GOVERNING BOARD Date of Meeting 20 July 2016

Agenda Item No

12 Title

Minutes of Other Meetings Purpose of Paper

To accept the following: • Minutes of the Clinical Strategy Committee meetings held on 4

May 2016 and 1 June 2016.

• Minutes of the Audit Committee meeting held on 2 March 2016.

• Minutes of the Health and Wellbeing Board meeting held on 2 December 2015.

• Minutes of the Primary Care Commissioning Committee

meeting held on 16 March 2016.

Recommendations/ Actions requested

Accept

Potential Conflicts of Interests for Board Members

None

Author

Various

Sponsoring member

Innes Richens – Chief Operating Officer

Date of Paper

8 July 2016

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Minutes of a Meeting of the Clinical Strategy Committee held on Wednesday 4 May 2016 at

1.00pm 3.00pm in the Committee Room, CCG Headquarters, 1 Guildhall Square, Portsmouth PO1 2GJ

Summary of Actions

Agenda Item

Action Who By

5,2.3.16 Lower limb pilot lymphoedema service as an enhancement of the current complex leg ulcer service. Keep on Agenda for updates.

Katie Hovenden

June 16

6, 6.4.16 Michael Drake to bring a Year End Report to the CSC on actual delivery of QIPP compare to the original plans for 15/16.

Mike Drake June 16

7a, 6.4.16 Long Term Conditions (LTCs) Hubs – Planned Care Lyn Darby to bring back the Project Plan with milestones and outcomes included to the CSC in June.

Lyn Darby June 16

9, 6.4.16

Out of Hospital Care Delivery Model Michelle Spandley and Jo York to discuss the issue of identification of resources. Also Michelle Spandley and Jo York to discuss with Solent using the project plan as part of their COBIC CQUIN via the Contracting route. Report back to CSC June 16

Michelle Spandley/Jo York

June 16

9, 6.4.16 Mark Compton to continue to work with the Alliance Partnership Group to produce a Plan on a Page for Out of Hospital Care Delivery Model and to identify three set areas to begin the project.

Mark Compton

June 16

10, 6.4.16 An update on GP OOHs Commissioning should be brought back to the CSC in June.

Jo York June

12, 6.4.16 Lyn Darby to look at the investment figures required for the HIU QIPP Scheme PID project and expected savings. The Project Plan to be brought back to June’s CSC for investment approval.

Lyn Darby June 16

5 Dr Matthew Smith to circulate the Mental Health Strategy to CSC members.

Dr Matt Smith

May 16

5 Dr Matthew Smith to bring the Mental Health Strategy document to the July CSC Meeting.

Dr Matt Smith

July 16

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Further work required to the Crisis Café and Recovery College Project Plans. More detail is required of the investment and finances required including success measures and benchmarking, to better articulate the outcomes of each scheme. The Plans to be brought back to June CSC.

Barry Dickinson

June 16

7 Acute Visiting Service Review and recommendations – Mark Compton to work with finance colleagues to ensure the proposal and finance figures are robust.

Mark Compton

May 16

7 The AVS proposal to be taken to the Primary Care Commissioning Committee for consideration before it is then taken to the Better Care PMG for technical sign off from the BCF budget.

Mark Compton

May 16

8 Public Health budgets – CCG Executive to work with Dr M Smith in investigating a route into Public Health, possibly via Health & Care Executive Board regarding concerns to services and budgets.

CCG Exec/ Dr Matt Smith

May/ June 16

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AOB – MS raised: When circumstances occur and a decision is required and there is the only one eligible voting member, due to COIs by the GP voting members of CSC: Dr Jim Hogan to ask DAC Beachcrofts to consider voting membership and quoracy of the committee in light of the above circumstances.

Dr Jim Hogan

June 16

Present: Dr Dapo Alalade - Clinical Executive Member Dr Linda Collie - Clinical Executive Member Dr Elizabeth Fellows - Clinical Executive Member and Chair of CCG Governing Board Dr Jim Hogan (Chair) - Clinical Leader/Chief Clinical Officer Carly Darwin - Practice Manager Representative Dr Jonathan Lake - Clinical Executive Member Dr Jonathan Price - Clinical Commissioning Lead Michelle Spandley - Chief Finance Officer Dr Kevin Vernon - Clinical Commissioning Lead In Attendance: Simon Cooper - Head of Prescribing Support (For Katie Hovenden) Jane Cole - Deputy Chief Finance Officer Lyn Darby - Deputy Chief Commissioning Officer (For Alex Berry) Michael Drake - Director of Planning and Performance Linda Foster - Executive Assistant (Minutes) Preeti Sheth - Head of Integrated Commissioning Matthew Smith - Consultant, Public Health 1. Apologies and Welcome

Dr Jim Hogan welcomed Simon Cooper and Lyn Darby to the meeting Apologies were received from: Innes Richens, Alex Berry, Suzannah Rosenberg and Katie Hovenden.

2. Declarations of Interest Potential declarations of interest were noted for the GP Executives, GP Commissioning Leads and the Practice Manager Representative for Agenda item 7.

3. Minutes of Previous Meeting The minutes of the Clinical Commissioning Committee held on Wednesday 6 April 2016 were approved as an accurate record The summary of actions from the Clinical Commissioning Committee held on Wednesday 6 April 2016 were discussed and reviewed as follows:

Agenda Item

Action Who

By Progress

4.2.3.16

Wheelchair Sustainability Report and recommendations. Suzannah Rosenberg to follow up with Jane Warren on the committees that the proposal will be taken to for engagement.

SR May 16 Completed

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5,2.3.16

Development of a lower limb pilot lymphoedema service as an enhancement of the current complex leg ulcer service. Katie Hovenden to follow up on progress.

KH June 16 Work in progress – to be kept on Agenda for updates.

