Progress report from the Chair of the Audit and Governance Committee (Public Session)

Date of Committee’s meeting: 23 February 2017

Key Achievements

A meeting of the Audit and Governance Committee took place on 23 February 2017. That part of the meeting held in public session is covered in this report. A separate confidential report covers two confidential sessions which took place.

The following are of particular note with regard to the business conducted at the public session of the meeting:

• AGREED the Terms of Reference for the Committee which reflect the Committee’s status as a

joint Committee of the CCGs led by a single Chair and members now sit as members of a joint Committee and not as separate Committee’s meeting jointly as formerly.

• NOTED an update from the Turnaround Board and an in year risk of financial delivery for Month 10, 2016/17. It was noted in spite of concerns in Month 9, the Month 10 position was back in line with where the CCGs expected to be. There continued to be close scrutiny on all areas of spend with particular focus on acute, prescribing and continuing health care services. There will be challenges for closing down the accounts at the end of March 2017 but the significant amount of work carried out to address the CCGs’ financial situation was noted.

• NOTED the key dates and challenges involved in the CCGs’ Annual Accounts Plan and Timetable for 2016/17 and that further detail is to be provided to the Committee’s next meeting.

• NOTED the further details requested in relation to Q2, 2016/17 off payroll arrangements and a single tender waiver for Q3, 2016/17.

• APPROVED the refreshed Risk Management Policy as presented noting a move away from ‘predicted risk’ with ‘residual risk’ given greater emphasis to simplify the situation. The involvement of Directors’ Group in the risk process was welcomed in relation to focus on risk scores and oversight to ensure consistency and appropriateness across both CCGs. It was considered a Governing Body development session would be helpful to look at the risk management.

• NOTED and WELCOMED Draft Version 2 of the Combined Assurance Framework. It was noted that residual risk scores reflected the challenging environment the CCGs were in and the level of pressure within the NHS and its partners. It was also noted that work will be on-going which will address matters discussed by the Committee. A final version is to be submitted to the Governing Bodies meeting.

• NOTED the Committee’s risk A&G1 in Version 10 of the M&A and N&S Risk Registers and this would be updated following the recent receipt of an Internal Audit report on Conflicts of Interest.

• NOTED and WELCOMED a report which confirmed a 6 month review had been done of the Alliance governance structure and work was on-going to ensure fitness for delivery of the Better Together Programme, the Alliance and high impact system delivery. It was noted a further update would also be provided to the respective Governing Bodies.

• NOTED an update from the Quality and Risk Committee’s meetings on 12 December and 6 February 2017.

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• NOTED an update from the Primary Care Commissioning Committee’s meetings on 22 December 2016 and 12 January 2017.

• NOTED CCCG Committee self-assessments would be part of the Annual Report process and there had been a good response from Committees.

• NOTED feedback from Professor Rachel Munton on the HFMA Interactive Learning and Networking meeting on 9 February 2017 and the Chair on the STP Lay Member event on 15 February 2017. It was noted the Chair has requested the Head of Business Change and Implementation to provide an assurance report for the Committee responding to the guidance and checklist for CCGs.

• NOTED the following from Internal Audit:

• Progress report which noted actual days against planned days in the Internal Audit Plans 2015/16 had been fully utilised and for 2016/17 utilisation was lower than expected at this stage for the due to various reasons as set out in the report. There would be no cost to the CCGs in respect of any un-used days.

• Managing Transformation – Project and Programme Management follow up report.

• Primary Care Co-commissioning report follow up report.

• Arrangements to delivery national tariff payments system in adult mental health services follow up report.

• Development and delivery of commissioning plans report.

• QIPP development of new schemes and monitoring of on-going schemes report which gave a clear insight in to the need to refresh the PMO function.

• Conflicts of Interest report which noted the CCGs as partially compliant. The issue which gave rise to this is the inconsistency of the CCGs’ Committees in the way in which conflicts of interest are recorded and actioned. This is being addressed by the CCGs.

• Head of Internal Audit Opinion/Governing Body Assurance Framework which noted that Stages 3 and 4 were to be completed in respect of the Head of Internal Audit Opinion for 2016/17.

• Commissioner Technical Update Q3, 2016/17.

• Terms of Reference for reviews relating to Safeguarding Children and Conflicts of Interest.

• External Audit Plans 2016/17 for each of the CCGs in relation to the external auditor’s role in the CCGs’ annual accounts process. The Plans were broadly similar for the two CCGs with some slight differences in respect of value for money and materiality.

The respective CCGs’ Governing Bodies are requested to: • NOTE the minutes of the open part of the joint meeting of the former Audit and Governance

Committee on 8 December 2016 (received at the last Governing Bodies’ meeting) as ratified in the open session of the meeting of the Committee on 23 February 2017 subject to slight revision.

• NOTE the unratified minutes of the open session of the meeting of the Audit and Governance Committees on 23 February 2017 attached at Annex A to this report.

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• NOTE the matters which the Committee wishes to highlight to the respective Governing Bodies’ from its open session discussions.

Issues Actions

None

None

Risks Actions

• Financial pressures faced by the CCGs:

• Governing Bodies’ updated awareness on the

Alliance and STP:

• Conflicts of Interest:

• Risk Management:

The Committees believe that everything possible is being done by the CCGs to contain the respective CCGs’ financial situations. It was noted a further update would be provided to the Governing Bodies to ensure members remained abreast of developments. Consistency is required in disclosure, recording and rulings across all CCG Committees as referred to in the recent Internal Audit report on Conflicts of Interest. A Governing Bodies’ development session on risk management has been suggested following the Committee’s approval of the refreshed Risk Management Policy.

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ANNEX A TO CHAIRS’ REPORT TO GOVERNING BODIES

Mansfield and Ashfield CCG Newark and Sherwood CCG

Audit and Governance Committee

Thursday 23 February 2017 – commenced at 12.15pm Main Meeting Room, Balderton Primary Care Centre, Balderton, Newark, NG24

3HJ DRAFT/UNRATIFIED MINUTES

Present: Mr Peter Clay M&A and N&S CCG GB Lay Member and Chair of Audit and

Governance Committee Professor Rachel Munton M&A and N&S GB Lay Member Dr Carter Singh M&A CCG GB GP Member Dr Gopinath Singaravel N&S GB GP Member Mr David Heathcote M&A and N&S Independent A&G Member In attendance: Ms Helen Brooks KPMG (External Audit) Ms Claire Page Client Manager, 360 Assurance (Internal Audit) Dr. Amanda Sullivan M&A and N&S CCGs Chief Officer Ms Sarah Bray M&A and N&S CCGs Chief Finance Officer Ms Sandy Hogg M&A and N&S CCGs Turnaround Director Ms Ruth Lloyd M&A and N&S CCGs Head of Corporate Governance Mrs Margaret Welton M&A and N&S CCGs Corporate Governance Officer (minutes) Apologies: Mr John Cornett KPMG (External Audit) Mrs Elaine Moss M&A and N&S CCGs Chief Nurse and Director of Quality and

Governance Mr Neil Moore M&A and N&S CCGs Director of Procurement and Market

Development A&G/17/007 WELCOME AND INTRODUCTIONS The Chair welcomed everyone to the first meeting of the newly formed joint CCGs’ Audit and Governance Committee and introductions were made. . A&G/17/008 APOLOGIES FOR ABSENCE AND QUORACY Apologies for absence were noted as stated above. Apologies for late arrival due to inclement weather were noted from Mr Heathcote and Dr Sullivan. It was noted all members of the Committee were present and the Chair declared the meeting quorate.

A&G/16/009 DECLARATIONS OF INTEREST Extracts from the CCGs’ respective registers of interests were circulated. The Chair asked for any actual or potential conflicts to be declared in relation to the business to be conducted and any changes to any declarations already recorded in the CCGs’ registers of interests. Professor Munton advised that one of her declared interests no longer applied as mentioned at the former Committees’ meeting on 8 December 2017. She noted this had not been deleted from the register. It was confirmed Mrs Welton would arrange for this to be done. It was noted no other declarations were made. The Chair therefore ruled that as no actual or potential interests were declared there was no need to preclude inclusion in debate and/or exclusion from the meeting. This would be kept under review as business progressed. A&G/17/010 TERMS OF REFERENCE The Chair presented the Committee’s Terms of Reference and explained these reflected:

• The status of the Committee as a joint Committee of the two CCGs; • It had a single Chair; and • Members sat as members of a joint Committee and no longer as members of

separate Committees who met jointly. Members’ attention was drawn to section 3 of the Terms of Reference which gave the Chair the ability to determine a Deputy Chair from one of the other Governing Body members on the Committee in the case of his absence. Ms Paige confirmed that other CCGs tended to have similar arrangements in place. The Chair asked if members were content with this and assured them that they would receive appropriate advice and assistance from the Corporate Governance Team when acting in that capacity. The Audit and Governance Committee AGREED to the Terms of Reference as drawn and RECOMMENDED to the respective Governing Bodies that they approve the Terms of Reference. The Chair ruled that the confidential items on the agenda would be dealt with later in this meeting. A&G/17/015 MINUTES OF OPEN SESSION OF THE JOINT MEETING OF AUDIT AND GOVERNANCE COMMITTEES ON 8 DECEMBER 2016 The Chair presented the minutes of the open session of the former Committees’ joint meeting held on 8 December 2016. Mr Heathcote joined the meeting at this point. The Audit and Governance Committees APPROVED the minutes from the open session of the joint meeting of the former Committees held on 8 December 2016 subject to the substitution of ‘Professor’ for ‘Ms’ in relation to all references to Rachel Munton. Dr Sullivan joined the meeting at this point. A&G/17/016 AUDIT FORWARD PLAN The Chair presented the Audit Forward Plan and explained the two former Audit Forward Plans had been combined.

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It was noted the Audit Forward Plan would be updated to include the following:

• The independent assessment report on 360 Assurance would be presented to the Committee in August 2017; and

• The Annual Internal Audit Report would be presented to the Committee on 4 and 25 May 2017.

Action: Mrs Welton to update the Audit Forward Plan accordingly. A&G/17/017 AUDIT ACTIONS The Chair presented the Audit Actions and explained the two former Audit Action sheets had been combined. The Audit Actions were reviewed and the following noted:

• MAAG/16/138/NS/A&G/16/090 (Circulate road map (providing commissioners’

guidance to CCGs’ officers) to A&G members: This action would be closed. • JAP/16/033 (Internal Audit contractual arrangements): It was noted a confidential

update would be provided in thee confidential session of this meeting. • MAAG/16/210/N&S/A&G/16/185 (GP sign ups): It was noted a report would be

presented to the 23 March 2017 meeting of the Committee. • MAAG/16/214/N&S/A&G/16/191 (HFMA Audit Committee Handbook): Ms Lloyd

advised this was on order and would be provided shortly to Professor Munton. • MAAG/16/214/N&S/A&G/16/191 (external assessment of 360 Assurance): It was

noted this would be included in the Audit Forward Plan for the Committee’s meeting in August 2017.

All other actions were noted as complete. A&G/17/018 RISK MANAGEMENT POLICY The Chair presented the refreshed Risk Management Policy and explained that included in the refresh revisions was a move away from ‘predicted risk’ with ‘residual risk’ given greater emphasis to simplify the situation. He also welcomed the focus from Directors’ Group on risk scores and oversight to ensure consistency and appropriateness across both CCGs. He reminded the Committee that at its meeting on 23 March 2017 it would have oversight of the new Combined Risk Register. Mr Heathcote queried the references to ‘clinical’ and ‘non-clinical’ areas within the Quality and Risk Committee’s remit as outlined in the Risk Management Policy. The Chair explained that the Quality and Risk Committee had overall responsibility for implementation of the CCGs’ risk management processes across all areas of the CCGs with Audit and Governance Committee having oversight. Professor Munton commented that she found the diagram in the Policy helpful in understanding the structure and format of how the CCGs dealt with the risk processes. She advised that a definitions list would be helpful and for the Governing Body to receive an edited version of the Policy for discussion at a Development Session. Dr Singh considered a refresh of the previous definitions list would be helpful. Dr Sullivan agreed a refreshed list of key definitions could be provided and a Governing Body Development Session to cover risk management and conflicts of interests would be arranged.

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Action: Mrs Moss to provide a list of key definitions relevant to the Risk Management Policy. Action: Ms Lloyd to arrange a Governing Body Development Session to cover risk management and conflicts of interests. The Audit and Governance Committee APPROVED the Risk Management Policy as presented. A&G/17/019 GOVERNING BODIES’ COMBINED ASSURANCE FRAMEWORK The Chair presented the CCGs’ Combined Assurance Framework draft version 2 and welcomed the combined document given most risks were common to both CCGs. Ms Page acknowledged a combined document would be helpful to the CCGs and noted a lot of work had been done to challenge risks and risk scoring. The Chair noted there were a number of residual risk scores that had increased and sought clarity on this. Dr Sullivan explained this reflected the increasing challenging environment and level of pressure within the NHS and its partners. Mr Heathcote noted the high dependency on the Alliance and STP with regard to risks GB1, GB2 and GB3. Dr Sullivan explained there was effective engagement, momentum and commitment between Alliance partners and governance at Board and Oversight Group continued to develop. Since December 2016 there had been high level collaborative working to reduce risk around delivery and transition activity was on-going. There had also been a lot of background work carried out on the commercial and payment mechanism areas and development of processes was on-going. The next stage was to populate the payment mechanisms. It had also recently been agreed at Board level to formalise and strengthen the PMO approach. It was a complex environment to navigate but significant progress had been made. Professor Munton advised that at a recent Conference ‘blending’ had been emphasised rather than discrete arrangements for the STP/Alliance/new models of care and she would like to be clear on the Mid Nottinghamshire approach. Dr Sullivan explained the STP was the governance structure for Nottinghamshire and the delivery vehicle was the Alliance. At STP level discussions were focused on the wider footprint (e.g. estates and acute services) whereas other areas depended on local delivery requirements with the new models of care merging in to the overall picture. These would feature in a refresh of the CCGs’ 5 year plan due at the end of March 2017. The Chair asked whether the governance arrangements were in print for the STP. Dr Sullivan confirmed this was the case and would be submitted to the programme executive board and to this Committee on 23 March 2017. The Chair commented that at a recent Conference he had attended the view was that the two CCGs were well ahead of others with the Alliance arrangements. The Chair sought clarification in relation to the gaps in benefits realisation referred to in risk GB1. Dr Sullivan explained this work was underway. The Chair also sought clarification regarding the gaps included in risk PC1. Dr Sullivan confirmed that best practice was in place which would align with Better Together. The development of localities and the new GP representative body (which had replaced the Clinical Cabinet) were positive steps.

