Bribery awareness which included a discussion on conflicts of interest. In total 42 members of staff attended the sessions which had included a session with Governing Body members. The sessions had been well received and feedback was included in the report for information.

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In response from a question from RW on the smaller private companies undertaking a Provider Organisation Crime Profile (OCP), MA responded that TIAA are helping those that request further assistance. Only those organisations with a contract value of £200k and over need to complete the profile. RW said that the Committee looked forward to receiving the Counter Fraud Annual Plan for 2016/17 at its next meeting. The Committee NOTED the reports AC16/08 Local Security Management Service (LSMS) TR gave the progress report that include a description of a workshop attended by LSMS in November 2015 that had been organised by NHS Protect to discuss the expectations in regards to Security Standards for Commissioners. TR reminded the Committee that the LSMS contract was for 10 days a year. It was agreed that the LSMS update would be added to the LCFS report from the next report to the Committee.

ACTION: Melanie Alflatt AC16/09 External Audit Report SI introduced the report and handed over to MD to present. MD reported that the progress report set out the planned timeframes reporting dates for the 2015-16 External Audit. He highlighted the following:

The formal Accounts Audit Plan was on track for the March meeting. The scope of work to inform the 2915/16 VfM conclusion had been revised by the National

Audit Office to ensure that the CCG has arrangements in place for best use of resources for; informed decision making, sustainable resource deployment and working with partners and third parties.

A cross sector review of audit committee effectiveness has been published. Hard copies of the report would be circulated to Committee members.

ACTION: Matt Dean/Lesley Aitken The Committee NOTED the detail of the report AC16/10 Annual Accounts Timetable and Plans 2015/16 and Month 9 Hard Close TR gave the reports. 10.1 Workplan (incorporating lessons learned) and Timetable The Annual Report and Accounts timetable and workplan has taken into account the key lessons learned identified in the reflective session. The key lesson highlighted in relation to the Annual Report was early preparation and that setting a firm deadline for comments. The guidance had slightly changed for the 2015-16 annual report with more focus on performance against the Constitutional Standards. A steering group would oversee the compilation of the annual report and accounts with the Deputy Director for Strategy and OD to have operational oversight as

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project lead and would link with management to ensure engagement with staff and teams across the CCG with accountability to the Chief Officer. There would also be a Readers Panel. The steering group would present the draft annual report and accounts to the Audit Committee. The Audit Committee, with delegated responsibility from the Governing Body, would approve the report on behalf of the CCG. The unaudited draft annual report and accounts were to be submitted to NHSE by Friday 22 April with the final reports to be submitted by Friday 27 May 2016. TR stressed that the draft in April needed to be as complete as possible. RW felt that the revised system was clearer. The Overview (last year called the Strategic Report) would need to be evidenced and relate to last year. At the March Delivery Committee stock would be taken on what was going to be reported on performance for the annual report. In response to a question from RW on where equality featured, TR said that this would be included throughout. The report would look at how the CCG’s objectives were met last year plus a look forward. RW confirmed that members of the Audit Committee would need to be independent of the production of the Annual Report as far as reasonably possible. 10.2 Governance Submission 21 January 2016 The early draft governance nil return was noted. 10.3 M9 Accounts TR reported that the account templates had been completed using Month 9 data which would identify problems before the close of accounts. The audited set would have the statements and notes which do not apply stripped out. The four financial statements for the year ended 31 March 2016 are:

1. Statement of Comprehensive Net Expenditure 2. Statement of Financial Position 3. Statement of Changes in Taxpayers Equity 4. Statement of Cash Flows

TR highlighted the following:

The increase in trade debtors and creditors, this was not unusual at M9. The cash flow forecast takes this into account.

Reductions in education and research was less than last year The additional charitable expenditure was due to the McMillan provision. Recorded staffing needs more narrative There is a miscoding on the supplies/services general note GP/PMS/GMS was low as did not have the performance element of the incentive

scheme The percentages for the BPPC were missing, it was known these exceeded 95% The operating lease was for the two copiers at Cantilever House The provisions note has to be completed by the end of the year.

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The figures were correct for the related party transactions note but these would change significantly with more disclosures

In response from a query from RW on the staff sickness absence and ill health retirement figures, TR said that this was due to one person who had been off sick long term, a narrative would help explain this. 10.4 Accounting Policies TR said that as explained earlier those notes and statements which did not apply would be stripped out and others expanded with further explanatory narrative. External Audit would review 1.7.1; Critical Judgement in Applying Accounting Policies and 1.7.2; Key Sources of Estimation Uncertainty. The Accounting Policies would come back to the April Audit Committee meeting. The Committee RECEIVED the Annual Report and Accounts workplan and the Month 9 accounts, NOTED the early draft governance nil return and APPROVED the accounting policies AC16/11 Planning for the commencement of Local Audit Arrangements and the

establishment of the Local Auditors Panel Internal and External Audit representatives left the meeting for this item. TR reported that it now the responsibility of the CCG to appoint its own External Auditor and directly manage their contracts for the audits for the financial year April 2017. The first step would be to set up a Local Auditor Panel to advise and oversee the auditor appointments. It has been agreed that the Audit Committee would form the Local Auditor Panel. These arrangements were shown in the revised TORs of the Audit Committee which went to the Governing Body for information. Discussions had been held between Audit Chairs and CFO’s in SE London on whether to procurement individually or jointly. It was agreed to have a single panel across the six CCGs. The panel would be set in good time so that by the end December 2016 the External Audit service could have been appointed for 2017/18. RW requested that the Terms of Reference for the Panel to go to the Governing Body for approval.

ACTION: Tony Read/Ray Warburton

RW confirmed that there would be one process for appointing the Auditors and that it would useful to have further conversations with SE London Audit Chairs and CFOs on the process. There had been pros and cons to having the same Auditors across the six CCGs. Any further information from these discussions would be passed onto the other Committee members if relevant. TR said the Committee should be aware that KPMG, the CCG’s Internal Auditors, may wish to undertake the External Audit provision but that could cause a conflict of interest. The Committee NOTED the requirement to appoint the external auditor for financial year 2017/18 onwards, NOTED the contents of Gateway Reference 04604 and AGREED the procurement arrangements and deadline

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Internal and External Auditors rejoined the meeting. AC16/12 Consultants over £50k TR reminded the Committee that all contracts over £50k required prior approval by NHSE. Two applications have come to the Committee for noting. Adult Integrated Care Programme Support £180k for the duration of six months; this was approved subject to the CCG providing the AICP TORs and structure to NHSE. This was an extension to the existing contract. Strategic Communications and Engagement Support £120k duration of four to six months; this was approved. This was through a competitive process and had been discussed at Part II of the Governing Body meeting. There would be a report next meeting on the ‘one version of the truth’ work which had been submitted to NHSE but not confirmed as yet. A rolling log of these contracts would be kept and brought to each Audit Committee meeting.

ACTION: Tony Read

TR confirmed that use of interim staff was not part of this process. The Committee NOTED the approval of two applications for consultancy over £50k AC16/13 Review of losses and special payments TR confirmed that there were no new losses or special payments made since the last meeting. AC16/14 Waiver of SFIs TR that the waiver for the AICP support contact would be circulated. This was a waiver due to being an extension of an existing contract.

ACTION: Tony Read

AC16/15 Business of other committees and review inter-relationships There was nothing in particular to note here. AC16/16 Any other business There was no other business reported at this time. AC16/17 Summary of key messages to report to the Governing Body The following was summarised by RW:

BAF and Risk Appetite workshop on 4 February The Delivery Committee feeding into the performance report part of the Annual Report Internal Audit Workforce Report Local Auditors arrangements Deep dive into Neighbourhoods and Primary Care risks – that assurance had been gained

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LCFS reports The External Audit process to follow at the end of the year and timetable

AC 16/18 Date of next meeting Tuesday 29 March 2016 14:00 – 17:00 at Cantilever House

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Actions closed at the last meeting

Minute Ref

Action Owner Agreed at meeting

Due Date Status Comments

05.1 Draft IA Plan 2016/17 to come to the next meeting.

Internal Audit February 2016

March 2016

Action to be closed

Draft IA on the Audit Committee agenda for

29 March 05.2 Results of the Audit Committee’s self-

assessment to be circulated to members before the March meeting if available

Internal Audit February 2016

March 2016

Action to be closed

On the Audit Committee agenda for 29 March

06.1 Discussions to be held at the Risk Management Committee on how to challenge IA recommendations

Martin Wilkinson

February 2016

16/08 LSMS to be incorporated into LCFS items from March meeting

LCFS February 2016

March 2016

Open To be actioned when the next LSMS report is

expected 16/09 Hard copies of the cross sector review of Audit

Committee effectiveness to be circulated. External Audit February

2016 Action to

be closed The review has been

circulated. 16/11 Terms of Reference for the Local Auditor’s

Panel to go to Governing Body for approval Tony Read February

2016 March Governing Body

Action to be closed

This is on the agenda for the March

Governing Body meeting

16/12 Contracts for consultants over £50k to be reported to each Committee meeting as a rolling log

Tony Read February 2016

March 2016

Action to be closed

New style reported from March Audit Committee

16/14 Waiver for the AICP contract to be circulated. Tony Read February 2016

March 2016

Action to be closed

New style reported from March Audit Committee

Minute Action Owner Agreed Due Date Status Comments

Enclosure 2

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Ref at meeting

15/103.1 The Workforce Control Process Audit Report to be circulated with an action plan when finalised.

Tony Read October 2015

Feb 2016 Closed On the agenda for the February 2016 meeting

15/105 Briefing to go to Delivery Committee on neuro- rehab.

Martin Wilkinson/Dee Carlin

October 2015

March 2016 Delivery Committee

Closed To go to the March 2016 Delivery Committee

15/106.3 If possible, to place a financial value on the number of fraud reports from commissioners. An awareness survey on LCFS training to be completed with a report back to the Committee

Melanie Alflatt October 2015 October 2015

Feb 2016 Feb 2016

Closed A verbal update to be given at the meeting On the agenda for the February 2016 meeting

15/83.1 Report to come back on lessons learned from the preparation of the Annual Report and Accounts.

Tony Read/Susanna Masters

July 2016 Feb 2016 meeting

Closed On the agenda for the February 2016 meeting 6.10.15: The action plan from the preparation of Annual Report and Audit exercise to be circulated to AC members following discussion at SMT

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AUDIT COMMITTEE

Minutes of the meeting held 29 March 2016

Room 1 Cantilever House

PRESENT Ray Warburton OBE (RW) Lay Deputy Chair (Chair), LCCG Prof Ami David MBE (AD) Registered Nurse Member, LCCG Shelagh Kirkland (SK) Independent Member, LCCG Dr Faruk Majid (FM) Senior Clinical Director, LCCG Rosemarie Ramsay MBE (RR) Lay Member, LCCG IN ATTENDANCE Lesley Aitken (LA) Board Secretary (minutes), LCCG Melanie Alflatt (MA) Local Counter Fraud Specialist, TIAA (from 27.4) Ali Azam (AA) Manager, Internal Audit, KPMG Matt Dean (MD) Audit Manager, External Audit, Grant Thornton Sarah Ironmonger (SI) Engagement Lead, External Audit, Grant Thornton Charles Malcolm-Smith (CMS) Deputy Director, Strategy and OD (for items 25/26) Marie Montgomery (MM) Interim Corporate Administrative Manager (Interim) Fleur Nieboer (FN) Director, Internal Audit, KPMG Tony Read (TR) Chief Financial Officer, LCCG Martin Wilkinson (MW) Chief Officer, LCCG APOLOGIES Dr Mark Hamilton (MH) Secondary Care Doctor, LCCG AC16/19 Welcome and introductions RW welcomed all to the meeting and introductions were made. In particular he welcomed Shelagh Kirland, the new independent member of the Committee. MM introduced herself and explained that she is the temporary Interim Corporate Administrative Manager (covering a secondment) and would be shadowing LA at the meeting. AC16/20 Declarations of Interest There were no interests declared by members which would knowingly affect the business of the meeting. Due to a potential conflict of interest the Internal and External Auditor attendees would leave the meeting for the Local Auditor Panel item. AC16/23 Minutes of the last meeting

Enclosure 15.1

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The minutes of the meeting held on 2 February 2016 were agreed as a correct record AC16/24 Matters arising 24.1 Action Log 06.1 TR reported that the importance of appropriate responses to Internal Audit recommendations, including confirmation of timelines and owners, had been discussed at the Risk Management Group. 16/08 TR advised that LSMS reports would be provided for the next meeting. Reports will remain separate and the LCFS will represent the LSMS, in his absence, at Committee meetings. The action log was updated and revised. 24.2 Any matters not covered on the action log 05.3 Draft HoIA Opinion FN confirmed that the draft HoIA Opinion had been completed and sent by the Chief Financial Officer to NHSE by 22 February. Copy to be circulated to Committee members after meeting.

ACTION: Tony Read 24.3 Glossary of Terms The glossary was received. RW asked that any additions or requests for clarifications to be sent to LA. AC16/25 Annual Report and Accounts 2015/16 TR introduced the item and explained that the Governing Body, at its March 2016 meeting, had agreed to delegate the authority for the Audit Committee to approve the 2015/16 Annual Report and Accounts. CMS, joining the meeting, circulated an update on the Annual Report preparation and confirmed that the draft would be circulated to the Committee by Friday 8 April in time for colleague’s comments to feed into the report by management before the Audit Committee meeting on19 April. The unaudited draft Annual Report and Accounts would be submitted to NHSE for Friday 22 April at 9am. It was recognised that the deadlines were tight. TR stated that the draft Annual Accounts would not be available one week before the 19 April meeting and would be circulated at the earliest opportunity. CMS explained that all the sections had some content but required updating. Committee members said that the Overview and Performance Analysis sections were an opportunity to tell the CCG’s story, with the balance being right between good news stories and where the CCG needed to do more work. FM felt that the readability and clarity of the report was key and that the Committee members needed to see the documents in time to allow for comments. The Audit Committee NOTED the timeline, NOTED that the Governing Body had agreed delegated authority to approve the 2015/16 Annual Report and Accounts to the Audit

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Committee, NOTED the management arrangements in place to prepare the content of the Annual Report and Accounts AC16/26 Board Assurance Framework – Deep Dive CMS gave the deep dive report on the development corporate objective; Planning and Control – Engagement and Equalities. He said that there were two risks on the BAF; 1) whether public engagement was not perceived to be meaningful and 2) being dominated by a single issue. CMS explained that OHSEL work was influencing public perception on the SEL models of care thereby providing assurance. He highlighted the following:

The deep dive by NHSE of the CCG’s engagement activities, reviewing these against the Annual Public Engagement record.

Substantive appointments to the Engagement Team The development of a local Public Engagement Plan which has been approved by the

Public Engagement Group (PEG). The Memberoo IT solution which supported engagement activity. Regular reports to PEG and JPEG on engagement and patient engagement activity Lessons learned included: the need to develop relationships with community groups such

as Vietnamese and Young People; the need to have better and clearer messages around areas such as Neighbourhood Care Networks (NCNs), to ensure internally that all commissioning plans include an engagement plan.

CMS added that the Risk Register and Board Assurance Framework provide assurance that the risks and their mitigations were being met. RR queried whether the risk descriptions on the BAF were sufficient and if they aligned with the Engagement Plan. She added that through the recently held Governance Review PEG would now be held workshop style to allow for discussion and the setting of targets. There was a need to look at the gap analysis on areas which needed to be targeted such as the Lesbian, Gay, Bisexual and Transgender (LGBT) groups. RW felt assured that management was on top of identifying the risks which flowed through the BAF and that some gaps were being identified and acted upon. However, it was important to fully identify the gaps and the action needed to manage and mitigate risks. Sometimes the read-across is not as good as it could be. RR asked for more narrative on the second risk. MW added that more needed to be done across the board including the area of services working together. CMS said that there was now focussed and meaningful engagement on NCNs.