4 IVF Complaint - Suzannah Rosenberg to share details with Lyn Darby.

SR May 16 The CCGs response is currently being finalised – action complete.

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Lyn Darby to discuss the Appeals Panel process with Chris Ashdown (CSU) and to identify how the CCG can obtain greater visibility of appeals eg reports to the CCG Governing Board Chair.

LD May 16

Suzannah Rosenberg is working with Chris Ashdown on this. Action complete. *Please see below.

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The Terms of Reference for the Portsmouth Planning Programme Board to be amended to reflect that Michelle Spandley will Chair the Meetings and that Executive Leads will be able to attend where they are sponsors of a particular project or programme.

MD May 16 Action completed. 1

st meeting held on

20/4/16.

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Michael Drake agreed to bring a Year End Report to the CSC on actual delivery of QIPP compare to the original plans for 15/16.

MD June 16 June CSC Meeting

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Long Term Conditions (LTCs) Hubs – Planned Care Lyn Darby to bring back the Project Plan with milestones and outcomes included to the CSC in June.

LD June 16 June CSC Meeting

9 Out of Hospital Care Delivery Model Michelle Spandley and Jo York to discuss the issue of identification of resources.

MS/JY

June 16 June CSC Meeting

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Michelle Spandley and Jo York to discuss with Solent using the project plan as part of their COBIC CQUIN via the Contracting route.

MS/JY

June 16 June CSC Meeting

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Mark Compton to continue to work with the Alliance Partnership Group to produce a Plan on a Page and to identify three set areas to begin the project.

MC June 16 June CSC Meeting

10 OOHs current future commissioning intentions will be discussed at PSEHCC. Lyn Darby to feedback to the CSC.

LD June 16 June CSC Meeting

10 It was agreed that an update on GP OOHs Commissioning should be brought back to the CSC a future meeting.

JY Future meeting

June CSC Meeting

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High Intensity Users QIPP Scheme Project PID - Suzannah Rosenberg to meet with Alan Horsborough, Dr Matt Smith and Alan Knobel to discuss lessons learned from a previous similar model.

SR/AH/MS/AK

ASAP Meeting held. Action completed.

12 HIU QIPP Scheme PID to be brought to the CSC for approval of the investment required and the expected savings.

LD Future meeting

** Please see below The Project Plan to come to CSC in June.

Matters Arising: *Katie Hovenden and Dr Jonathan Lake are currently looking at what information comes to the CCG from the CSU IFR team. Dr Lake noted that more information is now coming through than previously received.

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** Lyn Darby to look at the investment figures required for this project. The Project Plan to be brought back to June’s CSC for investment approval.

Action: L Darby

4. Planning Update Michael Drake presented the Planning Update paper to the CSC members to update them on Planning and QIPP for 2016/17 and beyond. The Planning Update paper contained attachments: 15/16 QIPP Delivery Overview paper and a Projects Summary Status Report. Michael Drake confirmed that all elements of the National Planning submissions have now been submitted to NHS England Area Team. The CCG Planning Team is awaiting formal feedback from NHSE. It was noted that NHSE’s particular focus has been on activity, with all CCGs required to match the iHAM growth modelling as a minimum. Michael Drake informed that some of the trajectory elements in the Operating Plan had not delivered against the standards required. Wider discussions have taken place with NHS England around A&E, RTT and Diagnostics and Cancer standards. This has also been considered and discussed at the Systems Resilience Group Meetings. The CCG gas identified QIPP of approximately £7.67 million however some of these values are pipeline schemes and are subject to further development and financial validation. In order to meet the non-elective activity growth requirement the CCG has needed to build in additional unidentified QIPP of £1.7 million into the financial position. This brings the overall QIPP challenge for the CCG to £9.37 million. Dr Jonathan Price queried whether the £1.7 million was due to non-elective activity. Michelle Spandley explained that NHSE have looked at historical data for non-elective activity. Michelle added that we need to recognise how we agree the approach to avoid activity going to PHT, and it is important that the QIPP schemes are robust. The Planning Update contained in table two, which provides project counts and values by stage of development in terms of Gateways. The table showed £2.914 million against Rightcare. Lyn Darby informed she had attended a meeting to look deeper into Rightcare projects, and that the £2.9 million is a ‘guesstimate’ figure. It was noted some of these savings are already identified in QIPP. Simon Cooper agreed with this and said that there is a similar issue with NOACCS; also already identified within the Prescribing QIPP savings but approx. £2 million is identified in RightCare. Simon advised that the Medicines Management team are awaiting a document from PresQIPP identifying that NOACCS is not fit for purpose. A meeting will be held to identify further savings, once all of the details are known; which will be circulated in a couple of weeks. It was agreed the real risk is RightCare. Michelle Spandley asked what the time-frame on this information was. Lyn Darby responded that they have asked Millimans for more information regarding Long Term Conditions and Pharmacy and that this is a work in progress. Dr Jim Hogan asked if the same elements affected our sister CCGs. Jane Cole informed the committee that the benchmark has been set from the Local Area Team across the patch and that in the past Portsmouth CCG has been in a good position. Jane added that the West is in a similar position to Portsmouth; there is nothing unique here. Michael Drake informed the CSC members that the first meeting of the Portsmouth Planning Programme Board had been held and that it had been a ‘paperless’ meeting. A

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summary portal designed from Covalent had been trialled at the meeting, which was well received. The Clinical Strategy Committee noted the progress made to date and agreed to the following actions:

To note the QIPP position for 16/17 and to provide drive and leadership to support the planning process and associated identification of savings

To provide strong clinical and executive support to work up plans to support the local system transformation agenda for 16/17; address the efficiency savings required; meet the national planning requirements for 16/17 and beyond

To note the risk regarding the need for traction in planning for 16/17 and beyond