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Professor Munton queried whether the current level of risks to service quality in relation to risk Q&R1 remained appropriate. The Chair confirmed that the risks on the Combined Assurance Framework were being updated following the recent review by the Quality and Risk Committee and an updated version would be presented to the next meeting of the Governing Bodies. Dr Sullivan explained that high level changes were taking place at SFHT and NUH and the CCGs were keeping their position under review for any impact on the risk. The Chair requested that Directors’ Group keep the situation under review and consider the risk impact on the CCGs. The Audit and Governance Committee NOTED the Combined Assurance Framework draft version 2. A&G/17/020 RISK REGISTER RISK A&G1 – CONFLICTS OF INTEREST The Chair requested that risk A&G1 be updated to reflect the recently received Internal Audit report on Conflicts of Interest. The Audit and Governance Committees NOTED risk A&G1 in Version 10 of M&A and N&S Risk Registers) pending further update following receipt of the Internal Audit Conflicts of Interest report. A&G/17/021 QUALITY AND RISK COMMITTEE UPDATE The Chair noted the position on training. Ms Lloyd confirmed that non-compliances had been shared with Directors so staff would be encouraged to complete the training modules. Dr Singh asked for an update on the ‘members’ training in a day’. Ms Lloyd confirmed a re-run of the previous training could be provided. The Audit and Governance Committee NOTED the update from the Quality and Risk Committee’s meetings held on 12 December 2016 and 6 February 2017. A&G/17/022 PRIMARY CARE COMMISSIONING COMMITTEE UPDATE The Chair confirmed that 2 new care hubs had recently been approved and would be up and running shortly. The Audit and Governance Committee NOTED the update from the Primary Care Commissioning’s meetings held on 22 December 2016 and 12 January 2016. A&G/17/023 AUDIT COMMITTEE SELF-ASSESSMENT AND PROGRESS BY OTHER COMMITTEES Ms Lloyd explained that reports from other CCG Committees would be part of the Annual Report process. This was on-going and there had been a good response. The Audit and Governance Committee NOTED the update provided on the Audit Committee self-assessment and progress by other CCG Committees. A&G/17/023 ALLIANCE GOVERNANCE 6 MONTHLY REVIEW REPORT Dr Sullivan presented the report and confirmed that a review of the Alliance governance structure had taken place and work was on-going to ensure fitness for delivery of the Better Together Programme, the Alliance and high impact system delivery.

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The Chair sought clarity on the Alliance Oversight Group’s purpose in the overall structure. Dr Sullivan explained the Alliance Oversight Group sat underneath the Alliance Leadership Board. The Group comprised senior executives, including senior representatives from the CCGs. The Group was a high powered group which focused on service development and co-ordination, it linked to the commercial side and it was an ‘unblocking’ of obstacles group. The Group was chaired by SFHT’s Director of Strategy and it reported to the Alliance Leadership Board. The Chair also queried whether the focus of patient involvement was right. Dr Sullivan explained the Citizens’ Board was part of the Alliance structure and the intention was it would be a conduit/interface with a range of stakeholders and it acted as a critical friend for public and patient involvement. Its recent focus had been on how the programme was running. Dr Sullivan confirmed she would be attending the Citizens’ Board meeting on 3 March 2017 to talk to members about the current financial challenges and a potential refocus on public and patient involvement in the light of those challenges. The Chair asked about the membership of the Citizens’ Board. Dr Sullivan explained the members were lay people who had been nominated by various patient groups to represent the views of the public and patients. Professor Munton requested that Directors consider how clarity on the arrangements could be shared with the Governing Bodies to ensure they were fully informed. Dr Sullivan confirmed that further work would be done with the Governing Bodies’ members. Mr Heathcote considered it would be helpful to have some key outputs from the work being undertaken. Ms Hogg confirmed that with all large programmes the benefits of delivery were longer term and it would be important to be clear on tracking to ensure the benefits were evident. The Chair welcomed the paper and requested a paper also be presented to the Governing Bodies to ensure they were further updated. Dr Sullivan confirmed this was planned. The Audit and Governance Committee NOTED the report on the 6 monthly review of the Alliance governance structure. The Committee took a short break at this point. A&G/17/025 FEEDBACK FROM HFMA INTERACTIVE LEARNING AND NETWORKING MEETING ON 9 FEBRUARY 2017 Professor Munton presented her report from the HFMA Interactive Learning and Networking meeting attended on 9 February 2017. She highlighted two areas for consideration by the Committee:

• The CCGs’ position in relation to housing providers; • The position on patients’ access to their own records within M&A and N&S GP

practices. Dr Sullivan explained that in the Alliance contract there was provision for Social Care to come on board. Mansfield District Council as a provider (which also managed a social housing stock) and one other home care provider had shown an interest. This area would be discussed at the April 2017 Alliance meeting. Professor Munton explained that a show of hands at the HFMA meeting indicated the low take up on patient access to their personal health records. Dr Singh advised that he saw

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merits in patients accessing their own records if they wished and he would not discourage this subject to usual exclusions and redactions where harm or distress would be caused or there were matters relevant to third parties. .Dr Singaravel confirmed he welcomed patient access and the transparency it afforded. The Audit and Governance Committee NOTED Professor Munton’s report providing feedback from the HFMA Interactive Learning and Networking meeting on 9 February 2017. A&G/17/026 FEEDBACK FROM STP LAY MEMBER EVENT ON 15 FEBRUARY 2017 The Chair explained the STP Lay Member event he attended on 15 February 2017 was sponsored by NHS England and hosted by lay members to give Audit Committees assurances on the STP. A guidance and checklist had been provided on what CCGs should be doing on STPs which he had shared with the Head of Business Change and Implementation with the request that a report be provided to this Committee in the next couple of months. The Audit and Governance Committee NOTED the Chair’s feedback from the STP Lay Member event on 15 February 2017. A&G/17/027 TURNAROUND BOARD AND FINANCIAL IN YEAR RISK OF FINANCIAL DELIVERY 2016/17 Ms Bray presented the financial review update for Month 10, 2016/17 which had been received at the Turnaround Board’s February 2016 meeting. The revised out-turn plan had been shared with NHS England and the CCGs were being closely monitored by NHS England. Month 9 had shown a concerning picture with some high value areas under discussion with SFHT particularly around coding of some services. Month 10 position was back in line with where the CCGs expected to be with a £3.8m deficit in year for Mansfield and Ashfield CCG and £2.7m deficit for Newark and Sherwood CCG. There were still significant challenges for closing down the accounts at the end of March 2017. All items with SFHT continued to be scrutinised and there continued to be high level focus on prescribing and continuing healthcare. The Chair confirmed that the papers had been through the Turnaround Board and Governing Bodies and asked the Committee if it was content or whether it needed to escalate any particular issues discussed to the Governing Bodies. Mr Heathcote expressed concern with the level of challenges facing the CCGs and the knock on effect for next financial year. He noted, however, that the volume of activity to address the situation had been significant. The Audit and Governance Committee NOTED the update from the Turnaround Board and Financial in year risk of financial delivery 2016/17. A&G/17/028 CCG ANNUAL ACCOUNTS 2016/17 PLAN AND TIMETABLE Ms Bray presented the paper and explained it set out the key dates and challenges involved with the annual accounts 2016/17 process. A further level of detail would be provided to the 23 March 2017 meeting of the Committee.

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The Audit and Governance Committee NOTED the outline dates and challenges with the CCGs’ annual accounts for 2016/17. A&G/17/029 COMPLIANCE WITH GOVERNANCE ARRANGEMENTS The Chair welcomed the further details in relation to the off payroll arrangements for Q2, 2016/17. Ms Page queried the second item on the list as there was inconsistency in the periods of the arrangement. Ms Bray explained these papers were part of vacancy control. The CCGs had tried for a 12 month fixed term contract but there had been no interest. In order to fill the post on a temporary basis, it had resulted in a 2 year fixed term through an agency route. The single waiver request was noted for Q3 relating to a 12 month contract with Ardens Health Informatics Limited to provide a support tool for all practices in Mid Nottinghamshire. The Chair confirmed that the Primary Care Commissioning Committee had approved this arrangement and it had been reported to Audit and Governance Committee for noting. The Audit and Governance Committee NOTED the additional details in relation to Q2, 2016/17 off payroll arrangements and the single tender waiver for Q3, 2016/17. The Chair agreed to take the following item out of order. A&G/17/037 INTERNAL AUDIT PROGRES REPORT Ms Page presented the Internal Audit progress report. She highlighted section 3 (contract performance) and explained that the actual days against planned days had been fully utilised in respect of the Internal Audit Plans for 2015/16. In respect of planned days in the Internal Audit Plans for 2016/17 had been utilised as indicated in the report which were lower than expected at this stage for the reasons set out therein. 7 days previously allocated to Primary Care Commissioning self-certification had been reallocated in agreement with the CCGs to the GP investigation. Any unused days from the 2016/17 Internal Audit Plans would be refunded or reallocated as agreed with the CCGs. Work was on-going on the Internal Audit Plan for 2017/18 and this would include quality guidance. The Audit and Governance Committee NOTED the Internal Audit progress report and APPROVED the changes to the 2015/16 and 2016/17 Internal Audit Plans. A&G/17/030 INTERNAL AUDIT FOLLOW UP REPORT – MANAGING TRANSFORMATION – PROJECT AND PROGRAMME MANAGEMENT The Internal Audit follow up report was noted. A&G/17/031 INTERNAL AUDIT FOLLOW UP REPORT – PRIMARY CARE CO-COMMISSIONING The Internal Audit follow up report was noted. The Chair requested that a copy of the report be shared with the Chair of the Primary Care Commissioning Committee. Ms Lloyd confirmed this was in hand. The Audit and Governance Committee NOTED the Internal Audit follow up report on Primary Care Co-commissioning. The Chair declared he would take agenda item A&G/17/032 later in the meeting.

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A&G/17/033 INTERNAL AUDIT FOLLOW UP REPORT – ARRANGEMENTS TO DELIVER NATIONAL TARIFF PAYMENTS SYSTEM IN ADULT MENTAL HEALTH SERVICES The Internal Audit follow up report was noted and that actions applied wider than the two CCGs. The Audit and Governance Committee NOTED the Internal Audit follow up report on arrangements to deliver a national tariff payments system in adult mental health services. A&G/17/034 INTERNAL AUDIT REPORT – DEVELOPMENT AND DELIVERY OF COMMISSIONING PLANS Ms Page explained this review covered the development and delivery of Commissioning Plans. The Chair noted that the significant assurance provided by Internal Audit assumed there was regular reporting to the Governing Bodies and asked for clarity on how this was done internally. Dr Sullivan explained it was a complex process involving operational planning across the CCGs’ teams which was aggregated in to the Commissioning Plans. The Commissioning Plans aligned with Better Together. Mr Heathcote queried how the outcome measures were assessed due to the need to track these. Ms Page explained this aspect and reporting of them was covered in one of the agreed actions. Dr Sullivan explained each year the CCGs received national planning guidance on what was to be included in the Commissioning Plans which changed year on year. There were also other national measures which differed. The requirements to track outcomes had changed each year as the CCGs had responded to changes in the outcome measures. The Audit and Governance Committee NOTED the Internal Audit report on development and delivery of Commissioning Plans. A&G/17/035 INTERNAL AUDIT REPORT – QIPP DEVELOPMENT OF NEW SCHEMES AND MONITORING ON-GOING SCHEMES Ms Hogg commented that the Internal Audit report was clear and gave good insight on the need to refresh the Programme Management Office function. The Audit and Governance Committee NOTED the Internal Audit report on QIPP development of new schemes and monitoring of on-going schemes. A&G/17/036 INTERNAL AUDIT UPDATE – HEAD OF INTERNAL AUDIT OPINION AND GOVERNING BODY ASSURANCE FRAMEWORK Ms Page explained that a staged approach was being taken and work was on-going. Stages 1 and 2 had been completed. Stages 3 and 4 remained to be concluded. The Audit and Governance Committee NOTED the Internal Update provided on the Head of Internal Audit Opinion/Governing Body Assurance Framework. A&G/17/038 INTERNAL AUDIT - COMMISSIONER TECHNICAL UPDATE Q3, 2016/17 The Internal Audit Q3, 2016/17 Commissioner Technical Update was noted.