ACTION: Charles Malcolm-Smith RW thanked CMS for the report. The Committee NOTED the report. AC16/27 Internal Audit FN introduced the item 27.1 Draft 2016/17 Work Plan

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FN gave the report on the plan which indicated reviews completed in the last two years, areas where some coverage was required to achieve the HoIA Opinion, potential risk based reviews for 2016/17 and potential reviews for future years. She added that the phasing of reviews was over five years. TR explained that some areas are required to be reviewed annually for the HOIA Opinion, and that we have flexibility for other reviews through the risk approach. FM asked whether IA would review the new internal committee structures around quality management. FN responded that IA had no concerns over the design of the new arrangements. MW added that management would review the new governance arrangements through the Risk Management Group as part of good practice. In response to a question from RR on the low aggregated risk rating for Equality and Diversity TR suggested that the risk matrix scores low risk ratings for stable and internal control systems. FN said that they could revisit the assessment. 27.2 Progress Report FN reported that for 2015/16 reviews had been completed for:

Financial Management – financial control environment assessment Information Governance Workforce Management – design of arrangements Risk Management

The Workforce Management – test of operations review and Management of CSU contract review would come to the May Committee meeting. Scoping was underway for the Data Management review and the timing was to be finalised for the Better Care Fund Governance Review. Since the last Committee meeting three recommendations had been raised from the review into Information Governance. There were six outstanding recommendations in relation to the Workforce Management report, of these, four were medium priorities, one low priority recommendation was not yet due and one medium priority recommendation was overdue. TR said that a Workforce Report went to a Senior Management Team (SMT) meeting monthly and there were identified issues around the report not being standardised and there not having adequate recording of actions, timelines and those responsible. In response to a comment from RW, TR said that the timings of reviews would be reviewed to avoid the bunching of reports at the end of the year. He added that some delays were due to management capacity. For example, the CCG needs to build contract management resource for the CSU contract. FN added that IA would compile a list on whom to contact for reviews in specific areas to avoid delays. MW added that the corporate objectives looked at capacity issues. The Committee NOTED the Progress Report and recommendation tracker and APPROVED the draft Internal Audit Plan and NOTED the Technical Update 27.3 Results of the Audit Committee’s Self-Assessment FN introduced the Audit Committee Self-Assessment Survey which was undertaken across 17 CCGs, she highlighted that the survey was undertaken a while ago and the score was the actual

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against the ideal. She said that the key points to highlight included overseeing the financial reporting and risk management and internal control. Committee members discussed some of the main findings, including ensuring that members feel equipped and supported for their role, and that succession planning is prioritised. RW requested that the self-assessment and any good learning areas which flowed from the report be discussed by the Audit Committee outside of the meeting.

ACTION: Ray Warburton/Audit Committee members

RW pointed out the Committee’s financial expertise was enhanced by the appointment of SK and that risk appetite/tolerance considerations were being addressed. There was now a full membership with the recent appointment to the secondary care doctor role. The Committee NOTED the Self-Assessment 27.4 Internal Audit Reviews

Information Governance FN introduced the report and said that all the recommendations were medium priorities. AA said that the design and operation of key Information Governance (IG) controls and an overall assessment of Partial Assurance with improvements required (amber/red) had been given. This rating showed that there was still work to do to demonstrate the minimum Level 2 compliance across all requirements by March 2016. Of the sample of six requirements selected for review, three of those scored a reasonable assessment; the other three were not agreed, as additional information would be required by the March 2016 deadline to demonstrate the minimum Level 2 score required by the Department of Health. The following areas were identified for improvement;

Business continuity Remote working Policies and procedures

TR said that policies and procedures have since been updated and agreed by the Information Governance Steering Group. The 31 March deadline was for submitting evidence in support of the 2015/16 toolkit. This has subsequently been reported to the Delivery Committee where agreement to the SIRO’s recommended 82% score was made. He highlighted that the reference to the SLA in the audit report under the policies and procedures recommendation was incorrect. The CCG’s SLA in force at the time of audit had an expiry date of 31 March 2016 (not September 2014). This date has since been extended by six months whilst the CCG prepares to use the Lead Provider Framework to procure future CSU services. All recommendations are now built into the CCG’s IG workplan. In response to a question TR said that there was planned ICT business continuity testing and that all directorates had resilience plans in place. The CCG’s SMT has reviewed which elements of the CCG’s business have critical operations and which are less critical.

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TR confirmed that the review was designed to cover only six out of the 25 IG toolkit requirements relevant to CCGs and as such the review’s findings are relevant to the 6 standards reviewed but not replicated across the full range of the CCG’s Information Governance arrangements. RW queried the IA assessment of ‘Partial assurance with improvements required’ given that the CCG scored well on the Information Governance Toolkit. However, in discussion it was agreed that in identifying a number of development points, the assessment was fair and balanced. The Committee NOTED the report AC16/28 Local Counter Fraud Specialist and Local Security Management Services MA gave the reports. 28.1 Draft 2016/17 Audit Plans MA said that the report showed the NHS Protect and Counter Fraud Service compliance work and the work undertaken on behalf of the CCG to meet the requirements. Under the section Prevent and Delay which asked if the organisation had processes in place for preventing, deterring fraud, bribery and corruption MA said that the CCG had budgeted for 22 days to meet the requirements. She confirmed that the RAG ratings linked to the NHS Protect Standards for Commissioners came from the Self Review Tool (SRT). The key risk areas were:

Commissioning Continuing Health Care Prescribing Integrated working Other internal risks

Days were now not allocated to specific tasks but total days were used which allowed flexibility. Responding to a question on the Counter Fraud awareness training, TR said that the training was mandatory and compliance was on track. TR and the LCFS are considering ways to evaluate how embedded the training material is with staff.

ACTION: Tony Read/Melanie Alflatt The Committee APPROVED the work plan with the caveat to evaluate the training. 28.2 Progress Report Since the last meeting the work plan had been developed which ensured compliance with the Self Review Tool (SRT) from NHS Protect. NHS Protect have issued an overview of the 2016/17 standards and a summary of changes for 2016/17. The full version of the standards would be published as soon as the NHS Standard Contract was issued. MA explained that the Standards for Commissioners are how NHS Protect measured the CCG’s fraud processes. 28.3 Fraud Risk Assessment MA reported that the Fraud Risk Assessment exercise had been concluded for 2016/17 but that the document would be reviewed to consider any new or upcoming risk areas during 2016/17.

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She confirmed that TIAA would undertake large scale investigations unless they were across borders which are undertaken by the national team. MA highlighted that prescribing fraud such as dispensing irregularities and patient services was a key area. NHSE are the commissioners of the service but that the financial impact was borne by the CCG. Referring to the diagram on the NHS Protect Q3 Commissioners Statistical Taxonomy Report, MA said that she would compare the number of information reports made in Q3 to those made in Q2 and report back.

ACTION: Melanie Alflatt 28.4 Local Security Management Service (LSMS) TR noted the disappointment of the Committee that the LSMS report was not included in the papers. A draft work plan and progress report would come to the next meeting. The Committee NOTED the report AC16/29 External Audit 29.1 2016/17 Audit Plan and Progress Report SI presented the Audit Plan for 2015/16 which set out the proposed work to address the risks identified to the audit of the 2015/16 financial statements and to reach the Value for Money (VfM) Conclusion. The Plan also gave the results of External Audit’s Interim Audit and the proposed fee for 2016/17 work. SI explained that to plan the audit work plan External Audit would need to understand the challenges and development areas which the CCG would face. One of the high risk areas identified was Secondary Healthcare commissioning and that External Audit had undertaken a review of the CCG’s processes and controls over this area but that further work and review was planned for 2016/17. For the VfM Conclusion the criteria for auditors to use was; in all significant respects the audited body takes properly informed decisions and deploys resources to achieve planned and sustainable outcomes for taxpayers and local people. The sub criteria supporting this are:

Informed decision making Sustainable resource deployment Working with partners and other third parties

SI indicated the results of the interim audit work to date and confirmed that there were no actions outstanding. A report would come to the end of May 2016 meeting with the results of the work undertaken. The 2014/15 audit fees of £63,600 + VAT were shown, this was a reduction from previous years. In response to a question from AD on whether, in relation to secondary care commissioning, a shift from secondary to primary healthcare would be looked into by External Audit, SI responded

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that they would look at the financial aspects. TR added that the VfM opinion looked at the sustainable achievements of priorities which also included GSTT and King’s as providers of secondary care as well as LGT. RW asked where co-commissioning for primary care at level 2 was being looked at, SI responded that External Audit would look at primary care via transactions through the accounts. However, as a level 2 co-commissioner the majority of primary care transactions will be recorded in NHS England’s accounts; not the CCG’s. In response to a question from RW, MD said that the VfM work would cover the sustainable use of resources and the five year plan. In response to RR asking in relation to the five year forward view across SEL whose responsibility was it to assure that at the three year stage that the right point had been reached, SI responded that there were system processes in place to give assurance and the External Audit was part of that assurance. MW added that the Committee in Common (CiC) would look at specific aspects of the strategy. The Committee APPROVED the details of the External Audit Plan for 2015-16 29.2 Annual Benchmark Review MD gave the report which compared the CCG’s 2014-15 Annual Report with other NHS Annual Reports and identified where the CCG was an outlier. MD explained that it was not necessarily bad to be an outlier as the contents and focus of annual report contents are specific to the circumstances of the organisations. For example an organisation in deficit may include more on the going concern that an organisation in recurrent surplus. Indicating the summary of the CCG’s benchmarking position RW queried the independence of lay members as an area the CCG was trailing on. MD said that the information reflected what was disclosed in the Annual Report. It was agreed that management and Audit Committee members would look at what was helpful to the CCG for future Annual Reports and liaise with TR.

ACTION: All Members/TR

The Committee NOTED the Grant Thornton’s Annual Report Benchmarking Report on Lewisham CCG’s 2014-15 Annual Report 102.1 External Audit CCG’s Key Issues Paper 2015-16 MD gave the summary paper which gave details of key issues facing the sector and those solutions being adopted across the country. The paper was broken down into sections on:

Emerging Issues Stubborn Issues Issues on the horizon

RW felt it was a useful report. TR added that the report showed that the CCG generally operated within the bounds of good practice. The CCG was mentioned in the issues on the horizon section on the devolution pilot to integrate physical and mental health alongside social care in Lewisham. The Audit Committee NOTED the Key Issues Paper AC16/30 Setting up the Local Auditor Panel (LAP) and its Terms of Reference

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Due to a conflict of interest Internal and External Auditor representatives were asked to leave the meeting. RW reported that the Terms of Reference for the Local Auditor Panel had been presented and approved by the Governing Body in March; these would require a minor change to the CCG’s Constitution. He reiterated that External Auditors were required to be appointed by the end of 2016. Lewisham CCG is working with the five other SEL CCGs to individually appoint external using a single procurement process. It was agreed that the Audit Committee members would also be that LAP members and that the business of both committees would be kept strictly separate. TR would provide professional support to the LAP. The procurement process would take up to six months. TR pointed out that the CCG’s Internal Audit contract ends on 31 March 2017 with no provision to extend. Therefore a similar process for appointing internal auditors would also need to be completed this year. This could be achieved through a staggered process in order not to overlap with the External Auditors appointment or could be a concurrent process. A LAP meeting would be held after the next meeting of the Audit Committee on 19 April 2016 to last 30 minutes.

TR suggested that the Audit Committee may wish to share the LAP TORs with External and Internal Audit for comment. The Audit Committee NOTED the Terms of Reference and the steps now required to set up the LAP and NOTED the DH has published guidance on the Local Procurement of External Auditors for NHS Trusts and CCGs with NHSE monitoring progress Internal and External Auditor rejoined the meeting. AC16/31 Consultants over £50k The report was, as suggested by SK at a prior meeting, presented as a rolling log of consultancy appointments over £50k. TR reminded the Committee that all contracts over £50k required prior approval by NHSE. Two applications have previously been reported to the Committee for noting. The Committee NOTED the approval of two applications for consultancy over £50k AC16/32 Waiver of SFIs The SFI waiver justifications for the above appointments were shown in the SFI Waiver Log presented in the papers. There were two waivers not previously reported to the Committee, as follows: 1. Procurement of phase 4 diagnostic of One Version of the Truth in relation to recovery

against the four hour A&E target. Approximate contract value £168k + VAT to be shared by all parties.

2. Support for the Adult Integrated Care Programme. Approximate contract value £180k + VAT

The Committee NOTED these waivers. AC16/33 Review of losses and special payments

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TR confirmed that there were no new losses or special payments made since the last meeting. AC16/34 Business of other committees and review inter-relationships There was nothing in particular to note here. AC16/35 Any other business There was no other business reported at this time. AC16/36 Summary of key messages to report to the Governing Body The following was summarised by RW: The IA and LCFS work plans presented at the meeting. The results of the Audit Committee’s Self-Assessment AC16/37 Items for Information 37.1 The Public Sector Audit Appointments (PSAA) 2016/17 works programme and scale fees;

was taken and noted for information. 37.2 SE CSU Service Auditor Report 2015/16 update; TR said that the final report would be

received soon. Internal Audit would advise if there was anything pertinent to the draft HoIA Opinion.

AC 16/38 Date of next meeting Tuesday 19 April 2016 14:00 – 17:00 at Cantilever House

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Minute Ref

Action Owner Agreed at meeting

Due Date Status Comments

16/26 Further narrative to be added to the risk on engagement and equalities being dominated by a single issue.

Charles Malcolm-Smith

March 2016

May 2016 Governing Body meeting

Open The BAF to be updated for the next Governing Body meeting

16/27 Internal Audit to review the low risk assessment for Equality and Diversity.

Internal Audit

March 2016

May 2016 meeting

Open To be upgraded to medium risk to reflect the feedback from the Audit Committee to be presented in the final version in May

16/27.3 The self-assessment and any good learning which flowed from the report to be discussed by the Audit Committee outside of the meeting.

Ray Warburton/ Committee members

March 2016

April 2016 meeting

Open A summary of responses to be given at the April meeting

16/28.1 To consider ways to test embedded knowledge of counter fraud.

Tony Read/Melanie Alflatt

March 2016

June 2016 meeting

Open Tony Read and Melanie Alflatt to bring an update to the June meeting.

16/28.3 To compare the number of information reports made in Q2 and Q3 reports.

Melanie Alflatt March 2016

June 2016 meeting

Open A report to come to the June Audit Committee meeting

16/29.2 GT report to be used to inform Annual report content for 2016-17 onwards.

Committee members/Tony Read

March 2016

June 2016 meeting

Open To be incorporated into the learning from the Annual Report and Account report

16/08 LSMS to be incorporated into LCFS items from March meeting

LCFS February 2016

April 2016 meeting

Action to be closed

Reports will remain separate and the LCFS will represent the LSMS, in their absence, at Committee meetings.

Enclosure 2

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Actions closed at the March 2016 meeting

06.1 Discussions to be held at the Risk Management Committee on how to challenge IA recommendations

Martin Wilkinson

February 2016

Closed at March 2016 meeting

Action closed

The importance of appropriate responses to Internal Audit recommendations had been discussed at the Risk Management Group

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Delivery Committee

Thursday 25 February 2016 Present

Martin Wilkinson (MW) Chief Officer (Chair) Dr David Abraham (DA) Senior Clinical Director Alison Browne (AB) Nursing and Quality Director Dr Sebastian Kalwij (SK) Clinical Director Dr Faruk Majid (FM) Senior Clinical Director Dr Angelika Razzaque (AR) Clinical Director Tony Read (TR) Chief Financial Officer Marc Rowland (MR) Chair Ray Warburton (RW) Lay Member Attending Mike Hellier (MH) Head of System Intelligence Susanna Masters (SM) Corporate Director Bobbie Scott (BS) Corporate Administrative Manager Richard Whittington (RWh) Deputy Director of Commissioning Apologies

Diana Braithwaite (DB) Commissioning Director Dee Carlin (DC) Head of Joint Commissioning 1. Welcome and Introductions MW welcomed all to the meeting. 2. Apologies Apologies were taken and noted. 3. Declaration of Interests (DoI) There were no new interests declared. 4(a). Minutes of previous meeting Minutes of the Delivery Committee meeting on Thursday 28 January 2016 were agreed with the following amendment:

- Page 6 - The Clinical Quality Reference Group should be the Cancer Pathway Clinical Review Group.

4(b). Action Log Jan 8.1: The improvement in the IAPT performance is included in the Performance Report. January 8.2: Six week wait data may not be available by neighbourhood.

Enclosure 16

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Sept 6.2: TR gave a verbal update on the lessons learned following the Information Governance (IG) incident, where safeguarding data was emailed to the correct people but not using secure email. The use of secure email addresses will be clarified and a list of secure email addresses included on the CCG’s intranet. Action: TR to send a formal note to the Delivery Committee on the lessons learnt from the Information Governance Incident. In response to FM’s question regarding the IG mandatory training, TR confirmed IG training needed to be undertaken annually, however it is transferable between organisations. All additional outstanding actions had been addressed and the action log updated. 5. Matters Arising There were no matters arising. 6. Integrated Performance Exception Report TR introduced the integrated performance report and highlighted the following areas of escalation/exception for further discussion:

- LGT responsiveness to complaints - Cancer Waits 62 Days from GP Referral to Treatment

LGT Responsiveness to Complaints

AB reported that the improvement plan was reviewed at the January CQRG. In November 2015 15% of complaints were responded to within 25 working days. In November a backlog of 313 complaints was identified in the PALS/Complaints office. The backlog is being addressed and by January 2016 it had been reduced to 234. The quality premium money invested by the CCG has been used to increase the capacity of PALS. A new staff structure is being implemented and substantive vacancies currently filled with interim staff will be recruited to permanently. A streamlined process for complaints has been introduced which will separate simple complaints to be responded to within 25 days and complex complaints where the response time will need to be agreed with the complainant.