5. Project Plans for Review

Michael Drake presented the Project Plans for Review by the Clinical Strategy Committee. Michael Drake gave an overview of the plans to be reviewed: Table 1 is a summary of two Cross Organisational Programme Operational plans: Substance Misuse Project and Transforming Mental Health Services Project. The project plans have not yet been financially validated are have been provided for information purposes only. There is one Operational Plan; Pharmacy Urgent Repeat Medicine (PURM) for which funding is requested and approval to proceed with the plan. 5 a) PURM Simon Cooper, Head of Prescribing Support presented the PURM Project Plan, the Pan Wessex Proposal for joint commissioning arrangement between NHS England and CCGs (as a Pharmacy Enhanced Service) and also the draft Specification for the Pharmacy Urgent Repeat Medicines (PURM) Simon Cooper informed that nationally up to 30% of all calls to NHS 111 services are on a Saturday are for urgent requests for repeat medication. The proposed PURM Service will facilitate appropriate access to repeat medication out of hours by signposting patients directly to community pharmacies. This will relieve pressure on urgent and emergency care services, saving money and shortening the patient pathway. The CSC members discussed the financial savings that PURM could achieve as shown in table 7 of the project plan. The proposal was well received by the committee and it was agreed the project was a good idea which will save money and workload. Dr Elizabeth Fellows raised a question regarding medications that are excluded from this service and how patients would obtain them. Simon Cooper said that the patient would still be able to obtain their medication through the Community Pharmacy Schedule 123. It was noted that no Controlled Drugs would are listed within the PURM specification and that patients would not be able to obtain medication via this route two times in a row. The Clinical Strategy Committee endorsed the proposal to jointly commission the PURM Service with NHS England as a pharmacy enhanced service. 5 b) BCF Projects

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Jo York, Head of Better Care presented an update and overview of the BCF Project Plans for 2015/16 and 2016/17. Jo York informed the committee that the BCF National Plan was submitted on 3 May 2016. The plan for 16/17 builds on last year’s plans and move to the wider Integration Plan and linking to the System Transformation Plan. The group discussed investment, funding and savings relating to the various projects. Jo York explained that the funding amount for 16/17 is unchanged from 15/16 with a pooled fund of £16 million. Investment funding of £2 million is recurrent for 16/17 recognising that BCF plan becomes part of the Portsmouth Blueprint and delivery of the Health & Care Portsmouth transformation programme to form part of the wider integration. BCF plans continue to meet the QIPP plan and the CCG expects to see a 3% reduction (£800,000). The BCF team is working with BI team to understand where savings will be. Jo York briefly highlighted key points for each of the eight project plans presented today which form part of the BCF Programme:

1) Integrated Localities – Co-location phase 1, Spring 2016 2) Portsmouth Living Well Project (Age UK) 3) Acute Visiting Service Project (Emergency Practitioner) proof of concept 1yr 4) Community Reablement Project 5) Review and redesign of clinical support delivered into Care Homes Project 6) Prevention Project 7) Carers Project 2016/17 8) Pill Dispensers Project

The Clinical Strategy Committee discussed in more detail: Community Reablement Project Jo York informed that community beds PRRT, Integrated Localities, Adult Social Care Reablement Project, SRG improving discharges are all supporting the Community Reablement Project to join up a single Portsmouth plan. Simon Nightingale, Michelle Spandley, Preeti Sheth and Jo York have worked together to ensure this project is not duplicating other work, A task and finish group has also been established. Jo York and Sarah Austin will be working together to ensure clarity around the plan and that it links into work with the Alliance and Solent. Pill Dispensers (device) Project The CSC discussed the similarities of the Pill Dispenser device to Telecare and Telehealth (devices already in use). It was noted that all Care Homes in Portsmouth use NOMADS. Jo York informed that Katie Hovenden and Janet Bowhill had been involved in the development of this project plan and it has been successful. Simon Cooper to be involved going forward with regards to the CCG management of the project. The Clinical Strategy Committee noted the progress made and agreed to ratify the 2016/2017 Better Care Programme Plan. 5 c) Adult Mental Health Projects Barry Dickinson presented the Adult Mental Health Project Plans. Barry explained that at the CSC Meeting in the Committee requested that an update on Adult Mental Health Project Plans be worked up and brought back with service pathways more developed and with more in depth funding details, to enable the CSC to make a more informed decision.

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Barry Dickinson provided an update across the different projects, he informed that The Mental Health Strategy has been signed off at Health & Wellbeing Board, and several of these involve CCG projects:

The Substance Misuse Service is currently out to tender and bids are due back by 23 May 16. The new service to commence 1st August 16.

Re-modelling of Community Services. Solent mental health services are moving of Oakdene this week collocating with Adult Social care Teams. The service will deliver an ‘all age’ model which will incorporate improved accessibility, crisis response and be recovery focus.

Transforming Mental Health Services Project (Cross Organisation). Using existing ECR re-provision and ongoing CQUIN funding from the CCG and vacant staff funding from Portsmouth City Council to provide training. Successful recruitment to 4 placements and savings to the CCG and PCC of £400,000. It is expected that 11 more placements will be made over the next six months, depending on infrastructure.

16/17 Crisis Concordat Project. The aim is to improve responses to people experiencing mental health crises of the Section 136 Suite in operation since 2015. The aim for 16/17 to develop a community based service to address the gap in support for people experiencing mental health crisis that do not meet the threshold for secondary care. The new service will utilise peer support and be developed through coproduction with stakeholders and in conjunction with the remodelling of NHS Solent Community Mental Health Services.

Crisis Café – request for support of provision to develop the model to meet people’s needs. The Crisis Café is run through the voluntary sector for a six months pilot.

The Recovery College – expansion of service (Solent Mind and Highbury College) to support primary care with focus on people with long term conditions. Funding runs out end of June 16.