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The Audit and Governance Committee NOTED the Internal Audit Commissioner Technical Update for Quarter 3, 2016/17. A&G/17/039 INTERNAL AUDIT – TERMS OF REFERENCE FOR REVIEWS The Internal Audit Terms of Reference, which had been circulated to members, were noted. The Audit and Governance Committee NOTED the Terms of Reference for Internal Audit reviews as follows:

• Nottinghamshire and Bassetlaw Safeguarding Children’s; and • Conflicts of Interest and Expected Key Control and Audit Testing Plan.

A&G/17/032 INTERNAL AUDIT REPORT – CONFLICTS OF INTEREST Ms Page explained that NHS England had prescribed the areas which were to be reviewed and assessed. The CCGs were generally compliant but there was one issue (21) where the CCGs were partially compliant. This related to way in which conflicts of interest were recorded in minutes of meetings which differed in practice. The CCGs would need to ensure there was consistency. There were also a number of advisory recommendations set out in the report. The Chair acknowledged that the CCGs would need to rectify this. Ms Lloyd confirmed that a meeting had taken place with staff which provide support to Committees and the Internal Audit report had been shared with them. It had also been discussed at a Senior Management Team meeting. The Chair also requested confirmation that the Committee’s risk A&G1 would be updated to reflect the Internal Audit report. Ms Lloyd confirmed this would be the case. Professor Munton and Dr Carter Singh acknowledged that a common sense approach should be taken in relation to disclosure and rulings on conflicts. The Audit and Governance Committee NOTED the Internal Audit report on Conflicts of Interest. The Committee adjourned its meeting at this stage to conduct business relating to the Joint Auditor Panel. On re-adjourning the Chair moved the following Confidential Motion in respect of the agenda items below: Under the Public Bodies (Admission to Meetings) Act 1960 the press and public be excluded from this meeting in relation to the items of business referred to below as they contain information that is commercially sensitive and are regarded as exempt notwithstanding the public interest test. Not to exempt these items would be likely to prejudice the CCGs’ and other parties’ respective commercial positions.

• A&G/17/005 – Confidential Session 1 – Arrangements with Internal Audit • A&G/16/012 – Confidential Session 2 - Confidential minutes of the joint

meeting of the former Audit and Governance Committees held on 8 December 2016;

• A&G/17/013 – Confidential Session 2 – Confidential financial update on the Forward Financial Plan 2017/18

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• A&G/17/014 – Confidential Session 2 – Confidential update on CNCS.

It was noted confidential minutes would record the discussions in relation to the above agenda items. The Chair asked the Internal and External Auditors to withdraw from the meeting whilst agenda item A&G/17/005 was discussed. A&G/17/005 CONFIDENTIAL SESSION 1 – ARRANGEMENTS WITH INTERNAL AUDIT The discussion on this item has been recorded in confidential minutes of this meeting relating to Confidential Session 1. The Internal and External Auditors re-joined the meeting at this point. A&G/17/012 CONFIDENTIAL SESSION 2 – CONFIDENTIAL MINUTES OF THE JOINT MEETING OF THE FORMER AUDIT AND GOVERNANCE COMMITTEES ON 8 DECEMBER 2017. The presentation of the confidential minutes took place in Confidential Session 2 and discussion on this item recorded in confidential minutes of this meeting. The Audit and Governance Committees APPROVED the confidential minutes of the joint meeting of the former Committees held on 8 December 2016 subject to the amendments recorded in the confidential minutes of this meeting relating to Confidential Session 2. A&G/17/013 CONFIDENTIAL SESSION 2 – CONFIDENTIAL FINANCIAL UPDATE ON THE FORWARD FINANCIAL PLAN 2017/18 The discussion on this item has been recorded in confidential minutes of this meeting relating to Confidential Session 2. A&G/17/014 CONFIDENTIAL SESSION 2 – CONFIDENTIAL UPDATE ON CNCS IN ADMINISTRATION The discussion on this item has been recorded in confidential minutes of this meeting relating to Confidential Session 2. The Committee reverted to its public status at this point. A&G/17/ EXTERNAL AUDIT – EXTERNAL AUDIT PLANS 2016/17 Ms Brookes presented the External Audit Plans 2016/17 for each of the CCGs. There were some slight differences between the two Plans in respect of value for money and materiality but other than that they were broadly the same. She confirmed the same KPMG team would be involved to last year to carry out the required work. The Audit and Governance Committee NOTED the External Audit Plans 2016/17 respectively for Mansfield and Ashfield CCG and Newark and Sherwood CCG. A&G/17/41 RISKS TO BE HIGHLIGHTED TO THE GOVERNING

BODIES The Chair highlighted the following matters to be brought to the respective Governing Bodies’ attention:-

• Financial pressures faced by the CCGs; • Governing Bodies’ updated awareness on the Alliance and STP;

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• Consistency in disclosure, recording and rulings across all CCG Committees. Date of next meeting: 23 March 2017 – Time and venue may be subject to change to be notified to members. This meeting closed at 2.55pm.

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Progress report from the Chair Joint Auditor Panel

Date of Panel: 23 February 2017

Key Achievements

The sixth meeting of the Joint Auditor Panel took place on 23 February 2017. The following are of particular note with regard to the business conducted:

• The Panel’s Terms of Reference had been refreshed to reflect the recent governance and membership changes, particularly, the single Chair responsibility and that membership was formed from the new Audit and Governance Committee. The Panel AGREED the revised Terms of Reference and RECOMMENDED that the respective Governing Bodies approve the revised Terms of Reference.

The respective CCGs’ Governing Bodies are requested to:

• NOTE the minutes of the Joint Auditor Panel meeting on 8 December 2016 (received at the last Governing Bodies’ meeting) were ratified by the Joint Auditor Panel at its meeting on 23 February 2017;

• NOTE the unratified minutes of the Joint Auditor Panel meeting on 23 February 2017 are attached at Annex B to this report.

Issues Actions

None

None

Risks Actions None

None

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Annex B to Chair’s report to Governing Bodies

Minutes of the NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG

Joint Auditor Panel Meeting Held on

Thursday 23 February 2017 at 2.35pm

Main Meeting Room, Balderton Primary Care Centre, Balderton, Newark, NG24 3HJ DRAFT/UNRATIFIED MINUTES

Present: Mr Peter Clay (Chair) M&A and N&S CCG GB Lay Member Professor Rachel Munton M&A and N&S CCG GB Lay Member Dr Carter Singh M&A CCG GB GP Member Dr Gopinath Singaravel N&S CCG GB GP Member Mr David Heathcote M&A and N&S CCG A&G Independent Member In attendance: Dr Amanda Sullivan M&A/N&S CCG Chief Officer Ms Sarah Bray M&A/N&S CCG Chief Finance Officer Ms Sandy Hogg M&A/N&S CCG Turnaround Director Ms Ruth Lloyd M&A/N&S CCGs Head of Corporate Governance Mrs Margaret Welton M&A/N&S CCGs Corporate Governance Officer (minutes) Apologies: Mr Neil Moore M&A/N&S CCG Director of Procurement and Market Dev JAP/17/001 WELCOME AND INTRODUCTIONS The Chair explained this meeting had been called to agree the Panel’s Terms of Reference following the recent changes to the governance structure and membership. JAP/17/002 APOLOGIES FOR ABSENCE AND QUORACY Apologies were noted as above. It was also noted that all members of the Joint Auditor Panel were present and the Chair declared the meeting quorate. JAP/17/003 DECLARATIONS OF INTEREST The Chair reminded the Panel that the CCGs’ registers of interests, an extract from which had been circulated, recorded general declarations in respect of relevant members and officers to the effect that those working within the NHS would from time to time have had professional working relationships with a range of external auditors by nature of their respective offices. There were also two specific declarations recorded but these were not significant.

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It was noted that there were no other special or particular interests declared. The Chair determined that the general declarations recorded in the CCGs’ registers of interests would continue to apply and no changes were currently required to the general or specific declarations already made. In accordance with due process, the Chair declared that there were no interests sufficient to give rise to any conflicts at this time and all present could remain in the meeting and take part in the debate. These would continue to be kept under review as relevant. JAP/17/004 MINUTES OF THE MEETING OF THE JOINT AUDITOR PANEL ON

8 DECEMBER 2016 The minutes of the meeting of the Joint Auditor Panel held on 8 December 2016 were presented for approval. The Joint Auditor Panel APPROVED the minutes of its meeting held on 8 December 2016 subject to the substitution of ‘Professor’ for ‘Ms’ in relation to all references to Rachel Munton. JAP/17/005 TERMS OF REFERENCE The Chair presented the refreshed Terms of Reference for the Joint Auditor Panel and explained these reflected the single Chair responsibility and membership from both CCGs. The Joint Auditor Panel AGREED the Terms of Reference as drawn and RECOMMENDED approval to the respective Governing Bodies. JAP/17/006 RISKS TO BE HIGHLIGHTED TO THE GOVERNING BODY There were no risks at this stage to be brought to the Governing Body’s attention. The meeting closed at 2.40pm. Next meeting: The next meeting would take on 23 March 2017 at 3.15pm. The venue may be revised and notified to members.

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Progress report from the

Clinical Executive Sub-Committee

Date of committee: 19 January 2017

Key Achievements • APPROVED the Vague Symptoms Pathway. • RECEIVED an overview of the financial performance of the CCGs to the period ending

November 2016. • RECEIVED the QIPP Report for Month 8. Mansfield and Ashfield CCG had delivered £7,031k

(108%) year to date against a plan of £6,486k; and Newark and Sherwood CCG had delivered £3,581k (93%) year to date against a plan of £3,846k.

• NOTED that every practice within Mansfield and Ashfield (with the exception of one); and 9 out of 14 practices within Newark and Sherwood had signed up to the Best Practice Scheme. This covered 98% of the population for Mansfield and Ashfield; and 83% for Newark and Sherwood.

Issues Actions As at Month 8, the deterioration in the position was slightly worse than the financial recovery plan trajectory produced in October. Mansfield and Ashfield CCG was showing a year to date deficit of £3,384k; and Newark and Sherwood CCG was showing a year to date deficit of £3,174k.

Mitigations had been identified to pull this back in the next few months. Robust monitoring and scrutiny required via the Turnaround Board to ensure delivery of the financial surplus.

The urgent and proactive care programme was below plan year to date delivering £2,057k (70%) from a plan of £2,951k for Mansfield and Ashfield CCG, the forecast was to deliver £4,883k. Of significant concern was the picture in Newark and Sherwood where only £751k (36%) had been delivered against a plan of £1,984k. The revised forecast was to deliver £1,922K. Mitigating actions were planned for the last quarter of the year.

Maximise delivery of QIPP Schemes in year. The CCG needed to be clear on what it was delivering and have clear sight of any slippage. A detailed review of scheme performance had been conducted in month and scenario analysis undertaken to derive the current likely forecast position. This risk-adjusted forecast would continue to be reviewed each month to ensure that mitigating actions were taken as necessary.

Issues identified in regard to late notifications of pharmacies administering the flu vaccine to patients, i.e. not reporting them within 48 hours. In addition, an issue with Pharmacy First who had declined care as they had no pharmacist on site and did not offer a later appointment. The challenge faced by practices ordering the correct amount of vaccines was noted. It was likely there would be over-ordering as a percentage of patients may go elsewhere for their vaccinations.

A sample of pharmacies to be contacted to ascertain whether they were undertaking vaccinations in order to gain an overview of the situation. Competition in the market was acknowledged. A coordinated response would be undertaken with NHS England.

Home visiting was causing difficulties for some practices. The acute home visiting business case had been approved, but the providers approached

Discussions being pursued with EMAS in regard to whether the current workforce could be ‘refashioned’ to support this.

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unfortunately did not have the workforce to deliver the service. Risks Actions There was a risk that the IAPT (Improving Access to Psychological Therapies) target would not be maintained due to clinical variations in referral rates and complexity of patients accessing the IAPT which would lead to non-achievement of the target and poorer outcomes for patients.

New providers had begun providing services from July 2016, significantly increasing capacity in the system. The 4th provider would go live in Q4. The information received from current providers in terms of output and quality of service would be analysed. Findings would be fed back to a future meeting.

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Minutes of the Joint Meeting of the NHS Mansfield and Ashfield and NHS Newark & Sherwood Clinical Commissioning Group

Clinical Executive Committee

Held on Thursday 19 January 2017, 1.30-4.30pm

Meeting Rooms 2/3, Birch House

Present: Dr Gavin Lunn Clinical Chair for Mansfield and Ashfield CCG (Chair) Dr Subash Das GP, Sherwood Medical Partnership Rick Gooch Practice Manager, Abbey Medical Group Ian Jackson Practice Nurse, Roundwood Surgery Dr Peter Macdougall GP, Ashfield House Surgery Luella Robb Practice Nurse, Crown Medical Centre Dr Jane Selwyn GP, Fountain Medical Centre Dr Milind Tadpatrikar GP, Roundwood Surgery David Ainsworth Director of Primary Care Sarah Bray Chief Finance Officer Ian Ellis Director of Contracting and Urgent Care In attendance: Rachel Bradley Executive Assistant to Chief Officer (minutes) Clare Frank Programme Manager

Item Action JCE/17/01 Apologies for absence

Apologies were received from:

• Thilan Bartholomeuz • Dawn Atkinson • Andrea Brown • Hilary Lovelock • Neil Moore • Elaine Moss • Amanda Sullivan

JCE/17/02 Declarations of Interest Declarations of Interest were as reported on the Register of Interest, with the exception of:

• Dr Das was a member of the Provider Cabinet and was starting to work for PICS.

• Mr Jackson was no longer a Practice Nurse on the Governing Body.

ACTION: Miss Bradley to advise Corporate Governance.