In response to RW’s question on whether the practice of the Chief Executive signing off all complaints resulted in delays, AB stated that all complaints are still signed off by the Chief Executive, which is good practice, however the quality of responses has improved and less are being returned to be re-written.

Action: AB to circulate the improvement trajectory along with a view on the robustness and deliverability of the improvement action plan. Cancer RWh gave the report on the Cancer Update outlining LGT’s current performance and the issues still to be addressed. The following was highlighted:

- There has been a significant improvement in performance across the Trust. In December the Trust recorded 84.6% against the 62 day standard. Performance in January is projected to be similar to December; a planned dip is expected in February which will be recovered in March. Both the 2WW and 31 day standard were met in December, being 95.7% and 98.8%

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respectively. The performance trajectory is monitored by weekly NHS England tripartite conference calls.

- The TCST has completed a capacity analysis across London and their assumptions on diagnostic activity have been built into the 2016/17 plan in addition to a 5% increase in endoscopy capacity. This will create pressure for surgery and a localised PMO process across SEL has been agreed to allow Trusts to access additional diagnostic and surgical capacity when required.

- Straight to test pathways have been recommended by the TCST for London. This has been agreed by GSTT and KCH however this is still being explored as part of the 2016/17 commissioning intentions with LGT.

- The issue with the KCH dermatology referrals reported at the January 2016 Delivery Committee has been resolved. A total of 15 patients had been removed incorrectly from the PTL and all have been put back on and will be treated.

MR commended the work.

DA stated that the CCG needs to be assured of the clinical perspective, expressed concerns regarding the straight to test pathways and highlighted the poor 2WW conversion rate and the need to address this across primary care. RWh responded that there is a SEL Patient Experience Group. A series of London wider cancer referral forms are being produced which the CCG will be able to localise. Work is also being undertaken to improve the SI root cause analysis for 100 day breaches to improve quality and get a better understanding on whether harm had resulted.

In response to RW’s question regarding the 2WW pathway information for patients, RWh stated that GPs need to explain to patients what the 2WW pathway means to allow patients to understand how quickly things will move.

In response to RW’s question regarding whether the level of effort to improve the performance is sustainable, RWh stated that maintaining the focus of the Trust is particularly important and it is envisaged that the weekly calls will continue into 2016/17.

DA stated that the risk is described in terms of process instead of population outcome. The risk is that patients with cancer do not get picked up early enough or the over investigation of those without cancer.

Action: Strategic public health outcomes to be reviewed in conjunction with the BAF for 2016/17.

MW reported that a letter had been received from NHS England regarding the Transforming Care Programme requesting confirmation on the planned discharges for patients with learning disabilities in restrictive settings. Confirmation has been received from Heather Hughes that one patient has been discharged within the last few weeks and another has a planned discharge date in March. A full update will be provided in the March performance report.

Action: An update on the planned discharges for patients with learning disabilities in restrictive settings to be included in the March performance report.

In response to RW’s question regarding the closure of the restrictive settings of care, MW stated that this requires a regional effort. Finance TR gave the month 10 finance report and highlighted that the CCG is forecasting to deliver its planned surplus of £7.6m at year end. The new allocations have been published, which along with price

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increases awarded to providers, will result in the CCG’s underlying surplus position diminishing from 2% in 2015/16 to 1.5% in 2016/17 to 0.5% in 2017/18. In response to RW’s question on what actions the CCG needs to take to improve its position, TR stated that the transformational work is imperative to spending less on a recurring basis by reducing demand. MW highlighted that clear practical steps are needed to achieve transformation and work is currently taking place to agree across the whole system deliverables for September 2016. RW stated that public health cuts have had an impact on demand and asked to what extent the CCG is using Right Care to identify opportunities. MW stated that the Right Care data is being discussed at the Joint Clinical Directors and SMT meeting on 3 March. TR responded that the CCG strategy requires significant public health investment at a time when the Local Authority is reducing the type of investment, skills and abilities that the CCG requires from Public Health. In response to AR’s question regarding what the quality premium is to be spent on, TR stated that this has not yet been decided, a list of priorities were produced however not all were short term initiatives. Action: Quality premium spend to be discussed at the March Clinical Directors. 7. Operating Plan TR gave the report summarising the Operating Plan submission of 8 February. A stocktake meeting with NHS England was held on 24 February and a further submission is required on 2 March with the final submission at the beginning of April. The key feedback from the stocktake meeting was highlighted:

- It was requested that the CCG consider a stretch target to recover the constitutional standards, in particular A&E.

- 1% non-recurrent funds should not be committed at the start of the year. - Contacts should be based on realistic activity. - Priority areas on quality improvement were requested.

The Operating Plan commits to delivering the constitutional standards except A&E. The Finance Plan delivers a £7.6m surplus and has a QIPP target of 2%. It was noted that there are not yet QIPP plans in place to deliver this target. LGT are to receive £16.6m sustainability funding in 2016/17 from NHS Improvement however this will come with conditions on the constitutional standards. In response to DA’s question regarding whether delayed transfers of care to community, readmissions and the link with quality and robustness of community services was discussed, MW responded that the meeting focused on activity and whether the CCG is commissioning enough to allow providers to meet constitutional standards. It was agreed that a clinician should be present at future meetings if possible. FM highlighted that the focus needs to be on more than the constitutional standards; the CCG could be delivering the constitutional standards and patient outcomes not improve. A&E MW stated that performance against the 4 hour standard has deteriorated over the last month. The CCG commissioned a review from Transformation Nous and reports have been published on supported discharge, the UHL and the QE site. A summary version of each pack has been produced and will be sent round for information. The main highlights include:

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- Ready for discharge patients are being delayed by the process, which is complex and involves too many stages. Attempts to improve the process in 2015/16 have resulted in additional layers. A priority going forward is to re-design the current arrangement for transferring the care of patients, empower front line staff with a more simplified process and merge health and social care cultures as much as possible.

- Complex patients account for a significant proportion of bed days and most require a supported discharge. A radical redesign of the process for transferring patients out of the hospital will increase capacity to provide care for the majority of patients.

- Expediting simple discharges can have a significant impact on flow and improvement has been made on the UHL site to bring simple discharges earlier in the day. The same improvement has not been seen on the QE site and further work is needed to implement ward and time specific discharge targets.

- Although attendances have declined compared to 2014 admissions have increased due to an increase in conversion rate. The increase in conversion rates during the first half of 2015 has been reversed during the second half of the year. Increasing the proportion of patients first seen by a consultant will improve the 4 hour performance.

- The analysis showed that when CDU is used as a proper CDU the 4 hour performance is at its highest. Efforts will be made to protect the CDU to ensure that it is used as a proper CDU rather than admitting patients who either do not need a bed or do require a bed for longer than 12/24 hours.

- Changes will be made to the medical mode with Dr Miell responsible for the Lewisham site. - Improvements will be made to the way of working of site managers and discharge coordinators - Referrals to admission avoidance services will be increased and the support provided from

system admissions avoidance teams enhanced.

In response to SK’s question regarding the use of discharge lounges, MW stated that these facilities were used on both sites. RW stated that the work was very hospital centric and asked to what extent transformational work was being undertaken to reduce demands. MW responded that within the CCG’s gift is to deliver improvements in admission avoidance services and the complex discharge process. Through the AICP and linked to the BCF, specifications for rapid response teams and a home ward are being developed to enhance admission avoidance services, work is also taking place to improve the Continuing Healthcare arrangements and processes. RW stated that plan should align to the CCG’s ambition to transfer resources from the acute to community. TR responded that the plan is driven by the increase in admissions and price increase and does not reflect the transfer of resources. A whole system solution is needed to shift resources. In 2015/16 the improvement in the flow through the hospital resulted in an increase to emergency admissions of £2m. Plans to shift resources cannot be put in place unless an agreement is reached to close capacity or a different risk management arrangement agreed. SK highlighted work in Southwark with teams of roving GPs which has reduced admissions by 30%. DA expressed concerns regarding the work on One Version of the Truth, which doesn’t reflect the shortages in community staffing. The hospital cannot work better until there is confidence in community services and clinicians are assured that patients will be clinically safe in the community. MW responded that the work of the AICP will encourage providers to work together and bring more ownership across the system to develop the community offer. It was recognised that the work on system resilience and integration needs to be interlinked.

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FM suggested that joint KPIs are developed for long term condition outcomes, which will help providers work together. MW responded that this is the ambition and a number of workshops were held on frailty however execution has been difficult and the timescale slipped to April 2017. DA stated that LAS needs to be included. The following areas of quality improvement were suggested:

- Responsiveness to complaints - Staffing – training/numbers/retention - Cancer – robustness of SI root cause analysis - Mortality levels - Maternity SIs - Leg ulcer healing rates - Bed days related to Delayed transfers of Care - Mental health - Patients feeling supported with long term conditions - Communication between professionals including quality of discharge summaries

Action: AB to review areas of quality improvement and update the Operating Plan 8. Contract Negotiation Update TR reported that negotiations with LGT and SLaM are focused on quantifying activity and agreeing the quality of alternative services that would enable to system to agree a different plan. In response to FM’s question regarding the need to increase bed provision for CAMHS, MW stated that tier 4 CAMHS was commissioned by NHS England. The Lewisham Children and Young People’s includes the Headstart bid which will increase tier 1 and prevention work. RW asked about SLaM’s action plan to improve the wards for older people. Action: Dee Carlin to provide an update on the SLaM contact negotiations including CQUINs and whether a CQC action plan has been produced to improve wards for older people. RWh gave an update on the LGT CQUIN which has a value of £3m. The local proportion (50%) will focus on facilitating the shift from acute to community and includes service line reporting, improvements in leadership and care planning with community services. 9. Report from sub-groups The FLAG, Prescribing and Medicines Management Group and System Resilience Group report were NOTED. 12. Key Items to be reported to the Governing Body - Operating Plan - Cancer Exception Report - Complaints Improvement Plan 13. Minutes from sub-groups FLAG The approved minutes of the FLAG meeting held on 14 January 2016 were taken for information.

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Prescribing and Medicines Management Group The approved minutes of the Prescribing and Medicines Management Group meeting held on 16 December 2015 were taken for information. 14. Any Other Business There was no other business. 15. Date of Next Meeting The next meeting would be held on Thursday 24 March 2016.

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OPEN ITEMS REF ACTIONS BY

WHOM TIMESCALE STATUS/COMMENT

Feb 4.1 A formal note to be circulated on the lessons learnt from the Information Governance Incident.

TR March

Feb 6.1 The complaints improve trajectory along with a view on the robustness and deliverability of the improvement action plan to be circulated

AB April 16.03.2016: The complaints improvement trajectory has been requested for the March CQRG

Feb 6.2 Strategic public health outcomes to be reviewed in conjunction with the BAF for 2016/17.

SM April 16.03.2016: A Risk Management workshop has been arranged for 12th April, which will be reviewing all risks including relevant public health strategic risks

Feb 6.3 An update on the planned discharges for patients with learning disabilities in restrictive settings to be included in the March performance report.

MH March 17.03.2016: Included in the Integrated Performance Report

Feb 6.4 Quality premium spend to be discussed at the March Clinical Directors.

TR March Completed

Feb 7 Review areas of quality improvement and update the Operating Plan

AB February 16.03.2016: Updated in the Corporate Objectives 16/17.

Feb 8 An update to be provided on the SLaM contact negotiations including CQUINs and whether a CQC action plan has been produced to improve wards for older people.

DC March 16.03.2016: Contract update included in the papers for the meeting on 24.03.2016 (item 9)

Jan 8.2 Six week wait data for neighbourhoods to be reviewed by Clinical Directors

MH March

Dec 8.2 MH to submit a report on RTT long waiting patients to FLAG

MH February and May via FLAG acute report.

19.01.2016: Currently, there are few longer waiting patients reported. However, when Kings College Hospitals resume reporting then there will probably be more.

Sept 6.3 IM&T work plan to come back when agreed TR January 16.03.2016: To be reviewed at the IM&T meeting on 23.03.2016 26.01.2016: Carried forward to Feb meeting 0.12.2015: Defer to January 2016

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Delivery Committee

Thursday 24 March 2016 Present

Martin Wilkinson (MW) Chief Officer (Chair) Dr Charles Gostling (CG) Clinical Director Dr Sebastian Kalwij (SK) Clinical Director Dr Faruk Majid (FM) Senior Clinical Director Dr Jacky McLeod (JM) Clinical Director Tony Read (TR) Chief Financial Officer Marc Rowland (MR) Chair, Lewisham CCG Ray Warburton (RW) Lay Member Attending George Absi (GA) System Intelligence Manager Graham Hewett (GH) Associate Director of Quality and DASM Bobbie Scott (BS) Corporate Administrative Manager Eileen White (EW) Head of Medicines Management Apologies

Dr David Abraham (DA) Senior Clinical Director Diana Braithwaite (DB) Commissioning Director Alison Browne (AB) Nursing and Quality Director Dee Carlin (DC) Head of Joint Commissioning Dr Angelika Razzaque (AR) Clinical Director 1. Welcome and Introductions MW welcomed all to the meeting. 2. Apologies Apologies were taken and noted. 3. Declaration of Interests (DoI) There were no new interests declared. 4(a). Minutes of previous meeting Minutes of the Delivery Committee meeting on Thursday 25 February were agreed. 4(b). Action Log Jan 8.2: A report on diagnostic waiting times has been produced; however a breakdown by neighbourhood is not available. The report will be shared with the Clinical Directors at their meeting on 21 April. Action closed.

Enclosure 16.1

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Dec 8.2: Kings are not currently reporting on referral to treatment targets. Action closed. All additional outstanding actions had been addressed and the action log updated. 5. Matters Arising Easter Assurance MW reported that LGT had requested extra GP cover in the Urgent Care Centre over Easter and the CCG has been working with SELDOC to provide cover. In response to MW’s question regarding anything further primary care could do to support the demand, JM stated that a longer term system approach is needed with a focus on planned care. FM reported that SELDOC have had difficulties filling rotas for a while; however there is an Emergency Management Plan which could be invoked if required. 6. Integrated Governance Committee MW gave the report requesting the Committee consider the feedback from the FLAG meeting and make recommendations on how the Integrated Governance Committee (IGC) will incorporate the current responsibilities of FLAG effectively. FM summarised the key issues to be considered namely population quality assurance, providers’ contract quality assurance, quality improvement and innovation and learning development. Consideration is also required on how the IGC will ensure the patient voice is heard, ensuring that performance reports are triangulated with the patient voice, and that the whole system is systematically covered including acute, mental health, community services, primary care and private providers. RW stated that he was pleased with the recommendation to merge the work of FLAG with Delivery Committee to form a new IGC due to concerns regarding duplication and the link with contract management however when the CCG achieved authorisation the focus on quality and learning was commended and should not be lost. CCG management and staff need to address issues of quality throughout their work with exception reports going to IGC when required. The Strategy and Development Workshop and Public Engagement and Communication Workshop should ensure learning. MW highlighted that management processes including the SI Panels and Leg Ulcer Panels will also ensure learning. GH responded that SI Panels provide learning for individual providers what is more difficult to ensure is the broader system learning to feed into service redesign and corporate objectives. FM stated that the learning cycle requires feedback, which is not always provided, for example feedback from the Quality Alerts is currently not being provided to the Membership. In response to MW’s question regarding the efficacy of FLAG’s quarterly rolling cycle focusing on different providers, GH stated that this had worked well, the dashboards do not move quickly enough to warrant monthly review and it allowed the committee time to focus. MW stated a balance was needed between a monthly focus on areas where performance/quality is a concern i.e. complaints, and ensuring there is time for deeper dives. GH stated that Chair’s reports from the LGT and SLaM CQRG’s could provide additional assurance to the committee. TR responded that a greater sight on information from the CQRGs would be welcomed; however it should not be done in isolation of the wider contract monitoring themes. JM stated that a Transformation and Sustainability dashboard with metrics to track the transformation and system change the CCG is working towards would be useful. MW responded that part of the work still to do on the Corporate Objectives is to be clear on the success measures and how to report these.