Dr Jim Hogan asked if the Mental Health Strategy is available on the Health & Wellbeing website, and what were the 11 pledges contained within the strategy. Matt Smith agreed to circulate the Mental Health Strategy to CSC members.

Action: M Smith Dr Matthew Smith agreed to bring the Mental Health Strategy document to the July Clinical Strategy Committee Meeting.

Action: M Smith The Clinical Strategy Committee discussed in detail the investment required and the savings envisioned for the Crisis Café and Recovery College Project Plans. It was noted that charitable donations had previously financed the Recovery College but that this had been a ‘one-off’ donation and could not be called upon again. Michelle Spandley commented that the project plans do not necessarily articulate the good outcomes and potential savings of the projects and how they fit with the Crisis Concordat Plan. It was agreed that further work is required on the Crisis Café and Recovery College project Plans. More detail is needed of the investment and finances required including success measures and benchmarking, to better articulate the outcomes of each scheme.

Action: B Dickinson The Crisis Café and Recovery College project plans to be brought back to the June Clinical Strategy Committee Meeting.

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Action: B Dickinson

6. CHC Uplifts Report Simon Nightingale attended the meeting to inform the Clinical Strategy Committee with two reports regarding Domiciliary Care and Residential Nursing Home Care. The reports are brought for information and noting purposes only to recommended proposed inflationary increases to hourly and bed rates for Continuing Health Care (CHC) funded packages of care and placements to private providers in Portsmouth for domiciliary care and residential nursing home care. Simon Nightingale explained that the CHC costs are reviewed annually and the uplift figures have been reviewed by Finance teams and have been taken to the Better Care Partnership Management Group for discussion and agreement.

The Clinical Strategy Committee discussed issues related to care and placement of patients with challenging behaviour. It was noted that regular engagement with local providers and partners is important to compare payment rates. Dr Jonathan Price commented that workforce assessments need to be carried out, as sometimes there is not always staff available to provide the care. It can also be difficult providing workforce for domiciliary care, as sometimes the carer will be going to the patient several times a day. Dr Price felt that paying more would be good and could help provide more staff.

The Clinical Strategy Committee noted the information regarding inflationary increases, which will be funded via the growth allocation for CHC, for CHC funded packages of care and placements contained within the report.

7. Acute Visiting Service Review Potential declarations of interest were noted for the GP Executives, GP Commissioning Leads and the Practice Manager Representative for this item. Mark Compton, Head of Primary Care Transformation presented the AVS Review and recommendations paper. Mark Compton explained that a review of the Acute Visiting Service (AVS) had been undertaken, following a six month pilot period by the Portsmouth Primary Care Alliance (PPCA). Last September the CCG agreed to fund £362,000 for a 12 month period funded from Better Care Funds pooled budget. It was agreed to review the pilot after 6 months, as an opportunity to either work as a break clause in the pilot (if the service was not meeting its objectives) or as an opportunity to amend or enhance the service. The paper proposed a number of recommendations and amendments to the pilot in order to enhance the effectiveness of the service. A review workshop was held on 22 March 2016 with a number of key stakeholders in order to review the pilot KPIs. Stakeholders were invited to submit suggested amendments and enhancements to the service for consideration at the workshop. The CSC was asked to examine the clinical and financial credibility of the proposed new service model, and endorse the recommendations below:

Continuation of the pilot

Increase Service Capacity - an additional GP on Monday mornings to help relieve additional demand at this time. It was noted that SCAS are keen on this increase.

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Proposed additional afternoon capacity (recognition of patients requiring an afternoon home visit)

SCAS direct referral. It was felt that this should be given more consideration and that patients should still be referred to AVS via their own GP.

Pilot Extension

If the proposed changes to the pilot are approved, then it is recommended that the pilot scheme is extended for a minimum of 12 months from the date when the amendments are introduced. The funding required to run a further 12 month pilot based on the proposed new service model would be approximately £540,000 (compared to £362,000 for the original pilot proposal). Mark Compton advised that all bar one of Portsmouth GP practices use the AVS service:

100% of GP practices rated the service as ‘good’ or ‘excellent’.

95% of patients rated the service ‘good’ or ‘excellent’ and 5% of patients preferred to see their own GP.

Mark Compton re-iterated the recommendations of the 6 month review point:

The service is doing very well and should continue

To increase service capacity by an additional GP on a Monday morning

It was noted that some of the finance figures are being scrutinised currently and may be subject to change. Mark advised of potential cost savings of £1.5 million due to saving hospital admissions. Lyn Darby advised to be cautious of using ‘perceived’ savings on admissions avoidance. Michelle Spandley felt the CCG needs to better understand the increase of GP extra hours, and that this needed to be better articulated. Mark Compton to work with finance colleagues to ensure the proposal and finance figures is robust.

Action: M Compton Mark Compton to take the AVS Proposal to the Primary Care Commissioning Committee for consideration before it is then taken to the Better Care Partnership Management Group (BC PMG) for technical sign off from the BCF budget.

Action: M Compton

Michelle Spandley as the only ‘eligible’ (non primary care) voting member in attendance, endorsed the review recommendations contained within the paper for the Acute Visiting Service.