RB

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Item Action JCE/17/03 Minutes and actions from the meeting held on:

8 December 2016 - Mansfield and Ashfield CCG The minutes of the meeting held on 8 December 2016 were agreed as an accurate record of discussion. 3 November 2016 – Newark and Sherwood CCG The minutes of the meeting held on 3 November 2016 were agreed as an accurate record of discussion.

JCE/17/04 Clinical Executive Committee Agenda structure Dr Lunn advised members that the new style of Agenda took into account the different style of Agendas for both Mansfield & Ashfield CCG and Newark & Sherwood CCG. It was noted that the main change for Mansfield and Ashfield was that there was now no locality feedback reported.

JCE/17/05

Terms of Reference Dr Lunn presented the Joint Clinical Executive Terms of Reference. The intention was that the meeting would be chaired by both Clinical Chairs on a rotational basis, with nominated deputies attending when absent. A discussion ensued in regard to membership. Members noted that there was 2 GP’s representing Newark and Sherwood CCG and 3 representing Mansfield and Ashfield CCG. It was agreed that Dr Lunn discuss final numbers with Dr Bartholomeuz, i.e. whether membership would increase to 6 GPs. In addition, lay representation would be considered. Members raised the point in regard to whether Mansfield and Ashfield CCG should also have Practice Manager representation. Members agreed that Practice Manager representation was a useful addition and would add value to discussions given they were slightly independent from clinical members. It was agreed that the Director responsible for overseeing the administration of the Committee would be Mr Ainsworth. Mr Ellis arrived at 1.50pm. Members raised the importance of including the Freedom of Information statement. ACTION: Mr Ainsworth to lead on updating the revised Joint Clinical Executive Committee Terms of Reference with Dr Lunn and Dr Bartholomeuz. To be brought back to the Joint Clinical Executive in February for approval. Miss Bradley to include on the Forward Programme.

DAin/ GL/TB

RB

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Item Action JCE/17/06 CCG Feedback

Mr Ainsworth gave thanks to all GPs and practice staff for their hard work during the busy winter season. Mr Ainsworth reported that the financial position remained very challenging and would require a great deal of focus over the coming months. It was noted that the CCGs were £1.7m off the financial recovery plan. Key assurance meetings were taking place with NHS England. Mr Ainsworth advised members that the provider structure for primary care remained on track with the intention it would go live from April 2017. The proposed model had been presented by Dr Greg Place, chair of the LMC and the provider cabinet, to Newark and Sherwood CCG’s PLT and would be presented to Mansfield and Ashfield CCG on 25 January. The model would be taken to the Alliance Development Leadership Board on 25 January for final agreement. Lead roles would be recruited to in March. Members queried how practices were affected who had already signed up to PICS. Mr Ainsworth explained that the mid-Nottinghamshire model was almost a sub-set of whatever ‘vehicle’ was decided. There was no issue if practices had already signed up to PICS, but the intention of the mid-Nottinghamshire model would be to use vanguard funding to pump prime, subject to financial approval. Practices would not be asked to fund it. Dr Macdougall arrived at 1.58pm. It was noted that GPs were not being asked to sign-up to PICS as it was currently. The structure that practices agreed to join would depend on the final structure. Members felt that the model would provide an opportunity to move forward with the support of PICS and was a positive move for primary care. Dr Macdougall queried whether it would be timely to review the Interpractice Agreement. Dr Lunn advised members that the document would remain separate for both CCGs. Mr Ainsworth reported that the Interpractice Agreement would be discussed on Wednesday 25 January. Dr Tadpatrikar raised his concern that the Joint Clinical Executive Committee was not the correct forum to be discussing PICS due to conflict of interest. Mr Ainsworth supported Dr Tadpatrikar’s view and confirmed that governance had been reported via the Primary Care Commissioning Committee, with a lay representative as Chair. Mr Ainsworth stated that he was providing a verbal update on the situation as part of CCG feedback and had not brought a paper or was asking for sign-off of any proposal. Mr Ainsworth gave a position statement on the Best Practice Scheme which had been launched in November. It was noted that

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Item Action

26 out of 27 practices in Mansfield and Ashfield; and 9 out of 14 practices in Newark and Sherwood had signed up. This covered 98% of the population for Mansfield and Ashfield and 83% for Newark and Sherwood respectively. It was noted that the Audit Committee had requested details of those practices who had not signed up and reasons why. Mr Ainsworth reported that KPIs were being monitored to understand what difference it was making for practices. It was noted that improvements had been seen, for example, an increase in the utilisation of call for care. Mr Ainsworth stated that thought needed to be given to the 2017/18 Best Practice Scheme and whether it was wanted. It was agreed that members send any suggestions to Mr Ainsworth for consideration. Any ideas would be taken through a governance route. Mr Ainsworth gave an overview of the GP Access Fund:

• Prime Minister’s Challenge Fund – those practices who it affected had been spoken to.

• Recurrent money – money was available for localities to offer extended access. The minimum requirement was 30 minutes per 1,000 population (£4.50). Approaching this as a locality could provide a shared way of covering service provision and attracting the practice income. It was noted that £86k was available for Mansfield and Ashfield and £53k for Newark and Sherwood. There was a requirement for practice managers to report back to NHS England on a monthly basis.

• Uncommitted money offered by NHS England – this was non-recurrent and would run out at the end of March 2017.

A discussion ensued. Members queried what was considered to be a ‘normal working day’ and raised the point that some practices currently went above and beyond offering increased appointment slots during the working day. An example was given of one practice which had reduced appointment slots from 10 to 7.5 minutes. Mr Ainsworth reported that Mr Yates had written a service specification for practices to sign-up to. Calculations had been made based on list size and how many additional slots could be made available. Mr Ainsworth acknowledged that variation existed between practices and service offered needed to be tackled. Mr Ainsworth added that the increased appointment slots could be telephone appointments which would be helpful. Service specifications would be issued on 19 January. The Joint Clinical Executive Committed NOTED the CCG feedback.

JCE/17/07 Financial Performance Report Mrs Bray gave an overview of the CCGs financial performance at

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Item Action

Month 8. It was noted that in the period April 2016 to November 2016, pressures continued across all key areas, including acute, prescribing and continuing healthcare. At Month 8 both CCGs had utilised their entire contingency. Mansfield and Ashfield CCG was showing a year to date deficit of £3,384k, and Newark and Sherwood CCG was showing a year to date deficit of £3,174k. It was noted, that the deterioration in Month 8 was slightly worse than the financial recovery plan trajectory produced in October, but mitigations had been identified to pull this back in the next few months. There still remained a significant level of risk to the position which would require robust monitoring and scrutiny via the Turnaround Board to ensure delivery of this position at the end of the year. Mrs Bray reported that at the end of November, QIPP performance for Mansfield and Ashfield was £545k better than forecast to give 108% delivery of the year to date target, which is an improvement from previous months. The delivery of QIPP for Newark and Sherwood was £264k under the forecast to give 93% delivery of the year to date target. Mrs Bray advised that the Month 9 position had been closed down and the verbal update received was that the position had not yet turned around. There was immense pressure on plan which would be very challenging for the final quarter. A discussion ensued in regard to reducing A&E admissions. Members suggested a ‘tick list’ of issues which could be used in A&E for turning away patients who had come to A&E inappropriately, for example, patients who turned up to A&E requesting a sick note. It was felt that it would be easier for officers to challenge acute trust behaviour if there was a robust service specification in place. It was noted that this had been raised before at the A&E Delivery Board and had not supported due to governance concerns. ACTION: Further discussion to take place at the Urgent Care Working Group. Mr Ellis to take forward. Members advised that they felt there was a data quality issue with coding as there were a considerable amount of conditions coded incorrectly which potentially could have repercussions for the patient. It was agreed that contracting should analyse the data from one practice in the first instance to gain a view of the situation. ACTION: Mr Ellis to take forward. The Joint Clinical Executive Committee NOTED the Financial Performance Report.

IE

IE

JCE/17/08

Vague Symptoms Pathway Ms Clare Frank advised members that following presentation of the Vague Symptoms pathway at the Mansfield and Ashfield CCG’s

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Item Action

Clinical Executive Committee in December, further information had been requested in regard to who would be responsible for the cost of investigations done in primary care and the impact of this. Ms Frank fed back comments from Dr Thilan Bartholomeuz who was not able to attend due to surgery commitments. It was reported that patients who would be suitable for this pathway were not new patients into the system as they were not undertaking active case finding through risk stratification or as a screening programme. It was noted that these were symptomatic patients presenting to their GPs and would be expected to have basic investigations done in primary care as part of an initial GP assessment. Ms Frank stated that as there was not currently national guidance, there was considerable clinical variability on GP assessments and some of these extra tests could be expensive. The pathway would guide GPs to have a consistent approach in the assessment of these patients which would provide an opportunity to streamline primary care assessments and facilitate a quicker diagnosis. The two main benefits would be improving patient outcomes and efficient use of investigations in primary care. In response to a query raised why the funds could not be allocated to Cancer of Unknown Primary (CUP) pathway, it was noted that this pathway was not a substitute for CUP. Patients would only be referred to a CUP pathway if identified as having metastasis (secondaries) following assessment by GPs but the primary source of cancer not being known. It was noted that vague / non-specific symptoms had been highlighted in 2005 NICE guidance and currently similar pilots were being run nationally. Ms Frank stated it was an opportunity for the CCG’s to develop a local pathway; and based on outcomes of the pilot, could decide on commissioning it based on lessons learnt locally. The Joint Clinical Executive Committee APPROVED the Vague Symptoms Pathway.

JCE/17/09 Flu vaccines via Pharmacies and Pharmacy First Mr Jackson raised the issue that there were late notifications of pharmacies administering the flu vaccine to patients, i.e. not reporting them within 48 hours. In addition there was an issue with Pharmacy First who had declined care as they had no pharmacist on site, but never offered a later appointment. It was noted that other pharmacies were not participating as they felt it required too much work. Members suggested that Mr Yates could call a sample of pharmacies to ascertain whether they were undertaking

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Item Action

vaccinations to gain an overview of the situation. Members noted the challenge faced by practices when ordering the correct amount of vaccines and that it was likely there would be over-ordering as a percentage of patients may go elsewhere for their vaccinations. The Clinical Executive acknowledged there was competition in the market and this would continue to exist, but it was agreed a coordinated response was required. ACTION: Mr Ainsworth to liaise with Ms Cathy Quinn and NHS England.

DAin

JCE/17/10 QIPP Update on Schemes Ms Clark gave an overview of the CCGs' QIPP performance at month 8. It was reported that Mansfield and Ashfield CCG had delivered £7,031k (108%) year to date against a plan of £6,486k; and Newark and Sherwood CCG had delivered £3,581k (93%) year to date against a plan of £3,846k. The urgent and proactive care programme was below plan year to date delivering £2,057k (70%) from a plan of £2,951k for Mansfield and Ashfield CCG, the forecast was to deliver £4,883k. Of significant concern was the picture in Newark and Sherwood where only £751k (36%) had been delivered against a plan of £1,984k. The revised forecast was to deliver £1,922K. Mitigating actions were planned for the last quarter of the year. The remainder of the main programme areas were broadly on track. Ms Clark explained that a detailed review of scheme performance had been conducted in month and scenario analysis undertaken to derive the current likely forecast position. This risk-adjusted forecast would continue to be reviewed each month to ensure that mitigating actions were taken as necessary. Ms Clark reported that 2 workshops had taken place with all providers to review how services could be used differently. The Alliance Leadership Development Board had oversight. Ms Clark advised that Phase one implementation commenced for Intensive Home Support Service and was live in Mansfield and Ashfield. It was noted that there were lots of respiratory admissions across the patch. Sherwood Forest Hospitals were piloting a change in approach of Respiratory Consultants with more integration with ED and EAU; looking at reducing avoidable admissions and reducing length of stay. Members acknowledged that not many patients took up FLO. It was agreed that patients needed to be encouraged to use technology to manage their medication, perhaps via the voluntary sector. Members queried how the performance of PRISM and support

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Item Action

teams were evaluated. Mr Ainsworth reported that Capita were undertaking in depth observations, analysis and interviews through the Better Together programme. A discussion ensued in regard to patients being sent to ED and some straight to CDU. It was agreed there would be a clinical variation from GP referrals across the patch. It was felt it was not beneficial for a patient to see a junior doctor who did not have access to the patient’s records. Mr Ainsworth suggested a GP assessment area in ED where specialists would come down and see patients and provide a senior decision. In addition, ED would have access to Systm1 to access the patient’s record, along with their blood test results to prevent re-doing them. Mr Ellis and Dr Tadpatrikar left at 4.30pm. The Clinical Executive Committee RECEIVED the QIPP update on schemes.

JCE/17/11 Better Together Update Dr Lunn reported that the Alliance were putting together their approach to high impact changes which would be implemented in the next few months. The Clinical Executive Committee RECEIVED the Better Together update on schemes.

JCE/17/12 Progress reports and minutes of CCG Joint sub-committees: The following minutes which were approved by the Chair of the respective meetings were circulated with the papers. No issues were raised by the members of the meeting in relation to these minutes.

• Prescribing Committee - 25 November • Quality and Risk Committee – 31 October and 12 December

2016 • Information Governance, Management and Technology

Committee – 16 December Ms Robb queried whether the Joint Vaccination and Immunisation Board minutes should be presented to the Joint Clinical Executive. Dr Lunn confirmed that he was happy for them to be included.

JCE/17/13 Summary points to be fed back to the member practices via the GP Constituency members • Financial Challenge • Vague Symptoms Pathway was approved. • Provider structure for primary care was moving forward.