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TR suggested that the IGC track in year strategic objectives in addition to the core objectives and the Strategy & Development Committee focus on looking forward. MR suggested having key learning as a standing item. RW stated further clarity and discussion is needed to agree risk tolerance. The CCG has demonstrated very limited risk tolerance over cancer and A&E performance but not for complaints. It is unclear when a relationship approach is required and a longer timeframe for improvement accepted and when a more rigorous and robust response is required. TR responded that the CCG needs to be clear what the risk tolerance is and set a mandate for the contract management team to find a solution and track the action. JM stated it would be useful for the performance report to include a timeline indicating how long targets had not been met for. In response to CG’s question regarding the reporting on the NHS Improvement & Assessment Framework, MW stated that this was currently a quarterly assurance process with NHS England. MW summarised the key points that need to inform the terms of reference of the IGC:

- Clarity to be provided on the reporting cycle and new agenda format - Consideration to be given to how to include the patient voice - Clarity to be provided on sub-structures including CQRG and CMB - Clarity to be provided on the reporting for the CCG’s strategic objectives

Action: Terms of reference for the IGC to come back to the first meeting on 28 April 2016. 7. Integrated Performance Exception Report TR introduced the integrated performance report and highlighted the following areas of escalation/exception for further discussion:

- LGT responsiveness to complaints - Cancer Waits 62 Days from GP referral to Treatment

RW stated that the LGT Board papers report responsiveness to complaints at 45% with a target of 70% for the same period that the CCG is reporting responsiveness at 39% and a target of 90%. TR responded that the Trust may be reporting all complaints whereas the CCG is reporting on complaints made by Lewisham patients however the target should be the same. Action: GA to check the complaints figures in the performance report. In response to RW’s question on the influence that the junior doctors strike had on the A&E performance and the reason it was included as a factor in the SRG report and not the performance exception report, TR responded that the exception report for the 4 hour A&E standard is on performance up to January 2016 whereas the SRG report is more recent. MW highlighted that there are other factors impacting on the performance against the 4 hour A&E standard including increased demand and infection control issues. In response to RW’s question regarding how many people wait more than 4 hours, TR stated that for LGT as a whole it can be up to 40 patients per day however these will not all be Lewisham patients. What is not clear is the clinical presentation of those waiting and whether the patient’s care is compromised as a result of having to wait over 4 hours. GH stated that the CQRG had performed deep dives and been assured that patients were being triaged and clinical quality and patient safety were good despite at times the wait leading to poor patient experience.

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In response to SK’s question regarding the role of LAS in admission avoidance, MW stated that Graham Norton, LAS Assistance Director of Operations, was attending the Joint Clinical Directors and SMT meeting on 7 April where this could be discussed. TR reported that overall performance against the cancer standards has improved and progress against the Cancer Recovery Plan is in line with expectations. A letter has been received from NHS England outlining an issue that is being experienced across a number of London Trusts, namely that patients are not being informed that they do not have cancer in a timely manner and correspondingly are not being removed from the Trust PTL data. The issue has been discussed with the Trust and the CCG clarified that where a diagnostic is unambiguous and no cancer is identified the patient should be told at the earliest possible juncture and not necessarily on a face to face basis. In response to RW’s question regarding the delay between the prostate biopsy and out-patient appointment to discuss the result, TR responded that the information is based on historical data however it is still valid and extra clinics have been put in place. MW left the meeting to attend the SEL surge management teleconference. It was noted that the meeting was not quorate however it was agreed to continue the discussion and for any decisions to be ratified by MW on his return. Finance TR gave the month 11 finance report and highlighted that the CCG is forecasting to deliver its planned surplus of £7.6m at year end. In month 11 the CCG received non recurrent finding of £54k from NHS England for the RTT data validation programme for LGT. The CCG is forecasting to meet all its financial statutory duties in 2016/17 and has low levels of debtors. RW stated that a strategic long term view on the underlying financial position is required. TR stated that through the transformation work the CCG needs to reduce recurrent expenditure while achieving the same if not better outcomes. JM stated that a large proportion of expenditure goes on acute care and the shift to the community is not being made. JM suggested prioritising the transformational metrics in the NHS Improvement & Assessment Framework rather than focusing on the transactional short term metrics. In response to JM’s question regarding the number of beds on the hospital site, TR stated that the number of beds on the Lewisham site has not increased however there is higher throughput of patients following the work to improve the performance against the 4 hour standard. The Integrated Performance Exception report was noted. 8. Operating Plan & Contract Negotiation Update TR reported that the CCG’s underlying surplus position diminishes from 2% in 2015/16 to 1.5% in 2016/17 and will decrease further in subsequent years. In addition the 1% traditionally set aside to pump prime investment is subject to different rules so there are no reserves set aside for investment in 2016/17. TR reported that contract negotiations with LGT were on-going and escalation meetings were taking place at Chief Officer level. The contract negotiation team is seeking to manage risk in the system by blocking some of the emergency activity. In response to JM’s question regarding whether the CCG is assured that the money in the community contract is being spent on community provision, TR confirmed that there was an audit trail for community funding. FM challenged that it is not transparent how money in the community contract has

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been spent as it is divided across different departments. CG stated that where there is vertical provision there is evidence that funding for community services is used to backfill the acute service. TR responded that LGT has a deficit and needs to focus on its acute provision; the incentive to focus on community services is at the point where acute capacity can be closed and more costs taken out than can be made from the acute activity. It was agreed that further discussion on community provision was required at a Strategy & Development Workshop. The update report on the SLaM contract negotiation was noted. MW re-joined the meeting. 9. Corporate Objectives 2016/17 MW gave the report detailing the progress on developing the Corporate Objectives for 2016/17. For 2016/17 the proposed Corporate Objectives are:

- Core Objectives o Quality care and best value o Governance and planning

- Developmental Objectives o General Practice and Primary care o Multi-disciplinary working in Neighbourhood Care Networks o Enhanced care and support

Work is in progress with the clinical and managerial leads to define the priority actions for 2016/17 to agree clear outputs and success measures, which will be used to monitor delivery in year, align the CCG’s clinical and managerial capacity and to identify the associated risks to inform the Corporate Risk Register. It is planned that the finalised Corporate Objectives and BAF are signed off by the Governing Body at its meeting in May 2016. FM highlighted that there is concern about the Neighbourhood Care Networks; MW responded that it is an early priority and will be discussed at the April Strategy & Development Workshop. RW highlighted that the outcome of the PMS review was not referenced; MW responded that this was a success measure. In response to FM’s question regarding priorities from the Membership, MW responded that priorities from the Membership need to be fed in by the Clinical Directors and then presented back to the Membership Forum. JM stated that feedback from practices on the Winter Assessment Team has been positive and include comments on their ability and willingness to take responsibility and feedback. Embedding good community services working in connection with GPs and Pharmacies should be a priority. There is concern that community services are not being properly resourced and that it is not feasible for the current team to deliver what is expected. EW joined the meeting. In response to FM’s question regarding whether the cost-effectiveness of procedures and medications are being reviewed, MW stated that the Treatment Access Policy is reviewed on an annual basis. EW stated that the Area Prescribing Committee applies scrutiny to new drugs on behalf of SEL however it is more in terms of efficacy rather than cost.

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The Committee noted the work in progress to develop the 2016/17 Corporate Objectives and endorsed the approach to finalise them. 10. Report from sub-groups Connect Care Programme Board TR gave the report on the Connect Care Programme highlighting the delays to the project, including delays to the delivery of EMIS integration. There is currently a lack of confidence in plans until focus and resources are applied by the provider Orion Health and the current project status is red. In response to RW’s question whether this should be included in the BAF as a key risk, TR stated that he did not think it should be added to the BAF, the resourcing issue has been escalated to the European Director of Orion Health and the CCG should continue to show its support to the Programme Board. The CCG needs to appoint a GP Governing Body member with a special interest in IT and a GP is needed on the Project Board. The report from the Connect Care Programme Board was noted. FLAG The report from FLAG was noted. Information Governance Steering Group TR gave the report from the Information Governance Steering Group and requested the Committee endorse the CCG’s preliminary Information Governance Toolkit assurance position and delegate to the SIRO the authority for final sign off of the Information Governance Toolkit self-assessment. TR highlighted the following:

- The IG toolkit overall score has reduced from 85% in 2014/15 to 82% in 2015/16. The worsening in year movements were highlighted and are the result of taking a risk based approach. The expectation is that all worsening requirements will return to level 3 in 2016/17.

- Requirement 134 requires 95% of staff to have completed mandatory IG training during the financial year. Currently performance is at 90% and staff who have not completed IG training are being followed up.

In response to RW’s question on the Clinical Information score of 66%, TR responded that there is only 1 requirement which the CCG has scored at level 2, which equates to 66%. In response to RW’s question regarding information breaches, TR responded that the CCG had on one occasion sent information via a non secure method and on about 6 occasions been in receipt of information it should not have received. All breaches are reported to the IGSG. The lessons learned are:

Review of email addresses on the mailing list to ensure that confidential emails are only sent to people using secure email systems

Communication to staff and updating the CCG intranet to ensure staff are aware of all the secure email systems that can be used for confidential communications.

Notifying all the individuals that do not use secure email systems that, in future, the CCG will not be sending them confidential emails until they start using secure a recommended secure email system

Below are the list of secure email systems that can be used with NHS mail; They have email addresses ending:

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o .cjsm.net (Criminal and Justice) o .gcsx.gov.uk (Local Government/Social Services) o .gse.gov.uk (Central Government) o .gsi.gov.uk (Central Government including Department of Health) o .gsx.gov.uk (Central Government) o .hscic.gov.uk (The Health and Social Care Information Centre) o .mod.uk (Military) o .nhs.net (NHSmail) o .pnn.police.uk (Police) o .scn.gov.uk (Criminal and Justice)

The Committee endorsed the CCG’s preliminary Information Governance Toolkit assurance position and delegated to the SIRO the authority for final sign off of the Information Governance Toolkit self-assessment. Prescribing and Medicines Management Group EW gave the report on the current prescribing budget position highlighting the continued cost pressures on prescribing. The overspend more than doubled between November and December but has come down in January to £848k (2.5%). Areas being looked at to address the cost pressures include a managed repeat prescribing project and the recruitment of a network of clinical pharmacists to support prescribing in practices on a neighbourhood basis. A Clinical Director to support the prescribing work has been requested.

In response to SK’s question regarding the overspend under central nervous system; EW stated that this related to the prescribing of pregabalin which will be addressed in the 2016/17 prescribing incentive scheme. In response to MR’s question regarding the anaesthesia overspend; EW stated that this related emollient prescribing. In response to JM’s question regarding where psychiatry prescribing is recorded; EW stated that psychiatry prescribing is recorded under central nervous system. In response to CG’s question regarding whether there was an emphasis on de-prescribing particularly around cardiovascular and diabetes; EW stated that this is part of the work of the LIMOS team and it is envisaged that neighbourhood pharmacists would also review prescribing. In response to RW’s question regarding whether practices are reviewing patients who have repeat prescriptions, EW stated that practices are good at reviewing their patients. System Resilience Group The report from the System Resilience Group was noted. 11. Key Items to be reported to the Governing Body

- Integrated Governance Committee - Information Governance Toolkit - Progress on Operating Plan

12. Minutes from sub-groups

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FLAG The approved minutes of the FLAG meeting held on 11 February and draft FLAG minutes of 10 March 2016 were taken for information. 13. Any Other Business There was no other business. 14. Date of Next Meeting The next meeting would be held on Thursday 28 April 2016.

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OPEN ITEMS REF ACTIONS BY

WHOM TIMESCALE STATUS/COMMENT

Mar 6 Terms of reference for the IGC to come back to the first meeting on 28 April 2016

SM April Completed: see Enclosure 2 of the Agenda for 28/04/2016

Mar 7 Complaints figures in the Performance Report to be checked.

GA April Completed: see Enclosure 3b of the Agenda for 28/04/2016.

Feb 4.1 A formal note to be circulated on the lessons learnt from the Information Governance Incident.

TR March To be discussed under ‘Review of Action Log’

Feb 6.1 The complaints improve trajectory along with a view on the robustness and deliverability of the improvement action plan to be circulated

AB April Completed: see Enclosure 3c of the Agenda for 28/04/2016.

Feb 6.2 Strategic public health outcomes to be reviewed in conjunction with the BAF for 2016/17.

SM April 16.03.2016: A Risk Management workshop took place on 12th April, which considered all risks, including relevant public health strategic risks.

Sept 6.3 IM&T work plan to come back when agreed TR January 20.04.2016:   Not discussed due to time limitations. On the Agenda for the IM&T Meeting of 26.04.2016. Carried forward Meeting of 26 May 2016.  16.03.2016: To be reviewed at the IM&T meeting on 23.03.2016 26.01.2016: Carried forward to Feb Meeting 0.12.2015: Defer to January 2016.

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Strategy and Development Committee Meeting Thursday 11 February 2016

Members: Dr David Abraham (DA) Senior Clinical Director (Chair) Charles Malcolm-Smith (CM-S) Deputy Director (Strategy & Organisational Development) Dr Jacky McLeod (JM) Clinical Director Rosemarie Ramsay MBE (RR) Lay Member Dr Angelika Razzaque (AR) Clinical Director Tony Read (TR) Chief Financial Officer Dr Marc Rowland (MR) Chair Martin Wilkinson (MW) Chief Officer In Attendance: Nigel Bowness (NB) Interim Chair, Healthwatch Lewisham Clive Caseley (CC) Verve Communications Prof. Ami David (AD) Nurse Member Dr Niamh Lennox-Chhugani (NL-C) Optimity Advisors Dr Sebastian Kalwij (SK) Clinical Director Sinthu Kulendran (SKu) GP Registrar, Public Health Dr Faruk Majid (FM) Senior Clinical Director Geri McKenna (GM) Optimity Advisors Jane Miller (JMi) Deputy Director of Public Health Bobbie Scott (BS) Corporate Administrative Manager Sarah Wainer (SW) Programme Lead Ray Warburton OBE (RW) Lay Member Apologies: Aileen Buckton (AB) Executive Director Community Services, LB Lewisham Susanna Masters (SM) Corporate Director Dr Jacky McLeod (JM) Clinical Director Dr Simon Parton (SP) LMC Chair Dr Danny Ruta (DR) Public Health Director, LB Lewisham

1. Welcome and Introductions DA welcomed all to the meeting.

2. Apologies for Absence Apologies were taken and recorded.

3. Declarations of Interests There were no new interests declared.

Enclosure 17

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Workshop: Future role of commissioners in the 2020 vision for a whole system model of care Session objective:

To explore what being a commissioner of a whole system model of care means in the future as the CCG progresses its work in moving towards a population health and care system, commissioning for outcomes with providers by 2020 and what this means our immediate development priorities need to be. Update on the Adult Integrated Care Programme MW gave an update on the Adult Integrated Care Programme (AICP) roadmap covering the 2020 vision and what this means for Lewisham CCG as a commissioner. The following key points were highlighted:

- Through integration the CCG needs to deliver its objectives of better health, best care within its financial means

- Integration is a whole system approach – health and social care, mental and physical health and primary and secondary care

- Care needs to be shaped around the individual and services patient centred - Touch choices need to be made in order to make services sustainable - Increased confidence is needed in community services for more services to be provided in the

community - By April 2016 each partner will have developed its own organisational narrative which reflects the

ACIP vision and priorities and options for provider delivery will be developed. - The 4 GP federations have been formed and the CCG is aiming to contract with them from April. - In Q1 of 2016/17 areas of collaboration with CYP will be identified and agreed - There will be a move from contracting for services towards outcome based contacts - The CCG needs to select the right outcomes with the population - The importance of developing the provider market was highlighted - Over the next 6 months the neighbourhoods will be made more visible and tangible to the public

and risk stratified target groups will be managed through multi-disciplinary working - Guidance for successful multi-disciplinary team working will be produced, co-location of

neighbourhood 1 staff in the Waldron will be achieved and neighbourhood 3 will be piloting an alternative approach to co-ordination.

- A digital community marketplace is being developed to provide easy access to information, advice and signposting.