8. Public Health Budgets Dr Matthew Smith gave a verbal update to CSC members on the current financial position and future challenges regarding the Public Health Budget. A Summary of 2016/17 public health budgets paper was tabled for noting. Dr Matthew Smith and Dr Elizabeth Fellows have been in discussions regarding how to more closely align the CCG and Public Health, but the ‘goal posts’ keep moving. The best case scenario being 2016/17 £18,8500 million public health budget will be cut year on year to £17,17900 million by 2019/20, and we must work to find the best use of these funds. Dr Smith advised that the 16/17 budget setting process has not yet begun, however restructuring is taking place. The Director of Public Health is working on a new structure

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which will be signed off mid-June. It is anticipated there will need to be cuts to implement the new budgets. Dr Smith advised that the cuts will not come from front-line services but that they will have an impact on delivery of other services. The Director of Public Health (DPH) vision is to sustain the Transformation Plans and Devolution and the Portsmouth Blueprint. The Clinical Strategy Committee discussed the ‘knock-on’ effect of budget cuts to other services. ie: Health Inequalities: Cuts to Substance Misuse services and Health Visitors would seriously impact on Domestic Abuse, Looked After Children, Toxic 3 services. Clinical concerns were raised that the cuts to budgets would be very unwise. Michelle Spandley asked whether the CCG could take concerns regarding the effect the cuts could have, to the CCG Health and Wellbeing Board or the Portsmouth Health and Care Executive Board. It was suggested that a collaborative work-stream across the system and impact assessments must be done to articulate the impact across all organisations. The CCG Clincal Executive GPs to work with Dr Matthew Smith in investigating a route into Public Health, possibly via the Health & Care Executive Board to inform of the CCGs concerns regarding cuts to services and budgets.

Action: CCG GP Exec/Dr Matt Smith 9. Any Other Business

There were four items of business raised:

Planned Care Commissioners requested a proposed wording change to the IFR policy which was previously agreed at Clinical Strategy Committee in March 2016; regarding the Functional Endoscopic Sinus surgery. After reviewing the wording of the procedure, the Clinical Lead felt that the existing identifier does not accurately represent the evidence available. Proposed amendment: Existing: Functional endoscopic sinus surgery (which may include septorhinoplasty) Proposed: Functional Nasal Airways Surgery The Clinical Strategy Committee approved the amendment to the wording as above.

Portsmouth Diabetes Service Contract Extension Paper A paper was tabled by the Commissioning Team seeking agreement to extend the current Portsmouth Diabetes Service Contract for an additional 12 months until September 30th 2017 with the option of an additional two 6 month extensions if required. The Clinical Strategy Committee supported the request to extend the current Portsmouth Diabetes Service Contract as stated above.

Michelle Spandley wished to raise that when circumstances occur where a decision is required and she is the only eligible voting member, due to Conflict of Interest by the GP voting members of the Clinical Strategy Committee; whether it would be beneficial to ensure the Chief Operating Officer or the Chief Strategic Officer are also in attendance. Dr Jim Hogan to ask DAC Beachcrofts to consider voting membership and quoracy of the committee in light of the above circumstances.

Action: Dr J Hogan

Michelle Spandley informed the CSC members that the Contract for PHT had been agreed and would be signed today. The Contract for Solent has also been agreed today but not yet signed.

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10. Date of Next Meeting

The next Clinical Strategy Committee Meeting will be held on Wednesday 1st June 2016 Minutes: L Foster - 5/5/16

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Minutes of a Meeting of the Clinical Strategy Committee held on Wednesday 1 June 2016 at

1.00pm 3.00pm in the Committee Room, CCG Headquarters, 1 Guildhall Square, Portsmouth PO1 2GJ

Summary of Actions

Agenda Item

Action Who By

3 9, 6.4.16.

Out of Hospital Care Delivery Model Project Plan – Jo York and Michelle Spandley working on COBIC CQUIN and will take through due process. An update to be brought to July CSC

Jo York/ MSpandley

July CSC

3 10,6.4.16.

GP OOHs Commissioning – an update to be brought to July CSC Jo York July CSC

3 5, 6.4.16.

Dr M Smith to bring the Mental Health Strategy to the July CSC meeting.

Dr M Smith July CSC

3 8,6.4.16.

Michelle Spandley & Innes Richens to discuss and agree how to escalate the concerns regarding likely cuts in Public Health budgets and the impact on health.

MSpandley/I Richens

July CSC

4 Lyn Darby to check whether the letter from Ursula Ward to Alex Berry has been formally responded to.

Lyn Darby June 2016

5 End of Life and Specialist Palliative Care – Project Plans Dr Price to continue to evaluate and test EPAC access via SCR before roll out to practices

Dr J Price On-going

5 Michelle Spandley and Lyn Darby to look at Specialist Palliative Care and any possible savings in acute care.

MSpandley L Darby

On-going

6 SHIP 8 Priorities Committee – Priority Statements for endorsement. Lyn Darby to produce a letter communicating the changes in policies for GP Practices

Lyn Darby June 2016

9 High Intensity Users QIPP scheme PID Final Suzannah Rosenberg to discuss with Alan Knobel.

Suzannah Rosenberg

June 2016

9 Dr Hogan to undertake ‘Chairs Action’ regarding approval for the HIU QIPP scheme project PID to be taken forward.

Dr J Hogan July CSC

Present: Dr Dapo Alalade - Clinical Executive Member Dr Elizabeth Fellows - Clinical Executive Member and Chair of CCG Governing Board Dr Jim Hogan (Chair) - Clinical Leader/Chief Clinical Officer Carly Darwin - Practice Manager Representative Dr Jonathan Price - Clinical Commissioning Lead Innes Richens - Chief Operating Officer Michelle Spandley - Chief Finance Officer Dr Kevin Vernon - Clinical Commissioning Lead In Attendance: Lyn Darby - Deputy Chief Commissioning Officer (deputising for Alex Berry) Linda Foster - Executive Assistant (Minutes) Lucy Mitchell - Planning Manager (deputising for Michael Drake)

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1. Apologies and Welcome Apologies were received from: Dr Linda Collie, Dr Jonathan Lake, Dr Matt Smith, Michael Drake, Jane Cole, Preeti Sheth and Alex Berry

2. Declarations of Interest There were no conflicts of interest in any of the Agenda items.

3. Minutes of Previous Meeting The minutes of the Clinical Commissioning Committee held on Wednesday 4 May 2016 were approved as an accurate record The summary of actions from the Clinical Commissioning Committee held on Wednesday 6 April 2016 were discussed and reviewed as follows:

Agenda Item

Action Who By Progress

5,2.3.16 Lower limb pilot lymphoedema service. KH Future meeting

Completed Scoping of service is in progress. Come back to a future CSC.