JCE/17/14 Any Other Business

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Item Action

Home visiting Dr Macdougall raised the issue that home visiting was causing difficulties for some practices. Mr Ainsworth advised that the acute home visiting business case had been approved, but unfortunately the providers that were approached did not have the workforce to deliver the service. Mr Ainsworth advised that discussions were being pursued with EMAS in regard to whether the current workforce could be ‘refashioned’ to support this. It was agreed that a good acute home visiting service needed to work in tandem with GPs. ACTION: Mr Ainsworth to liaise with Ms Stephanie Haslam to take forward.

DAin

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Schedule of Actions

Agenda ref Action Responsibility Progress

JCE/17/02 Declarations of Interest

Miss Bradley to advise Corporate Governance of the amendments to Dr Das and Mr Jackson’s Declarations of Interest.

RB Completed.

JCE/17/05 Terms of Reference

Mr Ainsworth to lead on updating the revised Joint Clinical Executive Terms of Reference with Dr Lunn and Dr Bartholomeuz. To be brought back to the February meeting for approval.

DAin Completed.

JCE/17/07 Financial Performance

Report

‘Tick list’ of health issues for inappropriate use of A&E to be discussed at the Urgent Care Working Group.

IE Discussion taken place at Urgent Care Working Group.

JCE/17/07 Financial Performance

Report

Mr Ellis to take forward the potential data quality issue of incorrect coding.

IE In progress.

JCE/17/09 Flu vaccines via Pharmacies and Pharmacy First

Mr Ainsworth to liaise with Ms Cathy Quinn and NHS England in regard to the ordering of vaccines.

DAin Completed. Now being led by Mrs Cathy Quinn.

JCE/17/14 Home Visiting

Mr Ainsworth to liaise with Ms Stephanie Haslam in regard to the acute home visiting service; and whether the current workforce could be ‘refashioned’ to support service delivery.

DAin Completed.

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Progress report from the

Clinical Executive Sub-Committee

Date of committee: 9 February 2017

Key Achievements • APPROVED the proposed community ophthalmology service and the joint procurement

approach (lead provider model, where the contract was awarded to one lead provider, with responsibility for delivering the community service) in conjunction with South Nottinghamshire CCGs.

• AGREED the following recommendations ahead of consideration by the Governing Bodies: o Stop NHS prescriptions of gluten free foods. o Stop NHS prescriptions of medicines not recommended for local use, including high

cost branded medicines. o Stop NHS prescriptions of medicines to treat common minor illnesses that were

suitable for self-care and could be managed using over-the-counter medicines. • AGREED the Terms of Reference subject to minor amendments. • RECEIVED an overview of the financial performance of the CCGs to the period ending

December 2016. • RECEIVED the QIPP Report for Month 9. Mansfield and Ashfield CCG had delivered £8223k

(107%) year to date against a plan of £7656k. Newark and Sherwood CCG had delivered £4368k (94%) year to date against a plan of £4670k.

• NOTED the Multi-morbidity Clinical Assessment and Management NICE guidance which had been published to take account of the rising number of people living with multi-morbidity. The new advice tackled the complexity of multi-morbidity; suggesting GPs could choose to reduce the treatment burden whilst optimising care and taking care when implementing single disease guidance in someone with multi-morbidity.

Issues Actions As at Month 9, both CCGs had utilised their entire contingency. Mansfield and Ashfield CCG was showing a year to date deficit of £4,367k; and Newark and Sherwood CCG was showing a year to date deficit of £3,522k. It should be noted that there had been a delay in the delivery of some specific planned mitigating actions relating to coding and counting challenges with the provider trust; and this had led to deterioration in the year to date position at month 9.

To deliver the agreed revised forecast outturn, a number of mitigating actions were identified and being progressed. Recovery of the year to date position was expected in month 10. Robust monitoring and scrutiny required via the Turnaround Board to ensure delivery of the financial surplus.

At month 9 the mid-Nottinghamshire CCGs had delivered £12.6m of QIPP savings. There was £6m required in the remaining 3 months to meet the QIPP target. The urgent and proactive care programme was below plan year to date delivering £2,344k (65%) from a plan of £3,595k for Mansfield and Ashfield CCG, the forecast was to deliver £4,883k. Of significant concern was the picture in Newark and Sherwood where only £869k (36%) had been delivered against a plan of £2,402k. The revised forecast was to deliver £1,922K. Mitigating actions were planned for the last quarter of the year.

Maximise delivery of QIPP Schemes in year. The CCG needed to be clear on what it was delivering and have clear sight of any slippage. The risk-adjusted forecast would continue to be reviewed each month to ensure that mitigating actions were taken as necessary. Greater use of call for care was encouraged.

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It was noted that there was interesting data on the admission of patients in A&E with acute mental health issues as there was a higher chance of being admitted when attending out of hours, potentially due to the availability of the liaison service. In addition, mental health admissions were increasing and over 10 days length of stay had grown by 40 patients since November 2016. Discharge peaked around 6pm and was not happening quick enough to enable patient flow. Delays for patients waiting for discharge assessment and to be admitted to care homes.

Joined up working with Continuing Healthcare was required; with an emphasis on ensuring patients were discharged in the morning. Discussions to take place with the mental health team.

There were issues with the lack of referrals into the National Diabetes Prevention Programme (NDPP). It was felt that this was due to clinicians not receiving confirmation of when the service was being rolled out along with issues around the offer of training.

Practices to refer their patients identified as pre-diabetes with a raised HbA1C, into the NDPP. Training and venue would be booked once the provider had enough people referred. It was suggested that administrative staff who were willing to, could be paid overtime in order to find recent patients to do the referrals retrospectively.

Reference was made to the prescribing of eye drops and members felt that there was confusion over the range of products and clear advice was needed on which medication should be prescribed, ideally by brand. Concern was also expressed about inadequate supplies of dressings post hospital discharge.

Discussion to take place at the Area Prescribing Committee.

Risks Actions There was a risk that the IAPT (Improving Access to Psychological Therapies) target would not be maintained due to clinical variations in referral rates and complexity of patients accessing the IAPT which would lead to non-achievement of the target and poorer outcomes for patients.

New providers had begun providing services from July 2016, significantly increasing capacity in the system. The 4th provider would go live in Q4. The information received from current providers in terms of output and quality of service would be analysed. Findings would be fed back to a future meeting.

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Minutes of the Joint Meeting of the NHS Mansfield and Ashfield and NHS Newark & Sherwood Clinical Commissioning Group

Clinical Executive Committee

Held on Thursday 9 February 2017, 2.00-5.00pm

Meeting Rooms 2/3, Birch House

Present: Dr Gavin Lunn Clinical Chair for Mansfield and Ashfield CCG (Chair) Dr Subash Das GP, Sherwood Medical Partnership Ian Jackson Practice Nurse, Roundwood Surgery Dr Hilary Lovelock GP, Brierley Park Medical Practice Dr Peter Macdougall GP, Ashfield House Surgery Luella Robb Practice Nurse, Crown Medical Centre Dr Jane Selwyn GP, Fountain Medical Centre Dr Milind Tadpatrikar GP, Roundwood Surgery David Ainsworth Director of Primary Care Sarah Bray Chief Finance Officer Barbara Brady Consultant in Public Health Ian Ellis Director of Contracting and Urgent Care In attendance: Rachel Bradley Executive Assistant to Chief Officer (minutes)

Item Action JCE/17/15 Apologies for absence

Apologies were received from:

• Thilan Bartholomeuz • Dawn Atkinson • Andrea Brown • Rick Gooch • Neil Moore • Elaine Moss • Amanda Sullivan

JCE/17/16 Declarations of Interest Declarations of Interest were as reported on the Register of Interest made available at the meeting. It was noted there were no potential or actual conflicts declared in relation to the business to be transacted at the meeting and all present would remain in the meeting at this point. It was agreed that reference would only need to be made once to Mr Ian Jackson’s wife being an Orthopaedic Specialist Nurse. In addition, Dr Gavin Lunn was no longer a member of the General Practitioner Provider Cabinet.

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Item Action

ACTION: Miss Bradley to inform Corporate Governance and request the Declaration of Interest was amended accordingly.

RB

JCE/17/17 Minutes and actions from the meeting held on: The minutes of the meeting held on 19 January 2017 were agreed as an accurate record of discussion, with the exception of: JCE/17/09/Flu Vaccines via Pharmacies and Pharmacy First – second paragraph should read “In addition there was an issue with Pharmacy First who had declined care as they had no pharmacist on site…”. Matters Arising JCE/17/07/Financial Performance Report – it was noted that the ‘tick list’ of health issues for inappropriate use of A&E had been discussed at the Urgent Care Working Group. Appropriate presentations would be circulated. JCE/17/07/Financial Performance Report – The potential data quality issue of incorrect coding was being progressed. Reference was made to the IV antibiotic service which had been commissioned since 1 November. Dr Lovelock reported that a short audit had identified that 8 patients had gone straight through A&E without being triaged; and the old and new pathways were running side by side; therefore paying twice. Members agreed it was important for someone to ‘walk’ the pathway to ensure it worked correctly. Mrs Bray and Mr Ellis arrived at 2.15pm.

JCE/17/18

Terms of Reference Dr Lunn presented the updated Joint Clinical Executive Terms of Reference. It had been agreed that lay membership was not required as it was felt to be an over-commitment. It was noted that representation at the Clinical Executive Committee was for a clinical focus, with the Chair of the CRP involved within the Clinical and Cost Effectiveness Committee, and subsequently at the Governing Body. Dr Lunn confirmed that the intention was that the meeting would be chaired by both Clinical Chairs on a rotational basis, with nominated deputies attending when absent. Dr Macdougall was nominated and accepted the role of Deputy Chair on behalf of Mansfield and Ashfield CCG. Reference was made in regard to the clinical membership. Dr Lunn explained that the committee was remodelled this way to enable it

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to act as a functioning unit. Dr Lunn reminded members that each quarter there would be a Clinical Senate with wider representation. Members stressed the importance of utilising the quarterly meetings to maximise efficiency and add value. Dr Lunn advised members that High Impact Changes would be discussed at the next Clinical Senate. Members felt that it would be helpful to have a matrix outlining membership for each committee for clarity. In addition it was agreed to recirculate the Business Case process. ACTION: Dr Lunn to liaise with Mrs Lloyd in regard to the matrix. Members made reference to the proportion of clinicians representing each CCG; 3 for Mansfield and Ashfield CCG and 2 for Newark and Sherwood CCG. Dr Lunn advised that the same principle had been used for the Governing Body and that there were still some assignment of roles. Dr Lunn reported that Dr Gopi would be a new Governing Body member representing Newark and Sherwood CCG. It was noted that he could potentially become a member of the Clinical Executive Committee, but it was up to Dr Thilan Bartholemeuz to have that discussion. The Joint Clinical Executive Committee AGREED the Terms of Reference subject to the changes discussed. Dr Lunn gave thanks to Dr Macdougall for agreeing to be Deputy Chair.

GL

JCE/17/19 CCG Feedback Mr Ainsworth reported that financial pressure continued across all key areas, including acute, prescribing and continuing healthcare. The CCGs were working hard to deliver the agreed revised forecast outturn. It was noted that the Alliance were implementing a number of actions to reduce admissions wherever possible, for example, saving one admission per day by implementing the DVT pathway. Mr Ainsworth stressed the importance of every part of the system playing its part in the implementation of schemes. Mr Ainsworth requested that GPs pay personal responsibility leading up to the end of March and refer only when absolutely necessary. A short discussion ensued in regard to ‘repeat cycles’ of patient admissions. An example was given of a patient who had been sent to A&E and discharged, but required an ambulance the following day. It was suggested that quality of care could be audited and a Palliative Care Consultant could be placed in A&E to provide a senior decision to help reduce the length of stay. It was noted that there was interesting data on the admission of patients in A&E with acute mental health issues as there was a higher chance of being admitted when attending out of hours, potentially due to the availability of the liaison service. ACTION: Mr Ellis to ask the Mental Health to look into.

IE

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Mr Ainsworth reported that there was 120 frequent fliers in the system and detailed work had been undertaken on the top 50. It was noted that these were young people, possibly with complex needs and chaotic lifestyles. Mr Ainsworth advised that the 4 main reasons for the frequent fliers attending A&E were recurrent falls, constipation, foreign bodies and mental health. Dr Das arrived at 2.44pm. Mr Ellis reported that mental health admissions were increasing and over 10 days length of stay had grown by 40 patients since November 2016. It was noted that discharge peaked around 6pm and was not happening quick enough during the day to enable patient flow. There were delays for patients waiting for discharge assessment and waiting to be admitted to care homes. Members agreed there needed to be joined up working with Continuing Healthcare and an emphasis on ensuring patients were discharged in the morning. Mr Ainsworth reported that there had only been 7 referrals into the National Diabetes Prevention Programme (NDPP). Dr Tadpatrikar stated that Mansfield and Ashfield GPs had not received confirmation of when the service was to be rolled out. Ms Robb stated that following discussions at the diabetes meetings she attended, she was aware that there had been more than 7 referrals from Newark and Sherwood CCG. Clinical members expressed their concern that there had been issues around the offer of training. Mr Ainsworth requested that practices refer their patients identified as pre-diabetes with a raised HbA1C, into the NDPP. Mr Ainsworth apologised for the confusion and advised that the training and venue would be booked once the provider had enough people referred. Mr Ainsworth suggested that administrative staff who were willing to, could be paid overtime in order to find recent patients to do the referrals retrospectively. ACTION: Mr Ainsworth to distribute information on referrals into the NDPP to all practices via ‘Snippets’. Mr Ainsworth informed members that the Primary Care Commissioning Committee had commissioned a survey in order to understand the CCGs estate for primary care. Suitability of the building and space utilisation would be looked at. It was noted that some premises were sitting empty and some were not fit for the future. Mr Ainsworth added that the review would also be beneficial to practices in regard to CQC inspections. Mr Ainsworth explained that practices could apply for money from the estates transformation fund to ensure they were DDA compliant. Mr Ainsworth suggested that localities could have a discussion in order to present the locality view of their estate. Mr Ainsworth reassured members that they should not be concerned about the survey and would inform the CCGs future care model.