- By summer 2016 models for admissions avoidance such as rapid response and home ward will be implemented

- An integrated estates strategy for Lewisham is being produced - We will need to incentivise and empower staff to deliver great care

MW highlighted what this means for commissioners:

- A different mind-set is needed. The CCG needs to keep a grip on the system while letting it evolve

- The CCG will be commissioning for outcomes by 2020 rather than commissioning specific institutions

- New skills are needed to develop outcome based frameworks - The utilisation risk will move from commissioners to providers. Providers will be responsible for

redesigning services and pathways to meet the population need. - Incentives need to be in the right place - The CCG’s informatics, business intelligence, analytics and epidemiology capabilities need to be

developed - As a system leader the CCG needs to support market developed and provider integration - The CCG needs a strong strategic commissioning role within the Health and Wellbeing Board - Devolution is an enabler to integration

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CM-S highlighted that at the Your Voice Counts Event the public stated they wanted to be involved in the co-design of Neighbourhood Care Networks (NCNs) and asked how the public will be involved in making the NCNs more tangible. MW responded that public engagement on NCNs is on-going, feedback received mainly focuses on primary care access. CM-S stated that at the Your Voice Counts Event the public wanted to be involved in the co-design of NCNs. In response to AD’s question regarding the focus on adults over 60 and whether the Right Care data had been used, MW stated that data on comorbidities and admissions gave the programme a clear focus of over 60s. In response to RW’s question regarding the difference between NCNs and Neighbourhood Community Teams (NCTs), MW stated that the NCTs currently consist of district nurses, social workers and therapists; mental health will also be linked going forward. These teams have been aligned to the four neighbourhoods. The NCN is everything within the neighbourhood including community assets, GPs, Pharmacies, schools and voluntary organisations. JMi stated that pharmacies are key in terms of health and wellbeing delivery and appear to be missing from the vision. MW responded that this was not a deliberate omission however the focus has been on GP provider development. The need to make pharmacies more explicitly part of the programme was recognised. Financial Context TR provided an update on the financial analysis being undertaken and highlighted the following:

- Financial allocations for the next three years have been communicated. These confirm that the growth in income does not match the current growth in population, needs and demands. The CCG’s underlying surplus will deteriorate and it will struggle to break even over the next two years.

- The CCG’s providers also have significant financial deficits and the budgets for social services and public health are also under pressure.

- The financial workstream of the AICP is undertaking a population level financial analysis on the over 60s and a service level financial analysis.

In response to RW’s question on why services are being costed rather than outcomes, TR stated that costing services will lead to some early actions and it gives something practical to model. RW expressed concern that this will lock us in to current services and models rather than looking at how needs and demand can be met differently. In response to JMi’s question regarding the scope of services being costed, TR stated that what is in and out of the scope had not yet been specified. In response to FM’s question regarding accountability when the responsibility for outcomes is proportioned across providers, TR stated that the financial workstream is not going to produce a cost for outcomes but a value statement on what resources are being spent today for the group of outcomes currently being achieved. How might we work differently to take this forward? How as commissioners the CCG needs to work differently to achieve the vision was discussed in Groups. RW asked for a deeper discussion on the vision.

The following feedback was shared:

- The current structures in place constrain and do not give the CCG the opportunities to deliver - Access to health is a public issue

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- Data and intelligence is available but it is not joined up and kept in silos. Data needs to be used more intelligently

- Better and earlier detection of disease is required - Co-design with the population on outcomes - Longer term contracts to incentivise progress - Identify failure and act early, implement effective penalties for persistent poor performance - Ensure the right people are around the table in meetings - Engage new providers and be innovative and patient focused - Housing is a key determinate of health and should be involved - Develop new providers rather than a monopoly - Involve and educate the public - Focus on upstream and prevention - Be genuinely transformational and not lock ourselves into a rearrangement of what is currently

provided. What does a genuinely transformational CCG look like? The Members individually wrote down what they thought a genuinely transformational CCG looks like:

- Lead, influence, challenge, be accountable and hold providers and partners to account - Share information and outcomes clearly - Makes a clear ask of providers and enforces penalties - Will colour outside the lines, not be risk adverse and test new models that are co-designed - Focuses on outcomes developed in conjunction with the diverse population and commission

services to deliver those outcomes, daring to begin again - Optimises the use of intelligence to identify outcomes, ensure providers work collaboratively,

identifies outcomes and holds providers to account. - Looks outside its own organisational boundaries before taking action - Insists on inclusive evidence based outcomes approach, using its leverage to change providers

and bring new providers in. - Has defined outcomes which evolve with population needs - Achieves better health outcomes while securing best value - Co-designs outcomes, ensures providers work collaboratively and holds providers to account - Listens and engages with local people to design outcomes for services and evaluates progress

In response to NL-C’s question regarding whether this translates to what MW shared at the beginning of the workshop, RW stated that it did to some extent however those involved in the conversation need to be broader and wider and the CCG needs to ensure it doesn’t lock itself into the usual providers and services. MW responded that there was a challenge for the AICP around engagement and the range of providers. The CCG is supporting the development of the GP Federation structure however it is going to take time. MW suggested that an honest reflection on the provider market to share transparently would be useful.

In response to MW’s question regarding what specifically the CCG needs to do next year to address inequalities, RW stated that there needs to be an appreciation of the diversity of the community, tracking back what is commissioned and how it specifically relates to those communities.

Key Themes - Outcomes need to be co-designed with the population - Enable providers to be innovative and transformational - Encourage an honest reflection with providers on provider development - Data and analytic capabilities are important

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Next Steps CM-S summarised the next steps:

- To develop the CCG’s OD plan - Complete the work on the CCG’s values - From April focus on the development of the executive leadership

NB, CC, AD, NL-C, SKu, SK, GM, SW and RW left the meeting. 4(a) Minutes of the previous meeting The minutes of the meeting on 10 December were agreed as an accurate record. 4(b) Review of Action Log/Tracker All outstanding actions had been addressed and the action log updated.

5. Matters Arising There were no matters arising.

6. IM&T Strategy

TR asked the Committee to agree the IM&T Strategy that was presented and discussed at the December Strategy and Development Committee meeting. Limited comments were received from members but those received had been incorporated. It is recognised that parts of the Strategy are generic however this will be addressed by the action plan to be produced by the Chief Information Officer once in post. JMi requested that a sentence is added regarding working with public health. DA requested that primary care IT is prioritised and the timeline is developed in conjunction with members. The Committee AGREED the IM&T Strategic endorsing the strategic priorities recognising that more work on the detail was required.

7. Estates Strategy

TR presented the interim Lewisham Estates Strategy (LES). CCGs are required to develop local estates strategies by the end of March 2016. The work is being supported by Community Health Partnerships and Essentia. The LES will support the CCG’s commissioning strategies, development of community based care and NCNs and improvement in primary care services. Access to the primary care transformational fund is limited to what is included in the strategy. Next steps include a review of GP premises, further work to link with the provider’s strategies and also a piece of work with the local authority. The following comments were made:

- Should it link to the pharmaceutical needs assessment? - There is a lot of detail on current premises rather than what is aspired to.

8. Any Other Business

There was no other business.

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9. Public Engagement Group Chair’s Report

The report from the Chair of the Public Engagement Group was taken for information.

10. Primary Care Programme Board Chair’s Report

The report from the Chair of the Primary Care Programme Board was taken for information.

11. Strategic Risks

The strategic risk register was taken for information.

12. Approved Minutes for Information Only

PEG: The approved minutes of the meeting held on 29.10.2015 were taken for information. Primary Care Programme Board: The approved minutes of the meeting held on 25.11.2015 were taken for information. Adult Joint Strategic Commissioning Group: The approved minutes of the meeting held on 22.10.2015 were taken for information

13. Date of Next Meeting To be confirmed pending the approval of the recommendations of phase 1 of the Governance review at the March Governing Body meeting.

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REFERENCE ACTIONS LEAD/S DEADLINE STATUS/COMMENT

10.12.2015/19 Strategic Risks Risk Management Group to review risk G8

RMG February 05.02.2016: Will be reviewed on 23.02.2016

01.10.2015/9a Voluntary Sector inclusion in NCN The Prevention and Early Intervention Workstream to be requested to review voluntary sector involvement in the AICP.

SM March 03.12.2015 The AICP is reviewing how it works with the voluntary and community sector more effectively, recognising its wider than the Prevention and Early Intervention scheme.

06.08.2015/11 Quality Improvement Strategy The Quality Improvement Action Plan to be developed further and come back to the October Strategy & Development Committee. Action plan to be monitored by the Committee every 6 months.

GH April 05.02.2016: Deferred to April 03.12.2015: Deferred to February 25.09.2015: Deferred to December

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MEETING NOTES

Clinical Strategy Committee Thursday 18 February 2016 Room 519, 160 Tooley Street Co-Chair Amr Zeineldine (for CCGs) and Jane Fryer (NHS England)

Members in Attendance Amr Zeineldine Chair CCB and CSC Sarah Blow Bexley CCG Andrew Bland Southwark CCG Ellen Wright Greenwich CCG Peter Gluckman Independent Chair, SE London Stakeholder Reference Group Andrew Eyres Lambeth CCG Angela Bhan Bromley CCG Nada Lemic Director of Public Health, NHS Bromley CCG, SE London Public Health Lead Mark Easton Programme Director Jane Fryer NHS England Jonty Heaversedge Southwark CCG Annabel Burn Greenwich CCG Andrew Parson Bromley CCG Marc Rowland Lewisham CCG Louis Levy Patient and public voice Sid Deshmukh Bexley CCG (for Nikita Kanani)

Apologies Zoe Lelliott Acting Managing Director, Health Innovation Network Nikita Kanani Bexley CCG Martin Wilkinson Lewisham CCG Adrian McLachlan Lambeth CCG

Other Attendees: Anna English Programme Team (Minutes)

DECISIONS FROM THIS GROUP MEETING ID Type Risk / Issue / Action

/ Decision Description

Owner Meeting Agreed Date

Due Date Status Comments

56 Action SRG mtg dates to be added to STP timeline

ML CSC 18 Feb 11 Mar Open

57 Action Managing Change Seminar to be organised for CiC members

ME CiC 18 Feb 11 Mar Open

58 Action AZ to write to SRG members thanking them for their input to OHSEL

AZ CSC 18 Feb 29 Feb Open

OUTSTANDING ACTIONS FROM PREVIOUS GROUP MEETINGS

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ID Type Risk / Issue / Action / Decision Description

Owner Meeting Agreed Date

Due Date

Status Comments

ACTIONS CLOSED AT THIS MEETING

ID Type Risk / Issue / Action / Decision

Description

Owner Meeting Agreed Date

Due Date

Status Comments

55 Action SRG report to be shared with PPAG and uploaded to website

PG/FG CSC 19 Nov 4 Dec Closed 18/2 Shared via website. Closed

54 Action Update the collaborative framework and share with CCGs ahead of governing body meetings

SEE CSC 19 Nov 18 Dec Closed 18/2 ME to pick up with SEE. Close

1. Welcome and Apologies:

1.1 The chair welcomed members to the meeting 1.2 Dr Sid Deshmukh to share his declaration of interests. There were no other changes declared 1.3 It was confirmed that the minutes were otherwise correct and that they should be forwarded to CCG

Governing Body meetings

2. STP Planning: 2.1 Mark Easton said that he welcomed the concept of integrated planning and that south east London was

well placed due to the work that OHSEL had already undertaken. There were still some requirements that needed to be included. The governance of the STP would be through the Partnership Group, as steered through the Exec Partnership Group (which is made up of CEO/CO).

2.2 Peter Gluckman wondered if the SRG meeting on 8 March should be added to the timeline, it would show that the programme was engaging with south east London citizens, as well as other stakeholders. Members thought this was a good idea (Action 56)

3. Urgent and Emergency Care Designation:

3.1 Angela Bhan updated members on the work that was taking place London-wide to develop a facilities specification for urgent and emergency care centres and walk in centres. This work was being led by Simon Eccles. The group were looking at what services were in place and what they offer to see how they meet the demand. The process was being overseen by the Urgent Care Network

3.2 Angela Bhan continued that a task and finish group had been set up which included both commissioners and providers who will agreed the recommendations for urgent care and walk in centres and emergency departments. These would then come back to CSC and IEG. The timeframe the group are looking at is for the next five years. Some centres may integrate into a Local Care Network. The following points were raised:

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Paper  B  

Page 3 of 4 Version: 1 Date: 24.02.16

the need to think about patient engagement early. Angela Bhan confirmed this was a very important element

Do we have any sites that meet the criteria? Angela Bhan advised throughout London but in south east London there are gaps, the plan was to refresh the gap analysis and be clear if it includes 7 day GP services. All urgent care and walk in centres will be part of this analysis

3.3 Amr Zeineldine asked that any update on process be bought back to this group at a future meeting 3.4 Peter Gluckman suggested that this may be a good topic for the SRG to look at and maybe set up a

group similar to the SRG Orthopaedics one 4. Communications and Engagement: 4.1 Mark Easton advised that he was flagging to members a Managing Change Seminar that was being run

by the Consultation Institute. The communications and engagement team had attended the training and thought it would be useful to offer more widely. It was agreed this should be offered to members of the Committee in Common (Action 57)

4.2 Andrew Bland had attended the training which was a ½ day session; he thought it would be beneficial for senior members to partake.

5. OHSEL Programme Update:

5.1 Mark Easton updated members on the discussion that took place at the Clinical Commissioning Board meeting earlier today, they had discussed STP, Orthopaedics, the LQS Outputs, CLG Delivery Planning and mental health interdependencies

5.2 Amr Zeineldine noted the progress on orthopaedic centres and that this would be taken to the Committee in Common

6. Stakeholder Reference Group:

6.1 Peter Gluckman took members through the work of the Stakeholder Reference Group (SRG) had undertaken over the last three years. He noted the appendix of work that was attached to the report and shared and advised the cost of the SRG in 2016/17 had been estimated at £24k or £4K per CCG. He asked CSC if they wished to continue with this group, and if they require any changes to the format of the meetings. Peter Gluckman advised that members of SRG found it helpful when CCG Chairs attended the meetings; he highlighted the topics of discussion from the last year that had been particularly helpful for the CCGs and OHSEL. Peter Gluckman had continued that the Joint Health and Overview Scrutiny Committee had been promoted via SRG. SRG worked best with one or two substantive items per agenda; three topics tended to squeeze the discussion too much. Peter Gluckman thought that the SRG would be a good basis to look at the mental health and learning difficulties pieces of work arising from the evolving Sustainability and Transformation Plan.

6.2 Mark Easton thought SRG was a very useful group and would strongly endorse it continue 6.3 Amr Zeineldine agreed the group was extremely valuable and he would recommend it continue.

Members AGREED with this recommendation 6.4 Andrew Eyres asked if there was anything the SRG members would like from CCG CO/Chairs to

ensure that SRG members felt included in the work that OHSEL was doing. Peter Gluckman thought members appreciated it when CCG CO/Chairs attend the meetings but that it might be a good idea if the Chair of CSC wrote to SRG members thanking them for their time and input (Action 58). Also SRG

re work programme.