6,6.4.16 Year End Report on delivery of QIPP compared to original plans 15/16

MD May/June

Completed – brought to May CSC meeting.

7a,6.4.16 LTCs Hubs – planned care project plan LD June On Agenda - completed

9,6.4.16

Out of Hospital Care Delivery Model. MSp and JY to discuss Solent using the project plan as part of COBIC CQUIN via the Contracting route.

MSp/JY

June

Update: MSp/JY working on COBIC CQUIN will take through due process Action completed

9,6.4.16 Out of Hospital Care Delivery Model. Project Plan

JY July JY to bring an update to July CSC

10,6.4.16 GP OOHs Commissioning JY July An update to be brought to July CSC

12,6.4.16 HIU QIPP Scheme PID – Lyn Darby to look at investment figures and expected savings and bring the project plan back to June CSC

LD June On Agenda - completed

5 Dr M Smith to circulate the Mental Health Strategy to CSC members

MS May Action completed

5 Dr M Smith to bring the Mental Health Strategy to the July CSC meeting.

MSm July July CSC

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Crisis Café and Recovery College project plans. More detail is required of the investment and finances required, including success measures and benchmarking to better articulate the outcomes of each scheme. Updated plans to June CSC.

BD June

MSp explained the plans are not yet ready. The plans will be brought to July CSC.

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Acute Visiting Service Review and recommendations. Mark Compton to work with finance colleagues on the proposal.

MC May Work in progress with Finance colleagues. Action completed.

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AVS proposal to be taken to the Primary Care Commissioning Committee for consideration before being taken to the Bettercare PMG for technical sign off.

MC May Taken to PCCC Action completed.

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Public Health budgets Michelle Spandley & Innes Richens to discuss and agree how to escalate the concerns regarding likely cuts in PH budgets and the impact on health.

MSp/IR

On-going

Work in progress MSp/IR

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AOB - Dr J Hogan to ask DAC Beechcrofts to consider voting membership and quoracy of the CSC when a decision is required and GPs are not eligible to vote due to COI.

JH On-going

Dr Hogan advised Tracy Sanders is liaising with DAC B. Action complete.

4. Planning Update

Lucy Mitchell, Planning Manager attended the meeting to deputise for Michael Drake, and to present the Planning Update paper to CSC members. The National Plans were re-submitted on 23 May 2016. There has not been any feedback received to date. Feedback may arise from meetings planned for next week. Local Planning The total number of projects currently planned is 90. The planning update contained summary tables of the plans. Table one provides project counts by category. Table two provided project counts and values by stage of development. Table three provides projects where there are key areas for concern and actions underway to address and work through. The CSC members were advised that QIPP is in a challenging position of £9.37million. £4.8 million has been identified to date however some of these values are pipeline and therefore subject to further development and financial validation. The current issues for planning are the need to gain traction with 16/17 plans, work programmes and identification of QIPP to ensure it is fully delivered. The high level of un-identified QIPP is a challenge. The current risks to planning for 16/17 are the uncertainty around the transformation agenda and emerging STP. The CCG is not yet where it needs to be in terms of finalising plans and associated QIPP for 16/17. A large proportion of the project plans and QIPP are not yet validated and signed off. The Planning Team Risk Register attached as appendix 1, provided additional information and context. Lucy Mitchell informed that the PHT Contract for QIPP was signed on 4 May 2016. The QIPP schemes agreed as part of the Contract have also now been signed. Dr Elizabeth Fellows enquired if the RightCare packs have been helpful in identifying QIPP. Lucy Mitchell responded that it was too early to say yet, the overall opportunity is unchanged but there is some information to go on. The Committee discussed SRG. Michelle Spandley asked if a letter from Ursula Ward to Alex Berry had been formally responded to. Lyn Darby agreed to check into whether this has been actioned.

Action: L Darby Portsmouth Clinical Strategy Committee noted the progress made to date and agreed to the following actions:

To note the QIPP position for 1617 and to provide drive and leadership to support the planning process and associated identification of efficiency savings

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To provide strong clinical and executive support to work up plans to support the local system transformation agenda for 1617; address the efficiency savings required; meet the national planning requirements for 1617+

To note the risk regarding the need for traction in planning for 16/17 and beyond.

5. Project Plans for Review Lucy Mitchell presented the Project Plans for Review by the Clinical Strategy Committee. Operational Plans for approval

End of Life Service Review – Planned Care & LTCs Programme

Diabetes Service Review - Planned Care & LTCs Programme

Elective Surgery Reviews - Planned Care & LTCs Programme (Service Reviews and Pathway Redesign programme)

Community Equipment Store Clinical Advisory Team pilot – Operational Projects (ICU)

EOL Dr Jonathan Price informed the committee members of meetings he has attended with our sister CCG colleagues around improving Palliative Care for EOL. Dr Price has also met with the Director of Nursing at PHT and Simon Holmes to discuss replacing the current EOL service. It was noted that extra investment is required. Currently no tariff is paid for EOL. Commissioners and PHT are looking at unpicking the tariff and the possibility of funding specialist palliative care via a CQUIN. A workshop has been held on the service provision for EOL and District Nursing. Lyn Darby advised the workshop was predominantly for F&G and SEH CCGs and should not impact on Portsmouth. Dr Price informed the committee members of a successful coordination centre in Bedford, run by a single provider and what impact this might have on Portsmouth. Lyn Darby commented that a single provider would make improvements for all. Dr Price gave a brief update on EPACs – the successor to the CFCR. Progress is being made for the Summary Care Record template to go onto SystemOne which will enable other system users to view the records. MiQuest reports can be run in GP practices, the templates will be launched soon and cost just under £40K Dr Elizabeth Fellows asked where we are in relation to getting the SCR into use. Lyn Darby explained that more content is required from patients, and that an education component for practices is to be included. Dr Price to continue to evaluate and test EPAC access via SCR before roll out to practices.