DAins

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Members queried whether there would be financial penalties if a premise closed. Mr Ainsworth assured members this would not be the case if due process had been followed. The Joint Clinical Executive Committed NOTED the CCG feedback.

JCE/17/20 Financial Performance Report Mrs Bray gave an overview of the CCGs financial performance to the period ending December 2016. Both CCGs were forecasting to meet all of their statutory financial duties in 2016/17 but with continued financial pressures across all key areas, including acute, prescribing and continuing healthcare. At month 9 both CCGs had utilised their entire contingency. Mansfield and Ashfield CCG was showing a year to date deficit of £4,367k, and Newark and Sherwood CCG was showing a year to date deficit of £3,522k Running costs for both CCGs were currently on plan. Both CCGs met targets to pay 95% of suppliers within 30 days and remain within the maximum cash drawdown Since the original plan, further work had been undertaken to refine the phasing of expected QIPP delivery and it was against this which performance was now being measured. Against the original planned QIPP phasing the year to date delivery would result in a marginally favourable variance year to date for Mansfield and Ashfield being 105% of plan, and would result in an adverse variance year to date for Newark and Sherwood CCG being 92% of plan. Mrs Bray reported that following a full review of the financial position after month 7 and a further assessment of the risk adjusted forecast position, the CCGs had met with NHS England to discuss the in-year final outturn. The latest assessment anticipated an in-year forecast outturn of £4.85m for Mansfield and Ashfield CCG and £2.56m for Newark and Sherwood CCG. To deliver the agreed revised forecast outturn, a number of mitigating actions were identified and put in place. It should be noted that there has been a delay in the delivery of some specific planned mitigating actions relating to coding and counting challenges with the provider trust; and this had led to deterioration in the year to date position at month 9. Actions were being progressed and the recovery of this year to date position was expected in month 10. The position continued to be kept under close scrutiny, by both the CCG’s Turnaround Board, the Executive team and also NHS England. Mrs Bray reported that the month 10 position had moved the CCGs towards where they needed to be by the end of the financial year, acknowledging that there were still financial pressures in the

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system continuing into February. Mrs Bray advised that they would be meeting with NHS England that afternoon and would then have an indication of where the CCGs stood nationally. Mrs Bray left the meeting at 3.05pm. The Joint Clinical Executive Committee NOTED the Financial Performance Report.

JCE/17/21

Outcomes of the Engagement Activity – Planned Changes to NHS Prescriptions Ms Cathy Quinn provided feedback on the outcomes from the prescribing engagement exercise involving gluten free foods, medicines for self-care and restricted use medicines. It was noted that an engagement exercise took place between 4 January and 1 February 2017 to seek comments from the public on planned changes to NHS prescriptions. These changes included stopping NHS prescriptions for gluten free foods, medicines for self-care and restricted use (non-formulary) medicines. In total, 88 people attended the public events. 52 (59%) people were in receipt of an NHS prescription for gluten free foods (or were a carer/relative of a person who receives Gluten Free Foods.) A range of engagement activity took place including an on-line survey to capture public feedback. It was noted that 679 surveys had been returned. Results had been analysed and were presented for consideration by the Clinical Executive Committee. Ms Quinn gave an overview of the following areas of prescribing: Gluten Free Foods – Ms Quinn reported that 33% supported stopping NHS prescriptions for all patients. There was mixed response around the gluten free (GF) food policy. Some people felt that these foods should not be available on NHS prescription as they were now widely available in supermarkets. Some respondents also felt that people with low income or vulnerable groups should be exempt from buying their foods. Almost all attendees that received GF foods on prescription (and some non-coeliac patients) were opposed to the planned changes. Concern was expressed that there may be unintended consequences from the policy, such as additional costs of treating the complications of Coeliac Disease from people not following a GF diet, or extra claims on the welfare system in response to a person’s financial situation. Members expressed concern in regard to a blanket ban on gluten-free food and felt that exceptions should be put in place. It was noted that the Clinical and Cost Effectiveness Committee had acknowledged that extra support would be required for GPs so they

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were clear on applying any changed policy decisions and when discretion should be considered. Clinical members stated that they felt they should not have to deal with complaints that came from not being able to prescribe. Ms Quinn advised that patient complaints should be directed to the patient engagement team, and there would be a central process to consider special cases. Mrs Brady stressed the importance of having clear and transparent criteria. Members agreed that expert advice was required to agree exceptionality. Medicines for Self-Care – Ms Quinn reported that there was broad agreement to the proposals to promote a self-care approach to managing minor illnesses with medicines available over-the-counter. Some comments were received about the inappropriateness of the policy, but this was felt to be a misunderstanding. Comments were also received about safety and financial impact for patients. Members asked that the NHS England Pharmacy First service be promoted better, which provided free advice and treatment for patients who did not pay for their prescriptions. It was noted that clarification was given around long-term treatment, including pain relief, as this was not part of the medicines for self-care policy. Clarity was also required that self-care was first line treatment and did not mean that NHS treatment was not available if the condition was not resolved following advice and treatment through a Community Pharmacist. Similarly, it was confirmed that more complex forms of minor illnesses would also be outside the scope of the policy. Concern was expressed around whether this policy could disengage vulnerable groups and whether it would have unintended consequences on other parts of the system e.g. A&E attendance. Hospital trust staff felt there would be value in giving a consistent message e.g. where people attended A&E or GU clinics for minor illnesses. Ms Quinn reported that 54% had suggested stopping prescribing for self-care. Members stressed the importance of clear and consistent messages to patients to encourage visiting the pharmacy first and having a well-stocked medicine cabinet. Restricted Use Medicines – Ms Quinn reported that there was broad agreement with not prescribing brands or other medicines of high cost where alternative equally effective medicines were available. It was noted that there had been some confusion around the policy and what would be excluded. Clarity was given that brands would still be available for people who needed to be maintained on a brand if it is required on clinical grounds. Reference was made to the prescribing of eye drops and members felt that there was confusion over the range of products and clear advice was needed on which medication should be prescribed, ideally by brand. Concern was also expressed about inadequate supplies of dressings post hospital discharge.

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ACTION: Ms Quinn to take back to the Area Prescribing Committee. Members agreed with the policies, but that there should be discretion for clinical need; and that there should be appropriate wording to cover the discretionary element. Ms Quinn advised that legal advice had been sought in regard to the proposed changes to prescribing. ACTION: Ms Quinn to circulate the summary legal advice obtained on the proposed changes to prescribing. The Joint Clinical Executive Committee AGREED the following recommendations:

• Stop NHS prescriptions of gluten free foods. • Stop NHS prescriptions of medicines not recommended for

local use, including high cost branded medicines. • Stop NHS prescriptions of medicines to treat common minor

illnesses that were suitable for self-care and could be managed using over-the-counter medicines.

JCE/17/22 Multi-morbidity Clinical Assessment and Management

Recommendations Mr Ainsworth reported that NICE had published guidance taking account of the rising number of people living with multi-morbidity. It was noted that previous NICE guidance tended to focus on single disease areas and this new advice tackled the complexity of multi-morbidity; suggesting GPs could choose to reduce the treatment burden whilst optimising care and taking care when implementing single disease guidance in someone with multi-morbidity. It was noted that multi-morbidity referred to the presence of 2 or more long-term health conditions, which could include defined physical and mental health conditions such as diabetes, ongoing conditions such as learning disabilities, symptom complexes such as frailty, sensory impairment or alcohol and substance misuse. Mr Ainsworth informed members that the Clinical and Cost Effectiveness Committee had requested the Clinical Executive to consider the NICE guidance and make recommendations relating to financial decommissioning/cost reduction initiatives as well as paying consideration to the guidelines on each practitioner’s own clinical practice. Ms Robb advised that there was already a nurse-led long-term conditions review taking place; which could be a model to look at to support this initiative. Members suggested that further discussion could take place within locality groups; noting that there should perhaps be a pause to see what happened with QOF. Members agreed that discussion should take place within the forthcoming

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PLT on frailty. ACTION: Mr Ainsworth to liaise with Mrs Pipes for discussion at the Education Forum. The Joint Clinical Executive Committee AGREED the recommendation, subject to changes within QOF.

DAins

JCE/17/23 Ophthalmology Service Review – Proposals for Community Provision Ms Thornley reported that ophthalmology was an area included in the Elective STP programme, with recognition from all stakeholders that this continued to be a pressure area. This was also highlighted as a priority area at the Elective Summit in October 2016, with strong emphasis on the need for standardised pathways. As part of the STP process discussions had taken place across Nottinghamshire to understand joint working opportunities. There was an opportunity to work alongside CCGs in South Notts to design a Community Ophthalmology Service and develop a joint procurement approach, where the contract was awarded to one lead provider, with responsibility for delivering the community service (Mid Notts colleagues had contributed to the development of the lead provider service specification). This would have the advantage of streamlining approach across secondary care providers and could be progressed in Q1 of 2017/18. Ms Thornley advised that the proposed model extended the scope of services delivered within the current community model and offered the opportunity to deliver a higher level of savings, with benefits to patients on the pathway. This was estimated to be in the region of £250,000 pa. Ms Thornley advised that there had been numerous discussions in regard to the joint approach to the community ophthalmology specification. The procurement options had been outlined at the Commissioning Committee on 4 January 2017 and members had agreed that the Lead Provider Model was the most viable option going forward. It was noted that procurement of the wider community service would include stable follow ups, post-operative cataracts and treatment of minor eye conditions. Wet AMD monitoring and minor eye conditions (MECS) were not included, but the CCGs reserved the right for these conditions to be revisited once the current provision had been procured. Ms Thornley advised that there was a small of amount of activity in regard to Wet AMD; which would be monitored and revisited where necessary. Dr Lovelock made reference to what she felt was a lack of trust in the system between clinicians and optometrists; and felt that MECS could be included. Dr Lovelock stressed the importance of doing

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what was right for patients and getting the governance right. Mrs Brady stated that she was keen to see the ‘prevention agenda’ in all pathways; specifically clinicians making ‘every contact count’, emphasising it should be an area they were held accountable for. Ms Thornley advised that the service would be an enhanced model of triage and treatment, with a better trained workforce to deliver the service and capacity for monitoring follow-up from secondary care. There was potential for more activity to be delivered. Reference was made to the GOS 18 referral and it was noted that it was contractual for the CCG to pay. Ms Thornley advised that the lead provider may pick up triage rather than it being handled through the Gateway. Members queried why the optometrist could not refer directly and then triage. It was noted that at the triage point, the GP would receive a letter, thereby reducing administrative work for the GP. Members queried what the difference was. Ms Thornley stated that the scope of conditions seen would be widened and follow-up activity would be monitored by opticians rather than secondary care. Members emphasised the importance of demonstrating links with secondary care to develop confidence, with the CCGs included in the dialogue. Dr Lunn stressed the importance of ‘walking the pathway’ to ensure it worked. Dr Lunn recommended looking at the optician referral pathway in order to take out the GOS 18. The Joint Clinical Executive Committee APPROVED:

• The proposed community ophthalmology service • The joint procurement approach (lead provider model,

where the contract was awarded to one lead provider, with responsibility for delivering the community service) in conjunction with South Nottinghamshire CCGs.

JCE/17/24 QIPP Performance Report – Month 9

Ms Clark reported that at month 9, the mid-Nottinghamshire CCGs had delivered £12.6m of QIPP savings. There was £6m required in the remaining 3 months to meet the QIPP target. Key schemes in remaining months were transformational, recognising the additional actions and interventions being implemented. At month 9 the Mid Nottinghamshire CCGs had delivered £12.6 million of QIPP savings: Run rate: - Quarter 1: £1.8 million (1.6%) - Quarter 2: £5.5million (4.7%) - Quarter 3: £5.3 million (4.5%) At Month 9 Mansfield and Ashfield CCG delivered QIPP above the Financial Recovery Plan and Newark and Sherwood were below: - Mansfield and Ashfield CCG had delivered £8223k (107%) year to date against a plan of £7656k. - Newark and Sherwood CCG had delivered £4368k (94%) year to

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date against a plan of £4670k. The urgent and proactive care programme was below plan year to date delivering £2,344k (65%) from a plan of £3,595k for Mansfield and Ashfield CCG, the forecast was to deliver £4,886k to the end of the year. Of significant concern was Newark and Sherwood CCG where only £869k (36%) had been delivered against a plan of £2,402k. The revised forecast was to deliver £1,922K. Mitigating actions were planned for the last quarter of the year. It was noted that the remainder of the main programme areas are broadly on track. Greater use of call for care was encouraged. The Clinical Executive Committee RECEIVED the QIPP Performance Report.

JCE/17/25 Better Together Update Dr Lunn presented the Turnaround PMO report. Key messages were:

• Activity pressures were continuing across the system and this was impacting on the delivery of the BT objectives.

• Delivery of financial and activity benefits were below the year-to-date plan, £1.3m under expected vanguard savings at month 7.