7. Committee in Common:

7.1 Mark Easton advised members of the difficulty that the team were having in getting a date for the first meeting of the Committee in Common. Two new dates had been shared but the feedback was that the meeting would not be quorate on either of these additional dates. The meeting requires two members per CCG in order to be quorate. Following discussion it was agreed to cancel Clinical Commissioning

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Board and Clinical Strategy Committee on 17 March and hold the Committee in Common on this date with a 9am start. AEn to update the diary accordingly (Action 59)

8. Any Other Business

8.1 There was no other business discussed

Date of next meeting Thursday 19 May 2016, 10:45-12:45 The Burfoot Court Room, Guys Hospital

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Primary Care Joint Committees (PCJC)

11 February 2016 Meeting held at:

John Major Room, Kia Oval, Surrey County Cricket Club, Kennington, SE1 5SS

Minutes

Meeting Chair Dr Greg Ussher (GU) Executive Support Tom Bunting (TB) Bexley Primary Care Joint Committee Attendees: Sandra Wakeford (SW) Member Committee Chair (Lay Patient Public Involvement) Keith Wood (KW) Member Committee Vice-Chair (Lay Governance) Mary Currie (MC) Member CCG Governing Body Nurse Sarah Blow (SB) Member CCG Chief Officer Dr Nikita Kanani (NK) Member CCG Chair Dr Sid Deshmukh (SD) Member CCG Governing Body GP Liz Wise (LW) Member NHS England (London) – (Director of Primary Care) Simon Evans-Evans (SE-E) Observer CCG Director of Governance & Quality Dr Richard P Money (RM) Observer Local Medical Committee Lotta Hackett (LH) Observer Healthwatch (Bexley) Apologies: Theresa Osborne CCG Chief Financial Officer Councillor Teresa O’Neill OBE   Health and Wellbeing Board  Dr Jane Fryer   NHS England (Medical Director for South London)  Matthew Trainer NHS England – London (Director of Commissioning

Operations) Bromley Primary Care Joint Committee Attendees:  Martin Lee (ML) Member Committee Chair (Lay Patient Public Involvement) Harvey Guntrip (HG) Member Committee Vice-Chair (Lay Governance) Sara Nelson (SN) Member CCG Governing Body Nurse Dr Angela Bhan (ABh) Member CCG Chief Officer Dr Andrew Parson (AP) Member CCG Chair Dr Miranda Selby (MSe) Member Governing Body GP (representing Dr Ruchira

Paranjape)

Co-­‐commissioning  of  Primary  Care                                                                                                                                                                            South  East  London’s  CCGs  and  NHS  England  Primary  Care  Joint  Committees

Enclosure 19

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Liz Wise (LW) Member NHS England – London (Director of Primary Care) Dr Mukesh Sahi (MSa) Observer Local Medical Committee Councillor David Jefferys (DJ) Observer Health and Wellbeing Board Apologies:  Dr Ruchira Paranjape   CCG Governing Body GP Linda Gabriel Healthwatch (Bromley) Matthew Trainer NHS England – London (Director of Commissioning

Operations) Dr Jane Fryer NHS England (Medical Director for South London) Greenwich Primary Care Joint Committee Attendees: Dr Greg Ussher (GU) Member Committee Chair (Lay Patient Public Involvement) Jim Wintour (JWi) Member Committee Vice-Chair (Lay Governance) Annabel Burn (ABu) Member   CCG Chief Officer Maggie Buckell (MB) Member CCG Governing Body Nurse Dr Ellen Wright (EW) Member   CCG Chair Liz Wise (LW) Member NHS England – London (Director of Primary Care) Dr Tuan Tran (TT) Observer   Local Medical Committee Dr Sim Kumar (SK) Observer Local Medical Committee Simon Hall (SH) Observer CCG Deputy Chief Officer/Director of Strategy &

Performance Councillor David Gardner (DG) Observer Health and Wellbeing Board Apologies:  Dr Iyngaran Vanniasegaram CCG Governing Body - Secondary Care Clinician Dr Nayan Patel CCG Governing Body GP Leceia Gordon-Mackenzie Healthwatch (Greenwich) Matthew Trainer NHS England – London (Director of Commissioning

Operations) Dr Jane Fryer NHS England (Medical Director for South London)  Lambeth Primary Care Joint Committee Attendees: Graham Laylee (GL) Member Committee Vice-Chair (Lay Governance) Andrew Eyres (AE) Member   CCG Chief Officer Dr Adrian McLachlan (AM) Member   CCG Chair Dr Martin Godfrey (MG) Member CCG Governing Body Clinical Member Professor Ami David (AD) Member   CCG Governing Body Nurse Member Liz Wise (LW) Member NHS England – London (Director of Primary Care) Andrew Parker (AP) Observer CCG Director of Primary Care Development Dr Penelope Jarrett (PJ) Observer Local Medical Committee (representing Dr Jenny Law) Jackie Ballard (JB) Observer Associate Member, CCG Governing Body Apologies:  Sue Gallagher Committee Chair (Lay Patient Public Involvement) Dr Jenny Law Local Medical Committee

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Councillor Jim Dixon Health and Wellbeing Board Catherine Pearson Healthwatch (Lambeth) Matthew Trainer NHS England – London (Director of Commissioning

Operations) Dr Jane Fryer NHS England (Medical Director for South London)  Lewisham Primary Care Joint Committee Attendees: Rosemarie Ramsey MBE (RR) Member   Committee Chair (Lay Patient Public Involvement) Ray Warburton OBE (RW) Member   Committee Vice-Chair (Lay Governance) Professor Ami David (AD) Member   CCG Governing Body Nurse Member Martin Wilkinson (MW) Member   CCG Chief Officer Dr Marc Rowland (MR) Member   CCG Chair Dr Faruk Majid (FM) Member   CCG Senior Clinical Director (representing Dr Jacky

McLeod) Liz Wise (LW) Member NHS England – London (Director of Primary Care) Diana Braithwaite (DB) Observer CCG Director of Commissioning and Primary Care Ashley O’Shaughnessy (AO) Observer CCG Associate Director of Commissioning Dr Simon Parton (SP) Observer   Local Medical Committee Peter Ramrayka (PR) Observer   Health and Wellbeing Board Apologies:  Dr Jacky McLeod   Governing Body GP and Clinical Director Nigel Bowness Healthwatch (Lewisham) Matthew Trainer NHS England – London (Director of Commissioning

Operations) Dr Jane Fryer   NHS England (Medical Director for South London)  Southwark Primary Care Joint Committee Attendees: Joy Ellery (JE) Member Committee Chair (Lay PPI) Richard Gibbs (RG) Member Committee Vice Chair (Lay Governance) Ami David (AD) Member   CCG Governing Body Nurse Member Andrew Bland (ABl) Member   CCG Chief Officer Dr Jonty Heaversedge (JH) Member CCG Chair Dr Emily Gibbs (EG) Member   CCG Governing Body GP Liz Wise (LW) Member NHS England – London (Director of Primary Care) Malcolm Hines (MH) Observer CCG Chief Financial Officer Caroline Gilmartin (CG) Observer   CCG Director of Integrated Commissioning Dr Kathy McAdam Freud (KM-F) Observer   Local Medical Committee Apologies:  Aarti Gandesha Healthwatch (Southwark) Councillor Barrie Hargrove Health and Wellbeing Board Matthew Trainer NHS England (Director of Commissioning Operations) Dr Jane Fryer NHS England (Medical Director for South London) Other attendees: Jill Webb (JWe) NHS England – London (Head of Primary Care) Richard Jeffery (RJ) NHS England – London (Director of Financial

Management)

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Item Action 1. Introduction and apologies

GU welcomed members, observers and members of the public to the fifth meeting of the Primary Care Joint Committees of:

NHS Bexley CCG and NHS England NHS Bromley CCG and NHS England NHS Greenwich CCG and NHS England NHS Lambeth CCG and NHS England NHS Lewisham CCG and NHS England NHS Southwark CCG and NHS England

GU informed members, observers and members of the public that the meeting was to be held in two parts, and that part one was a meeting held in public, rather than a public meeting. GU advised that the meeting would be recorded to help to ensure accuracy of the minutes, which would be published in advance of the next meeting, at which they would be formally approved by the Joint Committees. GU advised that there would be two public open space items during the meeting (one close to the start and the other close to the end) instead of only one, as at previous meetings to date. Apologies received in advance of the meeting: Theresa Osborne Bexley Primary Care Joint

Committee - Observer

CCG Chief Financial Officer

Councillor Teresa O’Neill OBE

Bexley Primary Care Joint Committee - Observer

Health and Wellbeing Board

Dr Ruchira Paranjape Bromley Primary Care Joint Committee - Member

CCG Governing Body GP

Linda Gabriel Bromley Primary Care Joint Committee - Observer

Healthwatch (Bromley)

Dr Nayan Patel Greenwich Primary Care Joint Committee - Member

CCG Governing Body GP

Leceia Gordon-Mackenzie

Greenwich Primary Care Joint Committee - Observer

Healthwatch (Greenwich)

Sue Gallagher Lambeth Primary Care Joint Committee - Member

Committee Chair (lay PPI)

Dr Jenny Law Lambeth Primary Care Joint Committee - Observer

Local Medical Committee

Dr Jacky McLeod Lewisham Primary Care Joint Committee - Member

CCG Clinical Director

Nigel Bowness Lewisham Primary Care Joint Committee - Observer

Healthwatch (Lewisham)

Aarti Gandesha Southwark Primary Care Healthwatch (Southwark)

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Joint Committee - Observer

Councillor Barrie Hargrove

Southwark Primary Care Joint Committee - Observer

Health and Wellbeing Board

Dr Jane Fryer NHS England (London) Medical Director - South London

Matthew Trainer NHS England (London) Director of Commissioning Operations

2. Declaration of Interests The following members and observers reported changes to their declarations. In cases where the attendee was representing a member or observer at the meeting, the declarations were noted as new entries to the declarations of interest register. Name Joint Committee Change Dr Richard P Money Bexley Primary Care

Joint Committee – LMC Observer

Amendment: Is now Chair of Bexley Health Limited (was previously listed as Director).

Dr Tuan Tran Greenwich Primary Care Joint Committee – LMC Observer

Additions: GP Partner. Shareholder of GPCC. Member of Riverview Health LLP. Undertake OOH work for Greenbrook Healthcare. These are Dr Tran’s only declared interests (he has not attended this meeting previously).

Dr Penelope Jarrett Lambeth Primary Care Joint Committee – LMC Observer

Additions: GP Partner, The Corner Surgery. The Corner Surgery is a shareholder in South East Lambeth Health Partnership. Clinical Lead for Dementia, Lambeth CCG Clinical Network. These are Dr Jarrett’s only declared interests (she has not attended previously (attended this meeting in place of Dr Jenny Law)).

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Andrew Bland Southwark Primary Care Joint Committee – Member

Is no longer Stakeholder Governor at South London and Maudsley NHS Foundation Trust.

Dr Kathy McAdam-Freud

Southwark Primary Care Joint Committee – LMC Observer

Addition: SELDOC GP member

3. Minutes of the last meeting, held on 10 December 2015 The minutes were agreed to be a correct record of the meeting. Action log Referring to the action tracker for the committees, TB noted that the only actions on the log had been set at the previous meeting (each relating to the Quality and Performance report), and that these had all been closed. The ongoing work to further develop the Quality and Performance report will be taken forward by the Transformation team and Primary Care Commissioning team, (both at NHS England (London)).

4. Public Open Space No written questions from the public had been received in advance of the meeting. Jennifer Quinton-Chelley (member of the Acorn and Gaumont GP Patient Participation Group in Southwark) raised three questions, as follows:

i. Jennifer Quinton-Chelley asked if GP practices in Southwark could request/be granted a break for one hour per day (during which time the practice would be closed and the telephone switchboard turned off) to help practices cope with increasing demand and staff overcome fatigue and longer opening hours for practices. JWe advised that there was some flexibility in the existing PMS contracts on this matter, and that there would be in the new PMS contracts, provided that practices maintained core opening hours of 8am-6.30pm, Monday to Friday. To take this forward practices would need to formally communicate with commissioners on this matter, to specify their requirements. JH advised that CCGs in south east London were aware that practice staff are having to cope with an increased patient demand, and that this had been the case for some time and was having an impact on staff in terms of morale and wellbeing. In Southwark, JH advised that the CCG had arranged to meet with practices later this month to discuss the issue of the level to which current demands were affecting staff wellbeing. JH advised that in Southwark there were regular (monthly) Practice Learning Time meetings (full-afternoon sessions) for all practices in the borough that had been established primarily with the purpose of the CCG providing support to the clinical work of the practices. Further to this, the CCG had built into this process additional sessions (on a biannual basis) for staff in each practice to set aside an afternoon session to review how services are being delivered, which would also serve as a break from service delivery. Jacqueline Best-Vassell (Lambeth and Southwark MIND, South London and Maudsley NHS Foundation Trust, Lewisham Patient Participation Group)

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reiterated the concern raised regarding the need to grant GP practices a break for one hour per day, pointing out that under EU Law all staff were entitled to a complete break for lunch and citing the potential for burnout and high turnover amongst all staff working in GP practices.

ii. Jennifer Quinton-Chelley raised a question about the NHS Online Patient Information, Appointments Booking and Cancellation Service, stating that it had not been working adequately during the past 12-18 months. Jennifer had suggested to her PPG that in response to this and to help local patients a smartphone application be made available and promoted for patients to be able to access this service, but had been advised that due to reductions in funding, this would not be possible. JWe responded to this question by stating that she would need to look into this issue further to better understand where the arrangements for updating the NHS Online Patient Information, Appointments Booking and Cancellation service needs to improve, and an assessment of where responsibility lies for it (between NHS England and CCGs).

iii. Jennifer Quinton-Chelley asked for confirmation that all patients’ responses on patient experience to NHS Patient Survey questionnaires and to the Friends and Family test were anonymous. Jennifer was concerned that the responses held patient details on them and that this might result in a lesser response overall. Jennifer also raised a concern that respondents might receive less favourable treatment by a provider if they had raised a complaint or scored the service as poor within their survey return, and additionally in her own case, that as a member of the Patient Participation Group, if she were to include critical or negative ratings that this would represent a conflict of interests. JWe advised that for both the online National patient survey (conducted by MORI), and the Friends and Family test (by GP practices), personal details provided by patients are anonymised and are not attributable to the respondent in any way by any staff providing NHS services, and that a provider would not be able to access any patient details of any respondent who had provided comments regarding that service.

JWe

For discussion   5.

Quality, Performance and Finance This item focused on matters of Finance only, given that Quality and Performance reports were available on a quarterly basis. Month 9 Finance report  RJ introduced the Primary Medical Services Financial report for south east London, month 9. RJ advised that there was no significant material change to the position as reported in previous month’s reports, both in year to date performance and the forecast outturn at month 9. The overall financial position for South East London Primary Medical Services showed an overspend of £1.4m (0.7%) against issued budgets for the 9 months to 31 December. The forecast outturn was a £1.7m deficit (0.7%) after further mitigation. The reported position on medical services budgets was in line with the rest of London (including level 1 and 2 CCGs as well as fully delegated CCGs). Overspend was largely due to under achievement of planned QIPP savings. This position comprised small overspends on PMS and GMS budgets with a large shortfall

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on the QIPP delivery target, which was shown separately. The forecast was driven by the QIPP shortfall but included further non-recurrent mitigations to be realised before the end of the financial year. This included the release of £1.8m non-recurrent 2014-15 accruals to date after further reviews. At present, on a London level, there remained at month 9 a shortfall of circa £3m of the target £20m QIPP, after the application of non-recurrent mitigations. In line with the response from CCGs to the QIPP letter from NHS England in October 2015, the region continued to seek to further mitigate the shortfall on QIPP through non-recurrent measures and other areas within Primary Care. As a result:

A) A QIPP delivery group had been proposed to support with identifying further opportunities and to enable sharing of transformational QIPP schemes across all areas of London.

B) An external QIPP review had been completed which had identified limited further actions for 2015-16, for NHS England or CCGs, but had highlighted areas for joint work in 2016-17.

C) RJ confirmed that NHSE would be able to cover the 2015/16 Medical QIPP shortfall from other non-recurrent mitigations across the whole of Primary Care and that no contribution would be sought from CCGs in 2015-16.

There had been a year on year growth of 0.8% in South East London’s weighted population from April 2014 to April 2015. The capitation report showed a growth of 1.3% year to 1 October 2015 (quarter 3). Demographic growth has been funded on an aggregate basis at 1.3% in the 2015-16 financial plan. Benefits from lower than budgeted growth had not been factored in to the YTD or forecast position, due to the unpredictable nature of population changes. Towards the end of the year, the potential benefit or pressure due to demographic growth would be incorporated, however there will be variations for individual CCGs as indicated in the table in the narrative report. Overall, in absolute terms the South East London population had seen an increase of 14,219 year on year and a growth of 23,866 year to date in its normalised weighted population. There was a notable range of variation in terms of percentage movement year to date across the six south east London CCGs (0.2% to 2.2%, which had increased in the month 10 report, which RJ had seen ahead of the meeting). RJ pointed to the increase in identified risk as the reports have moved to individual (smaller) CCG budgets from the south east London level. The normalised list sizes would include a full year effect in the next iteration of the report. RJ gave a brief summary of the impact of this year and a look forward to 2016-17 and beyond. RJ reported that Primary Care medical allocations for the next five years to 2020-21 had recently been published by each CCG. The allocations for the next three years were confirmed, and were stated on an indicative basis for the subsequent two years beyond that. NHS England viewed the settlement for 2016-17 as generous, given the state of public finances more generally and of the wider NHS at the current time. The settlement equated to a 4.78% increase in the primary care medical budgets for London in 2016-17 and largely throughout the next five years. For south east London CCGs the increase will be 4%. RJ stated that this would give CCGs in south east London the opportunity to stabilise the financial position for primary medical budgets in the coming year and in the next five years. There would be an impact of not making 15/16 savings on that growth, but even

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allowing for all of the QIPP shortfall, there would still remain an uplift of approximately £8m (3.5%) for south east London. The Joint Committees noted the report and this update. There were no questions raised for this item.