Action: J Price Michelle Spandley and Lyn Darby to look at Specialist Palliative Care and any possible savings in acute care. Action: M Spandley/L Darby

The Community Equipment Store Clinical Advisory Team Pilot It was noted that savings had been identified for this project plan. Closed Project for Information Lucy Mitchell informed of one project where approval to close is recommended:

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The closure of contracting of Lucentis injections is due to financial changes in the contract. It was noted that ophthalmologists and Care UK offer the service. National Tariff to be paid. Transformational Project Plans for Review: 5a) Long Term Conditions (LTC) Hubs Project Plan

The draft Community LTC Framework was included with the plan. Lyn Darby advised that the Community Long Term Conditions framework has been updated with dates and timescales on page 22. A Steering Group will take place later this month for GP Clinicians from the COMPACT CCGs, MCP GPs & Vanguard Leads to discuss. Dr Hogan agreed to Chair the meeting. Dr Jonathan Lake will also take the Framework to the GP Commissioning Evening on 15 June for discussion and feedback.

The Clinical Strategy Committee noted the content of the Draft Community LTC Framework and the LTC Hubs Project Plan.

5b) Integrated Personal Commissioning Programme 16/17

At the April CSC meeting, Committee members requested that further information into Integrated Personal Commissioning be undertaken by the ICU team and budgets. Natasha Koerner advised that further research has been undertaken into the investment NHSE Improvement Targets for effectiveness and numbers: 16/17 target cohorts are adults aged 50+ with two or more long-term conditions, children with complex needs and learning disabilities. IPC links in with existing project activity (Living Well, SEND and Transforming Care) Natasha Koerner informed CSC members of the IPC demonstrator site in Kent where IPC has been beneficial to mental health patients. Portsmouth is not set up for this yet, however the IPC team will continue with to research individuals who have their own personal budgets. Portsmouth has a target of 200 personal budgets, and it is anticipated that this will be achieved. It was noted that nationally two-thirds of IPC budget holders are on Continuing Health Care budgets.

NHS England has informed that 50 more IPC sites will be starting up in October. The Clinical Strategy Committee noted the update report on Integrated Personal Commissioning. 5c) Early screening for Unaccompanied Minors (USAC) Project PIPELINE Scheme Natasha Koerner and Andrew Smith from the Integrated Commissioning Service,

presented the UASC Pipeline Project; to seek guidance from and inform the CSC of current need, based on available data, for early screening of Unaccompanied Asylum Seeking Children (UASC) and Migrant Health (adults). Natasha Koerner explained that the purpose of the scheme is to align the early screening process for UASC with arrangements for indigenous children ie Looked After Children, which is 20 days. It was noted that numbers are rising and trends

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are changing; it is likely that more people will come to this area, and therefore the assessment and follow-up services required will change. Natasha Koerner advised that information from Hampshire Constabulary on Human Trafficking, “Operation Clock” identified the need for health screening of adults. Solent NHS Trust has produced a model and pathway for the health screening and assessments. Committee members discussed whether the pathway could be linked to USAC work and for Migrant Adults; or whether commissioners could adapt the pathways already in place for urgent healthcare services. It was agreed that it is important to identify what is needed and numbers required and to clearly understand what the project/pathways will look like in order to make a commitment to change existing pathways.

It was agreed the Project to be refocussed on defining existing pathways/services for UASCs and Migrant Workers. This information on what these people are entitled to should be shared with PHT/Treatment Centre/Solent NHS Trust services.

The Clinical Strategy Committee reviewed the information provided, and agreed for the existing pathways/services for Unaccompanied Asylum Seeking Children (to include Migrant Workers) to be made clear to GPs.

6. SHIP 8 Priorities Committee – Priority statements for endorsement

Lyn Darby presented the SHIP 8 Priorities Committee Policy Recommendations for: Knee Arthroscopy – The Priorities Committee recommends that arthroscopic lavage and debridement with or without partial-meniscectomy in not-traumatic and persistent knee pain with no clear history of mechanical locking is considered a low priority. This Committee discussed the policy recommendation, and agreed that as the Commissioner, PHT will have to implement the policy changes and not accept referrals for therapeutic reasons, as the evidence base does not support this. Payment will not be made if the coding is not trauma related. It was noted that this would need to be communicated clearly to GPs. Flexible Sigmoidoscopy – The Priorities Committee recommends that patients referred with rectal bleeding are offered sigmoidoscopy, with colonoscopy reserved for those in whom symptoms and the results of sigmoidoscopy suggest disease proximal to the splenic flexure. Cholecystectomy (removal of gallbladder) – The Priorities Committee recommends that:

1. Cholecystectomy for asymptomatic patients with gallstones or those where gallstones are unlikely to be the cause of the symptoms are a low priority

2. Cholecystectomy as an opportunistic intervention in an incidentally found asymptomatic patient is a low priority

3. Cholecystectomy for gallstones in the bile duct is a high priority

It was noted that Fareham & Gosport and South Eastern Hants CCG have approved the recommendations. Lyn Darby to produce a letter communicating the changes in policies for GP practices.

Action: L Darby The Clinical Strategy Committee endorsed the SHIP 8 Priorities Committee Policy Recommendations: Knee Arthroscopy, Flexible Sigmoidoscopy & Cholecystectomy.

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7. Local Estates Forum Terms of Reference Michelle Spandley presented the Terms of Reference for the Local Estates Forum (LEF) for approval by the Clinical Strategy Committee. The LEF is a Committee of the CCG Governing Board which reports via the Clincal Strategy Committee and has those executive powers specifically delegated to it by the CCG Governing Board within the Scheme of Delegation. The Clinical Strategy Committee approved the Terms of Reference for the Local Estates Forum.