• A number of agreed system-wide high impact changes had moved to implementation to support recovery of the position.

The Clinical Executive Committee RECEIVED the Better Together update on schemes.

JCE/17/26 Progress reports and minutes of CCG Joint sub-committees: The following minutes which were approved by the Chair of the respective meetings were circulated with the papers. No issues were raised by the members of the meeting in relation to these minutes.

• Primary Care Commissioning Committee – 22 December 2016.

JCE/17/27 Summary points to be fed back to the member practices via the GP Constituency members • Financial position remained a challenge. • Encourage practices to refer patients identified as pre-diabetes,

with a raised HbA1C, into the National Diabetes Prevention Programme.

• Reaffirm presentation of pathways. • Encourage GPs to feedback problems with coding. • Recommend that GPs pay personal responsibility leading up to

the end of March and refer only when absolutely necessary.

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ACTION: Mr Ainsworth to include in ‘Snippets’.

DAins

JCE/17/28 Any Other Business There was no other business.

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Schedule of Actions

Agenda ref Action Responsibility Progress

JCE/17/16 Declarations of Interest

Miss Bradley to inform Corporate Governance of amendments to the Declarations of Interest.

RB Completed.

JCE/17/18 Terms of Reference

Dr Lunn to liaise with Mrs Lloyd in regard to the completion of a committee matrix.

GL

JCE/17/19 CCG Feedback

Mr Ellis to request mental health to look into the data on the admission of patients with acute mental health issues. There was a higher chance of being admitted when attending out of hours due to the availability of the liaison service.

IE

JCE/17/19 CCG Feedback

Mr Ainsworth to distribute information on referrals into the NDPP to all practices via ‘snippets’.

DAins Completed.

JCE/17/21 Outcome of the

Engagement Activity – Planned changes to NHS

prescriptions

Ms Quinn to discuss the prescribing of branded eye drops medication with the APC. Ms Quinn to circulate the summary legal advice obtained on the proposed changes to prescribing.

CQ

CQ

Items raised with APC for consideration. Action in progress Completed.

JCE/17/22 Multi-morbidity Clinical

Assessment and Management

Recommendations

Mr Ainsworth to liaise with Mrs Pipes to arrange for multi-morbidity clinical assessment and management recommendations to be discussed at the Education Forum for inclusion in the forthcoming PLT on frailty.

DAins

JCE/17/27 Summary points to be fed back to member

practices

Mr Ainsworth to include in ‘snippets’ a recommendation that GPs paid personal responsibility leading up to the end of March and referred only when absolutely necessary.

DAins

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Progress report from the Quality and Risk Committee

Date of committee: 6 February 2017

Key Achievements Management of Risks – the Committee undertook its biannual wholesale review of all risks held on both CCGs’ Assurance Frameworks and Risk Registers. Each risk was reviewed to affirm that the current rating for risk was correct; the effectiveness of the mitigations; and for any areas of increased risk for the CCG. The session ensured all risks were considered together to ascertain whether there was any duplication and overlap, but also if there were any gaps in the CCGs’ coverage of risk. Actions from the session are being taken forward and will be reflected in the next iteration of the Assurance Framework and Risk Registers and fed back to the respective committees. New risks that were identified included the care home service. A number of generic matters common to all risks were highlighted; and the Committee asked for work to be undertaken to ensure the theme of equality and diversity was embedded in all risks and was made integral to CCG decision-making. Issues Actions Training rates for the mandatory information governance training module are below the 95% rate required to comply with the Information Governance Toolkit, which could lead to a non-compliant rating in the annual audit of the Toolkit. Continuing concern over the number of serious incidents at Nottingham University Hospitals

A mandatory training session will be held for all non-compliant members of staff. A deep dive will be undertaken for review at the next Committee meeting.

Risks Actions No risks were identified that required escalation.

1

QUALITY AND RISK COMMITTEE

Held on 6 February, 1pm

Hawthorn House, Ransomwood Present: Elaine Moss Chief Nurse, NHS Mansfield & Ashfield CCG and NHS Newark &

Sherwood CCG (Chair) Eleri de Gilbert Lay Member, NHS Mansfield & Ashfield CCG & NHS Newark and

Sherwood CCG Dr Nigel Marshall Dr Gavin Lunn

Clinical Advisor, NHS Newark & Sherwood CCG Clinical Chair, NHS Mansfield & Ashfield CCG

Susan Crosby David Ainsworth Rosa Waddingham

Lay Member, NHS Newark & Sherwood CCG Director of Primary Care, NHS Mansfield & Ashfield CCG and NHS Newark and Sherwood CCG Deputy Chief Nurse, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG

Ruth Lloyd Head of Corporate Governance, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG (item 1 and items 10-12)

Sue Barnitt Head of Quality and Adult Safeguarding, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG (item QRC/17/1)

Sue Bateman Head of Patient Safety and Experience, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG

CCG Staff In attendance: Sally Bird Paula Dudley Ian Ellis Clare Frank Gina Holmes Sue Wass (minutes)

Head of Infection Prevention and Control Team, NHS Mansfield and Ashfield CCG CCG Assistant Chief Finance Officer (item QRC/17/1) CCG Director of Contracting and Urgent Care (item QRC/17/1) CCG Programme Manager (item QRC/17/1) Corporate Governance Officer, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG (item QRC/17/11 only) Corporate Governance Officer, NHS Mansfield & Ashfield CCG and NHS Newark & Sherwood CCG

Apologies: Coral Osborn Senior Prescribing (North) and Governance Advisor on behalf of

Mid and South Notts CCGs Andrea Brown CCG Director of Programmes (item QRC/17/1) Dawn Atkinson CCG Head of Transformation and Business Change (item

QRC/17/1) Helen Pledger CCG Turnaround Director (item QRC/17/1) ASSURANCE FRAMEWORK AND RISK REGISTER: MANAGEMENT OF RISKS SIX MONTHLY REVIEW SESSION (QRC/17/01) The Chair introduced the session by explaining this was the six monthly review of all risks on the CCGs’ Assurance Frameworks and Risk Registers. Each risk would be examined to ask risk owners:

• Affirmation of where changes to the risk rating have either increased or decreased • A view on the effectiveness of the mitigations

• Any areas of increased risk for the CCG • Any areas of new risk for the CCG.

The review formed a key element of the CCGs’ Statements of Internal Control in relation to the CCGs’ management of risk and would be reviewed by both internal and external auditors. The Chair listed a number of generic matters common to most risk, which would be communicated to risk owners alongside the outcome of the review, which were: • Under controls in influences, can each be identified by either a (c) or (i) to denote control

or influence • Can each gap be numbered and ensure the corresponding mitigating action is numbered

to ensure ease of reference • Can all risk owners re visit the gaps to ensure that they are gaps and not statements or

actions • Correspondingly can all risk owners revisit their actions to ensure they are actions and

not statements • Dates should be put on all actions • Abbreviations should be put in full the first time they are specified in the risk 1 risk

No. Description Lead Action

2 AF TB4 (M&A) TB2 (N&S)

There is a risk that over performance against budgeted expenditure across key areas will continue, which would lead to the CCGs not achieving its their respective planned surplus targets

Sarah Bray

The Committee asked whether the CCGs would meet planned surplus targets. It was noted there were a number of actions to update on the risk, which could be closed for this financial year, with a new risk drafted for 17/18. ACTION: PD to update the actions on TB4 and recommend to the Turnaround Board that it be closed, and draft a new risk for the financial year 2017/18. The Committee discussed an additional related risk relating to the Alliance, with respect to NHSE and NHSI requesting differing control totals for providers, which were considered counter-intuitive. ACTION: PD to draft a risk for discussion at the Turnaround Board

3 RR TB7 (both)

There is a risk that the CCG cannot maintain and reduce organizational administrative costs within the running costs allowance which would lead to the CCG breaching one of its financial duties

Sarah Bray

The Committee asked whether this was still a risk considering that admin costs were within budget and that adequate controls were in place to monitor and control the budget. PD noted that there was still a risk to the CCG regarding agency spend. It was agreed that the risk should be reviewed and redrafted to describe the risk relating to agency spend, given the increased oversight by NHSE.

2

ACTION: PD to update the risk to focus it on agency spend.

4 RR TB8 (both)

There is a risk that the CCG cannot remain within its cash limit, which would lead to the CCG breaching one of its financial duties

Sarah Bray

The Committee asked whether there were sufficient controls in place. PD noted that a meeting would be taking place on 8 Feb to discuss the delivery of cash-releasing QIPP and the risk would need to be updated following this meeting. ACTION: PD to update risk TB8 following the meeting on 8 Feb.

5 AF TB11 There is a risk that QIPP schemes do not deliver as expected, either in terms of the level of savings anticipated or the timing of the realization of benefits

Helen Pledger

The Committee discussed whether the risk related to assurance of the management of the process or to the programme; and whether the mitigating actions as described would have any significant impact. The Committee discussed the impact of provider non-delivery of QIPP and the Turnaround Board's oversight of specific QIPP risks ACTION: HP to discuss the re drafting of risk TB11 with EM.

6 AF GB1 (both)

There is a risk that CCG elements of the system transformation plans are not delivered.

Dawn Atkinson

The Committee recommended that risks GB1 and GB2 be combined and a review of gaps undertaken by the Commissioning Committee once completed. ACTION: DAT to combined risks GB1 and GB2 and ask the Commissioning Committee to agree the risk as re scoped at their next meeting.

7 AF GB2 (both)

There is a risk that system TRANSFORMATION will not be achieved due to the CCG’s inability to influence and drive required system reconfiguration through other and health economy partners.

Dawn Atkinson

See risk GB1 above

3

8 AF GB3 (both)

There is a risk that system SUSTAINABILITY will not be achieved due to the CCG’s inability to influence and drive required future system reconfiguration through other and health economy partners.

Dawn Atkinson

The Committee agreed the risk with updates provided in writing by DAT and asked for abbreviations to be removed. ACTION: DAT to remove abbreviations in the next iteration of risk GB3

9 AF GB4 (M&A) GB5 (N&S)

There is a risk that service change across the local health economy will not be fully realised because of the local and national workforce matters

Dawn Atkinson

The Committee agreed that the risk needed to acknowledge that progress was limited by the availability of the current workforce, noting that even if all mitigating actions were delivered impact on the risk could be limited. The Committee asked that actions were developed to be profession-specific and timescales for delivery needed to be added. The Committee agreed that a further review would be needed to examine the effectiveness of actions overall. ACTION: DAT to update risk GB4 in light of discussion with discussion with EM if required

10 AF Q&R33 (both)

There is a risk of failure to deliver high quality and timely services in line with NHS constitutional pledges – A&E.

Ian Ellis

IE noted that the current rating was correct , but that the controls and influences required updating to take into account wider whole system impacts on A&E; and a paper (updated from the paper discussed at the A&E board) should be brought to the Governing Bodies to examine the system as a whole, the impact on providers and what actions were being undertaken to mitigate the risk. ACTION: IE to re-scope the risk and bring a paper to the April Quality and Risk Committee on actions to mitigate the risk, which would then be discussed at the May Governing Bodies.

11 AF Q&R34 (both)

There is a risk that East Midlands Ambulance Service performance in rural areas will lead to a failure to deliver safe, effective and quality services to

Ian Ellis

IE noted that the current rating was correct, however he asked the Committee whether the risk should be expanded to include the entire CCG area. There was a discussion relating to the levers the CCG had available to impact the risk. It was agreed that the level of risk relating to governance,

4

the CCG’s patients quality, finance and performance should be reflected in the risk and an internal risk summit should be held to reflect whether existing mitigating actions were sufficient to be able to have an impact on the risk score. ACTION: IE to redraft and expand risk Q&R33 in light of internal discussions on EMAS performance ACTION: EM to call an internal risk summit on EMAS

12 RR ET6 (M&A)

There is a risk that the target will not be maintained due to clinical variations in referral rates and complexity of patients accessing the IAPT (Improving Access to Psychological Therapies) which will lead to non-achievement of the target and poorer outcomes for patients

Ian Ellis

IE noted that access targets were being reached. There was a discussion on wider aspects of access to mental health provision and how to identify gaps in service. It was agreed that further work should be undertaken to identify 'what good looks like' in terms of mental health provision and what actions should be undertaken to fill any identified gaps in service. The risk should be re-drafted in the meantime to identify a risk to he achievement of parity of esteem in both CCG areas and gaps identified from the work above to be incorporated into the risk. The Committee noted that much was being done but it needed to be pulled together into a single overview of activity ACTION: IE to identify any gaps in service and re-scope the risk in light of any gaps to the achievement of parity of esteem.

13 RR CE11 (N&S)

The risk is that There is a risk that the CCG’s service improvement will not enable more people to exercise their choice to die in their preferred choice of care which could lead to patient preferences not being delivered

Clare Frank

The Committee asked for the risk to be updated to describe wider work being undertaken, for example CHC, and to give an overview of any gaps, with associated risks looking over the next two years. The positive impact of the Best Practice Scheme on EPCSCS was noted. ACTION: CF to update the risk to include potential gaps and risks to the service over the next two years.