6. Primary Care Premises Transformation (PCTF) Update on south east London CCG interim estates strategies MH introduced Enclosure E and gave a brief update on progress on estates strategies at both an individual CCG borough level and the south east London level (via the Our Healthier South East London strategic estates plans), following the update given at the previous meeting on 10 December. MH reported that in each borough there is a broad membership of each borough’s estates group, generally including appropriate representation from Local Authorities, Hospital Trusts, CCGs as well as Primary Care providers. The first drafts of the borough estates strategies were submitted to NHS England (London region) ahead of the deadline of 31 December 2015 in conjunction with work carried out with the London-wide Estates Board and Community Health Partnerships, both of whom had been commissioned by NHS England to provide assistance to CCGs in the development of the Estates strategies and bids. These versions were fairly high level and will require further detail and refresh, which the CCGs are working to produce via a series of workshops and meetings ahead of submission in April 2016. MH advised that a south east London group had also been established as part of the Our Healthier South East London strategy, with the same principles of membership as the individual borough estates groups that were working in conjunction with it. MH advised that this group had held two meetings so far, with further meetings scheduled. It was anticipated that there would be wider and more far-reaching opportunities for utilisation at this level, between commissioners/local authorities and providers, as business cases are reviewed in the course of 2016. MH said that some additional monies had been made available from NHS England (London) to support this work across London, which is being used in a range of different ways across the boroughs, including to progress utilisation surveys for a range of GP premises earmarked locally. It was expected that work would be completed around the end of the financial year, and will align with the emerging estates plans at borough and south east London level. MH reminded the Joint Committees of the position regarding capital bids. 2015-16 saw the first round of Primary Care Infrastructure Fund. In 2016-17 this was to be renamed as the Primary Care Transformation Fund (PCTF), moving into the second year for the four year, £250m investment programme, which will be a mixture of capital and revenue funding moving forward. It was noted that the guidance for the PCTF bids had not been issued by NHS England, but it was expected that the deadline for their submission would be extended to April, which was welcomed by the CCGs. It was noted that boroughs were currently working up project proposals and bids. MH also advised that the programme was being widened in scope to cover technology bids as well as estates building infrastructure bids.

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MH stated that the south east London estates strategy would be a key part of the Our Healthier South east London commissioning strategy across the six CCGs, and that it would in turn be a key part of the south east London Sustainability and Transformation plan, which was due to be submitted to NHS England in June 2016. JWe advised that as CCGs would be making bids to access the Primary Care Transformation Fund, it was expected that there would be a range of business cases for the development and transformation of GP practices in south east London that would be presented to the Primary Care Joint Committees for review and approval in the coming year. Therefore it was noted that this will be a significant standing item at future south east London Primary Care Joint Committee meetings. The overall aim of the PCTF and the bids for its allocation was to improve general practice and ensure that it is fit for purpose for patients and for staff working in primary care in south east London. The Joint Committees noted the report and this update. Several questions were raised by the Joint Committees. Bexley Joint Committee (RM) asked how patients will be involved in this process. JWe explained that this will be specific to each CCG, but that there was a requirement for Strategic Estates plans (although still in their infancy across the south east London boroughs) to be linked to local engagement with patients. JWe noted that PCTF bids would need to be clearly linked to the Strategic Estates Plan for any given borough, thus setting out the link across the breadth of this work with patient engagement and involvement. MH said that the precise mechanisms for patient engagement would vary across the six local CCG Estates Groups, but that as a general rule, patient representatives were involved in each of the local CCG Estates Groups and at the south East London Estates Board. Patient representatives would have an input to the identification of schemes and the review of bids ahead of their submission to NHS England. Lewisham Joint Committee (RW) asked how the allocations for the primary care transformation fund for estates plans would be divided/allocated – would this be on the basis of the highest level of need or on a fair shares basis. JWe replied, stating that the allocations had not been set at this point, but that they would be at a regional (rather than CCG) level. JWe advised that there were clear advantages to taking a regional approach. The nature of premises schemes (these being the vast majority of the schemes to date) had resulted in slippage in the completion of a number of the schemes. A CCG formulaic pro rata allocation was not considered by NHS England to be conducive to effective management and delivery of schemes, some of which would be likely to be delayed for periods of time, and a significant number of which would involve partner organisations from across provider sectors and different boroughs in south east London. Furthermore JWe advised that the programme was necessarily structured around setting and responding to priorities for development of primary care and use of the fund, as the volume of the bids across London will be far greater in excess than the amount of the PCTF. Alongside of the renaming of the Primary Care Infrastructure Fund(PCIF) to the PCTF, the latter is now considered as a three year programme, which will produce a pipeline of schemes in the next three years. RW stressed that there needed to be fairness applied in allocating funds to business cases over the remaining three year period. JWe responded further by stating that fairness was being applied as all CCGs in south east London were being supported on an equal basis in the development of their strategic estates plans by NHS England and the Strategic Planning Group. Therefore this was an opportunity for each CCG to submit the best plan possible in order access funding.

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For Decisions 7. NHS Lewisham CCG: Dr Arora single hander request to take on an additional partner

(contract variation) JWe introduced the paper (Enclosure F) that requested that the Joint Committee agree to a recommendation that Dr Shashi Arora, currently a single handed GP with a PMS contract (at Baring Road Medical Centre), take on an additional partner. Dr Arora had approached NHS England to request permission to take on an additional partner, in line with NHS England’s GP contractual procedure arrangements for PMS contract holders. An assessment report undertaken by NHS England (London) and Lewisham CCG setting out how the application met the criteria for allowing an additional clinical Contract signatory, was included in the paperwork for this Enclosure. Lewisham CCG and NHS England (London) had carefully reviewed the Business Case submitted by Dr Arora, and had found no issue to prevent a recommendation to approve it. JWe stated that the Local Medical Committee had been engaged with in the review of this Business Case and the agreement to the recommended approach.  Lewisham Joint Committee gave its approval for the recommended approach, with no conditions.

NHS England gave its approval.

NHS Lewisham CCG: Revised Terms of Reference for Joint Committee DB introduced the paper (Enclosure G), a revised Terms of Reference (ToR) for the Lewisham Primary Care Joint Committee. The revisions to the ToR had been recommended by the Lewisham CCG Primary Care Programme Board at its meeting on 27 January, to enable improved assurance, scrutiny and governance with regard to the management of conflicts of interest. The core aspects of the recommended revisions to the Joint Committee’s ToR were that (i) the CCG’s/Joint Committee’s Lay member for Governance (who is also the Joint Committee’s Vic Chair and the CCG’s Conflicts of Interest Champion) be added to the Primary Care Programme Board membership, and (ii) when mitigating any conflicts of interest of GP members by asking those members to leave a discussion at a Joint Committee meeting for the item(s) for which they are conflicted, that the lay member (who is a clinician but not a GP) be included in the Primary Care Management Board membership, to ensure there is quoracy and to maintain sound clinical input to decision-making. Lewisham Joint Committee gave its approval for the recommended approach. NHS England gave its approval.

NHS Southwark CCG: Dr Bhatti Bermondsey Spa CQC Breach and Remedial Notice JWe introduced the paper (Enclosure H) that recommended the issuing of a contract remedial notice to Bermondsey Spa Medical Centre. This was following an inspection by the Care Quality Commission (CQC) on 15 October 2015 whereby the above practice received an overall rating of “inadequate” for the quality of services provided by the practice. In addition to the rating applied by the CQC following its inspection, a

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number of component findings within the CQC’s inspection report amounted to contract breaches within NHS England’s contractual requirements. In accordance with the Framework for responding to CQC inspections of GP practices, NHS England is recommending a breach and remedial notice be issued to this practice. The detail of this was set out in Enclosure H. In parallel, NHS Southwark CCG and NHS England (London) will meet with the practice to confirm the action plan (agreed following the CQC report) and to offer support and set out the review process against the action plan. LMC support is also being sought by the practice as part of this process. KM-F stated that in her opinion there was not enough evidence and information in the cover paper in support of the recommendation for the Joint Committee to issue the breach and remedial notice. KM-F also advised that the London-wide LMC were working with this practice following the CQC report. Southwark Joint Committee gave its approval for the recommended approach.

NHS England gave its approval.

Report on decisions taken by NHS England on behalf of CCG 8. Bexley practice reversion to GMS

JWe introduced the paper (Enclosure I) that reported that Bexley Medical Group had approached NHS England to serve notice that it wished to revert its PMS contract to a GMS contract from 1 April 2016 in accordance with the National Health Service (Personal Medical Services Agreement) Regulations 2004. As there is provision within the PMS contract to revert to GMS, approval was not required and the paper (Enclosure I) was presented to the Primary Care Joint Committee for information. JWe advised the Joint Committee that there would be no diminution in services provided to registered patients at this practice as a result of this contractual change, as per the Enclosure I. Bexley Joint Committee and NHS England noted the decision made by the practice for this contractual change.

For information 9. NHS Bromley CCG: Stock Hill / Norheads reversion to GMS

JWe advised that this item would not be covered on the agenda as the paper had not been finalised in time. The item related to a proposed merger of two practices (Stock Hill and Norheads Lane). The Joint Committee noted that an urgent planned decision may need to take place on this ahead of the next south east London Primary Care Joint Committees meeting on 17 March. ML said that the practices had produced a draft Business Case for the proposed merger, which would require further review by the Bromley Joint Committee, and that this would take place outside of this forum

JWe

Other Business 10. GU advised the Joint Committees that the item for any other business would be

taken in advance of the further items for discussion, which would be the last substantive item on the agenda.

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There was no other business raised.

Further items for decision 11. London PMS Contracts

Managing conflicts of interest GU informed the meeting that the item would be taken in two parts. The first part would focus on the arrangements that had been made for managing conflicts of interest and assurance on clinical engagement. The second part would focus on the consideration of the PMS commissioning intentions, and a summary of those commissioning intentions, by each Joint Committee. ABl reminded the Joint Committees that, as announced at the previous meeting on 10 December, the extension for the completion of the PMS review had been granted by NHS England (on the basis that this would afford CCGs the required time to engage locally with patients, LMCs, member practices and other stakeholders on the PMS commissioning intentions), and that therefore the process would need to be completed by 31 March 2016. ABl explained that for the first part of this item (conflicts of interest and assurance on clinical engagement) all committee members would be present at their respective committee tables, but for the second part (commissioning intentions) the GP voting member of each committee and the LMC representative would be asked to retire to the public audience section of the meeting room. This process had been agreed by the Joint Committees in advance of the meeting in order to ensure that GPs were not involved in the agreement of the financial aspects of the agreement and decision-making regarding the PMS commissioning intentions, in order to best manage conflicts of interest. Following the completion of the item, the GP voting members and LMC representatives would be asked to return to their committee tables ahead of the final item on the agenda, which was the public open space, during which they would be permitted to ask questions (as members of the public) on aspects of the PMS commissioning intentions not relating to finances. RG commented on the importance of managing conflicts of interest whilst retaining vital clinical input to the development of the commissioning intentions appropriately. The process for this item was in line with local CCG policies on management of conflicts of interest and the Terms of Reference of each of the Joint Committees, which stated that decisions could be taken without the presence of GP voting members of each committee, provided that that committee remained quorate in doing so. RG advised that the six committee chairs would each be asked to confirm that they were content that the conflict of interest policy for their CCG had been followed, and that good clinical engagement had been secured in the development of the PMS commissioning intentions for their borough. GU asked each Joint Committee Chair to confirm the two principles above. Each of the Chairs confirmed that both principles had been achieved in their borough in the development of the PMS Commissioning Intentions, on behalf of their Joint Committee. GU asked the GP committee members and the LMC representative for each Joint Committee to leave the table and to be seated within the public audience section of

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the meeting room. PMS Commissioning Intentions JWe introduced the overarching cover paper to Enclosure J, which summarised the progress on the engagement work that had been carried out by NHS England (London region) on the London review of PMS contracts, and the local engagement work in each CCG borough. JWe reported that the London offer had been concluded following a series of consultation meetings held with the London wide LMC. NHS England (London region) had shared with all London CCGs the final agreed London offer for adoption as part of CCG local commissioning intentions. South east London was the first area in London to consider the PMS Review commissioning intentions at CCG level. The discussions had only concluded late in the week commencing 1 February, and as a result of that the London offer documentation has been amended twice in quick succession ahead of the meeting. The documentation was now publically available (via south east London CCG websites as the papers for this meeting) and was available electronically on request. The PMS review required that investment be retained in general practice, and JWe advised that this was being adopted across south east London CCGs. Furthermore, the PMS review gave NHS England (London region) and south east London CCGs as co-commissioners the platform to now begin to implement the Strategic Commissioning Framework (SCF), which had been consulted on extensively, and had been adopted as the standard for accessible care, coordinated care, and proactive care that commissioners aspired to deliver for their patients. This was demonstrated in the PMS commissioning intentions for each borough. JWe referred to the three documents comprising the London offer that were appended to the overarching cover paper in Enclosure J, which had been consulted on with London-wide LMCs and had been accepted. These were: PMS Core service specification, Premium service specification, and Key Performance Indicators. Some elements within this documentation were mandatory, ie CCGs had agreed that they should be consistently offered, and some areas were for local determination (predominantly in the premium service specification). JWe advised that NHS England required that the PMS review was concluded by the end of March, in accordance with the national timetable. By definition this meant that every PMS contract holder will have been offered the PMS contract by 31 March, followed by local negotiation with practices, to enable all contracts to be signed by 30 June (in line with the three month extension granted by NHS England). It was noted that this was a tight timetable of deliverables (which were listed in Enclosure I) ahead of the contracts being implemented for 1st July. JWe briefly summarised the position in terms of the agreement of the local commissioning intentions (with recommendations) in each CCG borough, stating that each CCG recommendation had a condition attached to it. Five out of six of those conditions were subject to a formal local consultation with the local LMC in each borough. JWe advised that this consultation had not been completed on the CCGs’ commissioning intentions at the current time, and was due to be completed by 31 March. GU advised the meeting that each Joint Committee would be asked to present their position regarding acceptance (or otherwise) of the PMS London offer, a summary of

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the PMS commissioning intentions in their borough and their compliance with the national requirements. In addition each Joint Committee would have the opportunity to ask questions for NHS England (London region) or for the members of their own committee. Bexley Joint Committee: SB confirmed that the recommendation of the Bexley Joint Committee was to accept the London offer, on the condition that Bexley would have first call on 2016-17 primary care growth monies (from NHS England) to enable the CCG to offer the full London PMS offer to all of its practices. This was due to the fact that the London offer was not affordable to the CCG due to the low level of premium that it has. SB stated that if this condition was not met the London offer would not be affordable to the CCG. SB also confirmed that Bexley CCG intends to ensure equalisation across GMS practices from 2016-17 and that it will also equalise for APMS practices along the lines of the PMS contract offer. SB stated that as part of the London offer Bexley CCG had discussed with local Healthwatch and the Patient Council the areas for inclusion for the patient voice for practices in Bexley. The local Healthwatch and Patient Council had recommended (i) overall experience and (ii) experience of getting an appointment as the priorities for the new premium offer. Bexley CCG had accepted these recommendations. There were no questions from the Bexley Joint Committee to NHS England. Bromley Joint Committee: ABh confirmed that the local LMC, Healthwatch and the Health and Wellbeing Board had been engaged in the development of the local commissioning intentions. Bromley CCG is intent on meeting the PMS premium at the level of £12.26 per patient. ABh noted that Bromley is in a different position to the other south east London boroughs in terms of its PMS coverage - 40% of the borough’s population are not covered by the PMS contract (as they are registered with GMS practices). ABh confirmed that the Bromley Joint Committee recommended the acceptance of the London offer. The CCG had also agreed to the development of some other indicators for inclusion (subject to further local negotiation between the CCG and LMC), which were in relation to key health priorities in the borough (including breast screening and bowel cancer screening). Bromley CCG is expecting to support practices to be involved in the major transformation programme in the borough including the development of integrated care networks and intends to use a proportion of the PMS premium to support practices to do so. The CCG intends to undergo a programme of equalisation of PMS and GMS practices and anticipates that this will be completed in year, but would require 2016-17 primary care growth monies to support this. There were no questions from the Bromley Joint Committee to NHS England. Greenwich Joint Committee:

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JWi confirmed that the Greenwich Joint Committee recommended the acceptance of the London offer, and proposed to use the remaining premium to incorporate two cancer screening KPIs, and to make it easier for Greenwich residents to register with GP practices on Saturday mornings, and to introduce a KPI on that. JWi advised that the above had been consulted on with Healthwatch, LMC and the Health and Wellbeing Board. There were no questions from the Greenwich Joint Committee to NHS England. GU noted that Healthwatch Greenwich (who were not able to attend the meeting) had submitted a question to the Joint Committee. The question related to how the CCG intends to further work with Healthwatch Greenwich to deliver patient and public engagement regarding these commissioning intentions). JWi advised that the Greenwich Joint Committee would write to Greenwich Healthwatch after the meeting to follow this up. Lambeth Joint Committee: AP advised that the Lambeth Joint Committee considered sustainable, supported and valued general practice in the borough as a vital part of what the CCG intends to achieve as part of the PMS review process and at a wider strategic level, both at individual practice and federation level. AP reported that the CCG’s member practices and other stakeholders had engaged enthusiastically in this process. AP confirmed that the Lambeth Joint Committee recommended the acceptance of the London offer. The CCG was in the process of working through a number of issues regarding weekend access to general practice. AP advised that there was a process under way to finalise the detail of KPIs through which to commission the local CCG premium elements, and that this would be a clinically led process with further meetings due to take place in the next week. There were no questions from the Lambeth Joint Committee to NHS England. Lewisham Joint Committee: MW confirmed that the Lewisham Joint Committee recommended the acceptance of the London offer in terms of the mandatory items for KPIs. MW reported that the CCG had undertaken significant clinical consultation with its membership and informally with the LMC regarding use of the premium locally. Through previous engagement with local patients, the 2 patient voice indicators selected were a) experience of making an appointment and b) support for Long Term Conditions management. In terms of the London service specifications, MW advised that Lewisham CCG had recommended the inclusion of improving access through the use of technology (online). However, MW noted that the CCG had recommended an alternative plan for weekend additional capacity (ie it was not accepting that component of the service specifications) but that the CCG instead recommended implementing arrangements to build on existing primary care services as part of a new model for primary and urgent care to be taken forward in Lewisham in 2016-17. MW said that Lewisham CCG recommended a range of indicators for the local Commissioning intentions in the areas of proactive care and coordinated care. MW confirmed that these were in line with the CCG’s local commissioning strategy and

JWi

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with the Health and Wellbeing Board. These were listed in more detail in Lewisham CCG section of Enclosure I. There were no questions from the Lewisham Joint Committee to NHS England.     Southwark Joint Committee: CG confirmed that the Joint Committee recommended the acceptance of the London offer.

The local variations on the offer were as follows: Breast screening KPI was included in use of the local premium (this had been omitted from the overarching London offer). CG advised that the two patient voice KPIs selected were overall experience and experience of making an appointment, and that these were included as a result of engagement with patient groups and GP practices locally. For the access specification CCG said that the CCG has local arrangements in place which enable it to offer 8am-8pm access seven days per week. This meant that the CCG would not include the Saturday mornings opening specification but that the CCG would be including the online access specification. There had been extensive engagement with Council of members, practice locality groups, Patient Participation Groups and via CCG Board seminars, and as a result of this ten KPIs had been agreed that encompassed the accessible care, coordinated care and proactive care areas. On that basis the CCG was confident that it had developed a recommended approach that meets the required standards to demonstrate measurable outcomes, to develop services that go beyond the core, meet the statutory responsibility to reduce health inequalities for the local population. There were no questions from the Southwark Joint Committee to NHS England. GU asked the Joint Committees for any final questions regarding the London offer or the local commissioning intentions. Lewisham Joint Committee (RW) asked how well the equity of access service delivery requirement had been monitored under previous contracts and how had GP practices performed against it in the past and how would it be monitored under the new contract. This would help to indicate trends in performance and ensure consistency of approach. JWe advised that there is a vast multitude of indicators that could potentially be included for monitoring in GP contracts. This service description was slightly different from the national contract in that it better defines what is asked of general practice in terms of treating every patient according to needs. JWe said that there is currently a self-assessment assurance statement which must be completed by all practices –regardless of contract type - on an annual basis to address these types of questions. There was the option for any CCG to develop this specification further (for example to commission a practice to do some specific health promotion work for a particular grouping of patients as part of a commissioning arrangements), which would be costed and monitored separately. DB supported JWe’s statement. With regard to requirement 1.3, DB noted that the current contractual requirement was for practices to opportunistically collect the data on ethnic origin, and that the Lewisham Joint Committee welcomed its inclusion in the new PMS contract. Lewisham CCG has an

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active Primary Care Equalities programme in place to support practices in identifying where there are gaps in ethnic origin of the registered patient population so that this issue can be addressed. SE-E (Bexley Joint Committee) reminded the Joint Committees that there are a total of nine protected characteristics – and that all of them are required to be adhered to, in compliance with the Equalities Act and Disabilities Discrimination Act and other national guidance. Greenwich Joint Committee (ABu) asked if there was a process in place for bidding for additional primary care growth monies for 2016-17. This was in reference to the condition that the Bexley Joint Committee had applied regarding the acceptance of the London PMS offer and to the difference in available PMS premium as experienced across south east London CCGs. LW replied by advising that for 2016-17 primary care uplifts had already been set at individual CCG borough level. For delegated CCGs that would form part of their allocation. For non-delegated CCGs (such as those in south east London), although the growth was held by NHS England, its Primary Care Team was working with SPG leads across London to develop a set of guidance/business rules for use of those growth monies, but it is expected that CCGs would work within the limits of the growth allocations as already published, within national guidelines for planning purposes. RJ further confirmed that that the growth allocations had been published and that the allocations would not be affected by the level of delegation for a CCG. ABl made a comment in his capacity as SPG lead for south east London. ABl reported that there were encouraging and ongoing conversations taking place between CCGs and NHS England (London region). It was anticipated that in the next week a set of draft proposals would go to London CCG Chief Officers for consideration. GU requested that each Joint Committee in turn confirm their acceptance of their recommendation to approve the CCGs’ PMS commissioning intentions: SW confirmed the approval of the Bexley PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Bexley Joint Committee. This was on the condition that Bexley would have first call on growth monies for 2016-17 in order to deliver the premium. ML confirmed the approval of the Bromley PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Bromley Joint Committee. ABh reminded the Joint Committees of the issue re GMS equalisation in Bromley (as referred to above). JWi confirmed the approval of the Greenwich PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Greenwich Joint Committee. GL confirmed the approval of the Lambeth PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Lambeth Joint Committee. RR confirmed the approval of the Lewisham PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Lewisham Joint Committee. JE confirmed the approval of the Southwark PMS Commissioning Intentions (as set out in the Enclosure J) on behalf the Southwark Joint Committee. NHS England confirmed its agreement with the above. LW indicated that NHS England was supportive of the approach set out by the Bexley Joint Committee with regard to growth monies in 2016-17 (see above), but noted that NHS England would

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need to work through applications for growth monies before being able to commit to this condition. GU asked the GP committee members and the LMC representative for each Joint Committee to return to their respective Joint Committee tables following the completion of this section of the item.

Public 12. Public Open Space

Alison Angus (Lambeth Patient Participation Group Network) commented that the number of members of the public and patient groups present at the meeting was quite low, and that she felt it was difficult for those observers of the meeting to follow all of the items due to some of the terminology used, in spite of the attempts of the Joint Committees to alleviate this by including a glossary at the back of the pack of papers. AE (Lambeth Joint Committee) thanked Alison for her contributions to the meeting and thanked all of the PPG network representatives in Lambeth for their fabulous ongoing contributions. This was highly valued by the CCG who continued to support the Lambeth PPG network via Lambeth Healthwatch. AE said that Lambeth was collectively making good progress on how to engage with public and patients in our local communities, and in working to ensure that general practice is a key focal point for this engagement. Alison Angus asked the Joint Committees about how the CCGs in south east London were responding to the issue of food poverty and what patient-focused innovations they are using to address it. NK (Bexley Joint Committee) noted the seriousness of the issue of food poverty and said that the response to it required clear patient and public leadership to work in partnership with commissioners, providers and local authorities. NK noted that as clinicians she and her counterparts across south east London saw homeless patients at their GP practices and were very mindful of this issue when reviewing services. Alison Angus referred to the item on Primary Care estates strategies, and said that there was a significant issue of underutilisation of buildings in parts of south east London. Alison made reference to the social entrepreneurs and charities with a focus on health and care that were currently desperate to find building space to work from – and who could make a real contribution in partnership with primary care to address health promotion in ways that general practice did not have the capacity to. AE (Lambeth Joint Committee) agreed and advised that there were very many examples of general practice working with the third sector to address and promote healthy lifestyles and wellbeing issues in the borough, and referred to work that general practices had initiated with Age UK that was being taken forward in Lambeth. GU (Greenwich Joint Committee), as someone who works locally in the third sector, noted the amount of pressure on local charities in terms of being at the sharp end in terms of seeing the serious effects (of some of the issues raised) at the heart of communities, and referred to the changes that had taken place in the third sector and the levels of stress that this was imposing on clients for charities’ services and the staff in those charities providing them. GU also commended the point made by Alison Angus regarding the need to think and work more creatively in identifying premises opportunities for charities and third sector organisations, both for office space and utilise for clients and said that this was a very pertinent point. Alison Angus described the serious issue of childhood obesity as being prevalent in the boroughs of Lambeth, Southwark and Lewisham, which was well above the

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national average. Alison asked the CCGs present to facilitate a way for Alison and the network of general practice Patient Participation Groups to contribute to the commissioner response to this problem. NK (Bexley Joint Committee) responded by stating that the issue of a childhood obesity was a major concern to herself and other GPs and commissioners locally. NK advised that this was a subject due to be discussed at her local (Bexley) Health and Wellbeing Board meeting in March, where an item was scheduled to focus on how health commissioners and local authorities could best use the relatively small amounts of public health funding that were now available in order to help families to adopt different habits, in particular where there are cycles of deprivation. NK offered to speak to Alison on this issue following the meeting so that any useful ideas on this could be exchanged. AE (Lambeth Joint Committee) gave the example of Lambeth GP food growing cooperatives that had been implemented locally in Lambeth as just one response to the issue of healthy food and childhood obesity, and supported the importance that Alison had placed on this issue. Helen Chown (DMC Crystal Palace Road Patients and Participation Group and a patient and resident in Southwark) raised a concern that patients were not able to adequately feed in their views on general practice to forums such as this one, and to practices themselves. Helen said that in submitting a concern to a general practice, patients have to do so via the practice administration function. Helen stated that in her experience, the practice administration function was quite selective in what it processed and what it consulted with patients on, in terms of the concerns that were being submitted. Part of this issue was due to the administration functions within practices not being resourced adequately enough to cope with the volume of contact from the public, and Helen also cited the impact of new encoding systems that would place greater strain on them. Helen stressed the importance of this issue in terms of the limit that it set for public views to be heard, and suggested that there should be a PMS KPI on how well practices respond to queries, concerns and complaints raised by patients. SW advised that Bexley CCG had introduced a mystery shopper’s scheme to give commissioners and general practices an additional channel through which to hear the views of patients. Under this scheme any member of the public could apply to become a mystery shopper, and the scheme provided commissioners with real, live information on patients’ experiences across the full range of health services and that it had was a very useful way of understanding this in detail. JWe responded to the point made on this regarding the lack of confidence that patient’s’ views could be represented. JWe advised that this was in fact already covered in the KPIs for the PMS contract, via metrics on patient experience covered in the National Patient Survey and the Friends and Family test. Both of these sets of data were covered at the practice level, but were submitted nationally on a contractualised basis, therefore the data collection was complete. JH (Southwark Joint Committee) advised Helen that there were a range of available means to feed in concerns and suggestions regarding general practice that were not limited to doing so via any given practice. JH offered to speak with Helen after the meeting to set out the various channels available to her, which included via the PPGs and via the CCG itself. JH also described how a number of practices in Southwark (and their patients) had benefitted from working together on sharing learning and good practice on how to compile and respond to this type of information, and also by pooling resources in meeting this demand (ie, taking pressure off a single practice where there may be particular issues around resourcing or volume of information coming in).

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Bob Skelly (South Southwark Patient Participation Group) raised a question regarding the data as shown in the quality and performance report (as covered at the previous PCJC meeting on 10 December), with particular reference to patient satisfaction as the statistics as reported indicated that 24.4% of Southwark registered patients were dissatisfied with general practice access, which showed the borough to be an outlier in south east London. Bob Skelly asked if the figures on this came as a surprise, whether they were felt to be accurate, and if so what the CCG was doing in response to them. JH (Southwark Joint Committee) advised that he did not have the papers from the last meeting to refer to, but said that there were many challenges as well as complexities associated with patient satisfaction levels with general practice (as illustrated by JH specifically at the last meeting). However, JH said that the CCG trusted the validity of the statistics as reported and were continuing to act on them. To give an example JH said that commissioners in Southwark had listened to patients in Southwark regarding their desire for the provision of 8am-8pm access to general practice, seven days per week and that the CCG was continuing to listen to local patient groups to further understand what was creating this level of dissatisfaction. CG advised that she had been in receipt of this question (written) ahead of the recent Southwark Governing Body meeting and advised that a written response to it had been prepared and issued (or that it was in the process of being issued). A number of further points regarding the PMS review were raised by Joint Committee members during this section. SP (Lewisham Joint Committee) stated that the Lewisham LMC had concerns re the timeline for completion of the PMS review (by 31 March) and queried whether there was any flexibility on timescales in the event that further time was required to address all issues that were raised in the local discussions. JWe acknowledged that even with the three-month extension that had been granted by NHS England for London for the completion of the PMS review, the timescales were very tight. JWe noted that a number of CCGs had held preliminary meetings with their GP memberships and with LMCs on this already, which should serve to support the conclusion of reviews within the current timeline, and she encouraged LMC and CCG lead representatives to ensure that dates for further meetings were confirmed in diaries as soon as possible, if they weren’t already finalised. SP welcomed the fact that Lewisham CCG had initiated pre-engagement with the LMC on the PMS review and looked forward to the further meetings to come. The deadline of 31 March for completion of the PMS review engagement process had been mandated on CCGs by NHS England in line with the national timetable on this. SP raised several queries regarding the core London contract offer. Firstly, the referral system for urgent suspected cancer – as worded in the contract documentation, the requirement was for referrals to be faxed within 24 hours. SP queried whether this was intended to be 24 working hours. SP cited the example scenario of a referral being made the day prior to a public holiday and urged that this be considered in the interests of patient safety. JWe advised that this aspect had been reviewed with London LMCs in a great level of detail. LW noted that these timings were in accordance with the protocols of the acute Trusts with whom the practices were working with and where these urgent referrals were going to. Bexley Joint Committee (MC) advised that the Bexley Joint Committee strongly encouraged the use of e-referrals and the phasing out of faxed referrals (as had been enacted with providers in secondary care) and that this should be reflected in the core London offer. SP requested clarification on item 4.1 (Enhanced Services). SP’s reading of this item within the PMS contract documentation was that practices signing up to the core

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London aspect of the PMS contract would be contractually required to provide all enhanced services. SP asked if practices had an option to either offer the service directly or to identify another scheme through which to deliver it. JWe advised that the enhanced services would have to be delivered locally and that this could be via practices directly or that practices could make alternative sub-contracting arrangements for how patients could access the enhanced services. The important principle behind this was that, in line with the overall purpose of the PMS review, all registered patients should receive the same breadth and quality of general practice service provision regardless of where they are registered in London. There is a level of flexibility in terms of how that is delivered, as JWe had described. (NK) Bexley Joint Committee applauded the principle of equity of premium and raised a point regarding service provision for patients accessing general practice services across London, pointing out that Bexley was due to receive a disproportionately low amount of funding and held the lowest premium in London. Jennifer Quinton-Chelley (Southwark Patients and Participation Group) raised a concern that, in her view, owing to the large number of residents in Southwark of Latin American and Afro-Caribbean heritage, that the chances of the Zika virus spreading to London might be higher, and that the NHS and the Local Authority should consider reserving contingency funds in order to manage the impact of this scenario. JH replied by stating that there has been no recorded trace of the Zika virus or the mosquito that spreads it in London (or the United Kingdom) but that the borough’s Public Health team were keeping a monitor on this.

For reference Glossary of Terms

The Joint Committees noted the contents of the Glossary of Terms. No updates had been received since the last meeting.

Date of Next Meeting 17 March 2016, 6-8.30pm at Millwall Football Club.

Close    

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Primary Care Joint Committees

11 February 2016

Signed Attendance Sheet (Public and other observers)

Gary Beard NHS England

Sharon Fernandez NHS England

Leslie Elliot Member of the public

Bob Skelly

South Southwark Patients and Participation Group

Bianca Blake Member of the public

Deborah Haworth Cancer Research UK (south London)  

Chris Beirne Member of the public

Jacqueline Best-Vassell

Lambeth and Southwark MIND, works for South London and Maudsley NHS Foundation Trust, is on Lewisham Patients and Participation Group.

M. Shepherd

Lambeth and Southwark MIND

Jennifer Quinton-Chelley Peckham resident, member of the Acorn and Gaumont GP Patients and Participation Group, member of Southwark Pensioners Action Group and Southwark Pensioners Forum

Ali Angus Lambeth Patients and Participation Group

Rob Danavell Southwark Carers

Helen Chown DMC Crystal Palace Road Patients and Participation Group

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