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14 RR CE15 (N&S)

There is a risk that SFHFT will not deliver quality services and continued delivery

Clare Frank

The Committee asked for the risk to be re scoped to be wider than SFH and describe the actual risk, whether it be workforce, capacity, system ownership or delivery of the pathway. The Committee noted the impact of staffing and asked that the risk focused on the impact of this rather than the staffing itself. ACTION: CF to redraft the risk to describe the actual risk

45 RR PC6 (both)

There is a risk of the CCG failing to communicate and engage with local patient groups and the wider local community in the implementation of the Primary Care Strategy

Andrea Brown

The Committee considered that there was a wider risk around engagement that extended further than the Primary Care Strategy, which incorporated risks around consultations and demand outstripping resource, specifically noting expertise required to facilitate engagement and formal consultation requirements associated with service changes. ACTION: EM to discuss risk PC6 with AB

16 AF GB4 (N&S)

There is a risk that the Newark Hospital Strategy is not fully implemented leading to a loss of trust and confidence in the local NHS.

Andrea Brown

The Committee agreed that the risk needed a wholesale review to understand what the current risks were around delivery of services in Newark, given the recent investment in the hospital and the Newark Primary Care Hub. ACTION: EM to discuss risk GB4 with AB

17 TB4 (NS) TB9 (M&A)

There is a risk that clinical variations in GP referrals to secondary care and community pathways will lead to practice overspend on budgets impacting on CCG financial control

David Ainsworth

DA noted that the risk was not yet adequately described and assessed and that it would be reviewed in time for the next meeting. ACTION: DA to review the risk for the April meeting.

18 AF PC1 (both)

There is a risk to successful delivery of the Primary Care Strategies and the stated population health outcomes within Mid-Notts Better Together approach

David Ainsworth

DA noted that the risk needed to be updated to include elements of the GP Forward View

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19 AF TB10 There is a risk that prescribing costs will exceed the budgets set for 2016/17 which would lead to additional cost pressures for the CCGs

David Ainsworth

DA recommended to the committee that the risk rating was correct and up to date. This was agreed.

20 RR PC3 (both)

There is a risk that Primary Care fails to engage in and proactively support Information sharing at practice level

David Ainsworth

DA requested that PC3, PC4 and PC7 be incorporated into risk PC1 as there were elements of duplication and this was agreed ACTION: DA to incorporate PC3 into PC1

21 RR PC4 (both)

There is a risk to the development of Primary Care transformation due to limited practice engagement and capacity head room

David Ainsworth

ACTION: DA to incorporate PC4 into PC1

22 RR PC7 (both)

There is a risk that Mid Nottinghamshire patient population will not receive consistently high standards of care in Primary Care due to variation in the quality of services

David Ainsworth

ACTION: DA to incorporate PC7 into PC1

23 RR Q&R25 (both)

There is a risk that Business Continuity Planning across the health community is not tested to be robust and that planning is not connected across the healthcare system to anticipate the impact of business continuity events and the associated impacts on service provision

Ruth Lloyd

RL noted that an additional action would be added to the risk relating to the annual reminder to all staff of their roles and responsibilities. ACTION: RL to update risk Q&R 25 to include additional actions relating to annual reminders for staff

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24 RR A&G1 (both)

NHS England in June 2016 has published guidance regarding the management of conflicts of interest and there is a risk that the uniform management (Identification, registration, review in line with agenda items, and effectively managing the actual or perceived conflict including the recording of these decisions) are not in place not only within the CCG’s committee structure but within the structure in which the CCG is a partner including the Alliance Leadership Board

Ruth Lloyd

RL asked the Committee to note that an internal audit review of declarations of interest processes was soon to be completed and the risk would be updated on any additional actions that needed to be incorporated and the rating for the risk reviewed in light of the report. ACTION: RL to review and update risk A&G1 following the publication of the internal audit review of the CCG management of declarations of interest

25 AF TB6 (both)

There is a risk that the costs associated with continuing healthcare continue to rise which would lead to additional cost pressures for the CCG

Elaine Moss

EM noted this was a significant risk of the CCG and work was in train to examine specific ways of managing the risk. The Committee agreed the risk rating was correct.

26 AF Q&R1 (both)

There is a risk that safe, effective and quality services may not be provided by Sherwood Forest Hospital NHS Foundation Trust to the CCG’s patients due to governance, leadership and financial issues.

Elaine Moss

EM asked the Committee to consider lowering the risk due to the significant work undertaken by the trust over the past year and consequent improvements in governance processes. The QSG had removed the trust from intense scrutiny and the proposal was to lower the risk to 3x2, which was agreed.

27 RR Q&R19 (both)

There is a risk that statutory and mandatory training duties are not being met due to poor uptake of annual training

Elaine Moss

RL noted that this was a continuing issue to encourage uptake of training and it was agreed to revisit the issue later at the Quality and Risk meeting, with a view to raising it to the Governing Body

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28 RR SC2 (both)

The risk is that Children and Young People in Care of the Local Authority may be detrimentally affected by not receiving initial health assessments within statutory timescales

Safeguarding Committee

EM asked the Committee to agree that further work should be undertaken to ascertain if the Nottinghamshire area was an outlier, and to understand the processes, as assurance could not be given. ACTION: the Safeguarding Committee to undertake a further investigation and report to the Quality and Risk Committee in due course

29 RR SC3 (both)

The risk is that due to lack of national and local clarity, the potential ability of health services to be able to respond in a timely way to the needs of unaccompanied migrant children being placed in Nottinghamshire is compromised

Safeguarding Committee

The Committee agreed that this was not a risk if the Safeguarding Committee was assured that sufficiently robust processes were in place to give early notice of a large number of placements. They asked that the Safeguarding Committee discussed whether they had this assurance at their next meeting. If they were assured processes were in place, the risk could be closed. If they did not think robust processes were in place, the risk should be re-drafted to reflect gaps in assurance. the Committee asked for this approach to be similar to business continuity planning, where organisations agreed a protocol to work together to agree how and where services can flex to meet needs. ACTION: Safeguarding Committee to discuss the risk in light of this discussion at their next meeting

30 RR SC4 (both)

The risk is that there are gaps in services for victims/survivors of historical child abuse who as a result are not adequately or effectively supported and thus do not have the confidence to report

Safeguarding Committee

EM asked the Committee to note that SC4, SC5 and SC6 were risks identified by the joint local authority/Nottinghamshire Police/health commissioner Operation Equinox Strategic Management Group; however they were not risks currently for the CCG and the recommendation would be to remove them from the risk registers. This was agreed. ACTION: Safeguarding Committee to remove the risk from its register

31 RR SC5 (both)

Local survivors of historical child abuse are accessing unregulated services that are not quality assured; or that few external support

Safeguarding Committee

EM asked the Committee to note that SC4, SC5 and SC6 were risks identified by the joint local authority/Nottinghamshire Police/health commissioner Operation Equinox Strategic Management Group; however they were not risks currently for the

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services have any external quality assurance oversight. (This relates to risk above)

CCG and the recommendation would be to remove them from the risk registers. This was agreed. ACTION: Safeguarding Committee to remove the risk from its register

32 RR SC6 (both)

The risk is that an increase in the number of civil claims in relation to historical children sexual abuse has resource implications, impacting on budgets; and on the number of staff dealing with the allegations

Safeguarding Committee

EM asked the Committee to note that SC4, SC5 and SC6 were risks identified by the joint local authority/Nottinghamshire Police/health commissioner Operation Equinox Strategic Management Group; however they were not risks currently for the CCG and the recommendation would be to remove them from the risk registers. This was agreed. ACTION: Safeguarding Committee to remove the risk from its register

33 RR SC8 (both)

Reduced professional capacity in MASH may affect safeguarding decisions / assessments and adversely affect performance data

Safeguarding Committee

The Committee asked that the risk be re-drafted to explain the over arching consequences of reduced staffing for the CCG rather than describing the staffing issue itself. ACTION: EM to lead on the re drafting of risk SC8 to articulate the overarching consequences to the CCG of reduced staffing at MASH.

New risks identified were confirmed as the risk relating to the Alliance, with respect to NHSE and NHSI requesting differing control totals for providers; and a risk relating to care home provision, which would be drafted for the next meeting. ACTION: RW to scope and bring new risk relating to care home provision to the Committee for approval in due course. There was a discussion relating to the need for equality and diversity to be integral to all risks. It was agreed for the Quality Team to undertake work to scope what processes were in place and identify gaps in process before adding to the risk register. ACTION: RW to lead on a review of processes and policies to ensure equality and diversity were integral to CCG decision making. It was agreed that the next risk review would take place in August. The Chair thanked the members of staff that had attended the risk assurance session and moved the meeting to the main Quality and Risk Committee agenda.

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WELCOME AND INTRODUCTIONS (QRC/17/02) The Chair welcomed members to the meeting. APOLOGIES FOR ABSENCE (QRC/17/03) Apologies were received from Mrs Osborn and Mrs Barnitt. The meeting was declared quorate. DECLARATIONS OF INTEREST (QRC/17/04) All members confirmed that their declaration of interests were as detailed on the register. No additional interests were declared on any items on this agenda by the rest of the Committee members. MINUTES OF THE QUALITY AND RISK COMMITTEE MEETING HELD ON 12 DECEMBER 2016 (QRC/17/05) The minutes of the meeting held on 12 December were accepted as representing an accurate record of discussions. MATTERS ARISING (QRC/17/06) A number of actions were noted as having moved on the forward work programme to accommodate the risk review session. The following items were noted as being outstanding: • QRC/16/102 End of Life Strategy: It had been agreed under item 1 that the existing risk

CE11 would be redrafted to cover the Mansfield and Ashfield area. Action closed. • QRC/16/101 SEND Report update: This action remained outstanding. It was agreed

that Mrs Waddingham would raise this issue with Mrs Andrea Brown to raise at the ICYP Committee.

• QRC/16/103 Quality Dashboard: Sue Barnitt to work with Charlotte Lawson to report on actions providers were taking on workforce indicators, to form part of the paper for the February meeting , ref QRC/16/97 above and to report whether the indicators were an outlier in national comparisons for the next Committee meeting. This would form part of the paper for the April meeting.

All other actions were noted as completed or on the Committee’s forward work plan. NOTTINGHAMSHIREJOINT HANDLING OF HEALTH AND SCOIAL CARE COMPLAINTS PROTOCOL (QRC/17/07) Mrs Waddingham reported that this policy had recently been updated. The policy had been in existence across Nottinghamshire for some years to provide a framework for how commissioners and providers worked together to manage complaints. The Committee was assured that this protocol was consistent with the CCGs’ own complaints policy and approved the revised protocol. QUALITY DASHBOARD HIGHLIGHT REPORT (QRC/17/08) Mrs Moss asked the Committee to note that going forward the format of the Quality Dashboard would change. Moreover, as a highlight report of the quality dashboard had been received so positively at a recent meeting of the Governing Bodies, it was proposed that this report would continue to be presented there and that the Committee continue to discuss the full Quality Dashboard at every other meeting. This was agreed. This would give

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opportunities to consider deep dives, which would then be presented to the Governing Bodies. After consideration of the report, it was agreed that a deep dive on Nottingham University Hospitals would be undertaken for the next meeting, with the recent rise in mortality rates at Nottinghamshire Healthcare Trust being examined at the June Committee.

• ACTION: SW to add the deep dives to the Committee forward work programme. PATIENT STORY (QRC/17/09) Mrs Bateman presented a questionnaire that had been developed to capture feedback on patient stories in order to inform how and where patient stories were used going forward and to give patients the assurance that their experiences were being used to improve services. The Committee heard Albert’s story, a patient who had not received a good standard of care from both health and social services. Since his experiences, the story explained that improved procedures had been put in place. The Committee agreed this was a good story and discussed a number of questions and issues that the Governing Bodies were likely to raise. Mrs Moss asked that going forward, patient stories should try to reflect key issues on the Governing Bodies’ agenda in order to give more of the patient voice, and this was agreed where possible.

• ACTION: Mrs Bateman to work with the Corporate Governance Team to match patient stories to the Governing bodies’ forward work plan.

ESCALATION OF RISKS ARISING FROM QUALITY/EQUALITY IMPACT ASSESSMENTS (QRC/17/10) Mrs Bateman reported that work had been undertaken to identify any actions that were required to improve the quality and equality impact assessment process. This piece of work had also identified a potential risk around the need to capture the cumulative impacts of the assessments. It was noted that the current process needed to be enhanced to ensure they provided assurance for the CCG, particularly to capture the cumulative impacts. Work was already underway with CCG delivery teams to ensure all projects had an equality and quality impact assessments attached when they were discussed at the Finance, Performance and Delivery Group. Information on all current projects was also being pulled together in one tracking log and a session would be held to embed the revised processes. An update would be given at the next Committee meeting.

• ACTION: Mrs Bateman to update the Committee on progress to review the quality/equality impact assessment process at the next meeting.

CORPORATE GOVERNANCE REPORTS (QRC/17/11) Mrs Holmes updated the Committee on a number of Corporate Governance work streams. Regarding mandatory training rates for information governance, it was noted that compliance was below the 95% rate needed to meet the requirements of the Information Governance Toolkit, which would lead to a non-compliant rating for the CCGs.

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The Committee considered this position to be untenable and asked Mrs Holmes to convene a mandated session for all non-compliant members of staff after confirming that the electronic recording system was accurate. It was also noted that the advanced life support training module was not relevant to CCG staff and should be removed from the list of training requirements, which was agreed. ACTIONS:

• Mrs Holmes to confirm which members of staff were required to undertake Information Governance Training and arrange a mandated session in February.

• Mrs Homes to remove the advanced life support training module from the CCGs’ list of statutory and mandatory training

ANY OTHER BUSINESS (QRC/17/12) There was no other business. AGREEMENT OF KEY MESSAGES FOR FEEDBACK TO GOVERNING BODIES (QRC/17/13) The risk assurance session, action on mandatory training.

DATE OF NEXT MEETING: Monday 10 April 2017, Hawthorn House

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