8. Minutes of Other Meetings for noting The following Minutes were presented for noting:

Minutes of the Local Estates Forum Meeting held on 30 November 2015

Minutes of the Local Estates Forum Meeting held on 11 January 2016

Minutes of the Clinical Executive Committee held on 23 March 2016

The Clinical Strategy Committee accepted the above Minutes.

9. Any Other Business

High Intensity Users QIPP scheme PID Final The updated HIU QIPP scheme Project PID was a late addition to the Agenda and was circulated via email prior to the meeting for information. At the Clinical Strategy Committee meeting held in April, the Committee requested clarification on certain points raised at the meeting regarding the PID. There were concerns regarding duplication of a previous project that failed to deliver outcomes. The PID has been updated with financial and benefit estimates and seeks CSC approval of the investment required and the expected savings. Since the April CSC, a meeting was held between the Unscheduled Care Commissioning Officer and Public Health colleagues to discuss the lessons learned and outcomes of a previous similar High Intensity User (HIU) project. It was concluded that the two projects compliment each other.

Lyn Darby advised that this model has been very successful in Blackpool, where the demographics are similar to Portsmouth. It was noted that, the Alcohol Nurse at PHT (previous HIU project) was a Portsmouth only project. Lyn Darby explained that this new HIU Project PID was not just limited to alcohol; issues such as high intensity users of the services for substance misuse and mental health. The Committee members discussed the issues raised noting the focus for this project is the emergency admissions element. Innes Richens asked for further clarification as to how this new project differs from the previous one. Suzannah Rosenberg to discuss with Alan Knobel.

Action: S Rosenberg

On consideration of the information provided; Dr Hogan to undertake ‘Chairs Action’ regarding approval for the for the High Intensity Users QIPP scheme Project PID to be taken forward.

Action: Dr Hogan

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10. Date of Next Meeting

The next Clinical Strategy Committee Meeting will be held on Wednesday 6 July 2016 NB: Agenda papers for future meetings will be produced on white paper going forward.

Minutes: L Foster – 13 June 2016

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Minutes of a Meeting of the Audit Committee held on Wednesday 2 March 2016, 10:00am – 12:00 midday

in the Committee Room, NHS Portsmouth CCG Headquarters, Civic Offices

Summary of Actions

Agenda Item

Action Who By

5b Use of a table/diagram in the value for money risks section in future External Audit Plans

KH Next meeting

6d Rolling Internal Audit Strategic Plan for the 3 year period to be taken to the next Clinical Executive on 23 March, with the final document being brought back to the next Audit Committee meeting

MS / JC

Next meeting

7a Contact Communications Team to ensure that the newsletter, ‘Fraud Matters’, is disseminated to the correct people

MS Next meeting

Present: Julie Cullen - Registered Nurse Representative Dr Elizabeth Fellows - Clinical Executive Member Tom Morton - Lay Member Jackie Powell - Lay Member Andy Silvester - Audit Committee Chair In attendance: Will Barnard - Audit Manager, TIAA Ltd Nikki Burnett - Finance Manager Jane Cole - Deputy Chief Finance Officer Simon Cooper - Head of Prescribing Support (in attendance for item 10a) Kate Handy - Audit Director, Ernst & Young Heather Greenhowe - Local Counter Fraud Specialist, Hampshire & Isle of Wight Fraud & Security Management Service Debbie O’Connor - Personal Assistant to Chief Finance Officer Giles Parratt - Director of Audit, TIAA Ltd Tracy Sanders - Chief Strategic Officer Michelle Spandley - Chief Finance Officer Angela Sumner - Information Governance Manager, NHS South Commissioning Support Unit (in attendance for item 9a) David White - Manager, Ernst & Young Tim Wilkinson - Chair, Governing Board 1. Apologies and Welcome

Andy Silvester introduced himself as the new Chair of Audit Committee having taken over the role from Tom Morton who will now lead on Primary Care and Estates and Chair of the Primary Care Commissioning Committee. Andy Silvester wanted to thank Tom Morton, on behalf of the Audit Committee, for the excellent work he had undertaken over the years in his role as Audit Chair. After introductions around the table, apologies were received from Dr Jim Hogan and Innes Richens.

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2. Declarations of Interest

There were no declarations of interest. 3. Minutes of the meeting held on 9 December 2015

Add Julie Cullen’s name to the ‘in attendance’ list, otherwise the minutes of the Audit Committee meeting held on Wednesday 9 December 2015 were approved as an accurate record.

4. Matters Arising 4.1 a. Summary of Actions The summary of actions from the last meeting were discussed and reviewed as follows:

Agenda Item

Action Who By Progress

9c (09/09/15)

Circulate SBS/ESR SARS reports when available

MS Next meeting

Completed. Circulated in January and resent 29 February. No concerns to report.

11 (09/09/15)

Bring back final Reports from Sample Audit of Conflicts of Interest Management in Primary Care Co-Commissioning Arrangements and share these with Internal Audit

TS Next meeting

These reports were shared with Internal Audit and would be incorporated in the internal audit which had been done and therefore completed. This cannot be brought to the full committee as not all parties present had signed the waiver required by Deliottes for them to have access. However, this had been shared with the relevant members of the Committee/Board.

5a Send a link to the auditor guidance on the new VFM conclusion criteria for 2015/16 to Michelle Spandley

KH Next meeting

Completed.

6c Liaise with Innes Richens regarding the middle three sections in the Previous Internal Audit Actions Progress Report relating to, ‘Aligned Commissioning & Strategy Development for Integrated Care: Interface with Partners’, with a view to revising these

WB Next meeting

Completed. Updated and reflected in the schedule.

6d Email Mental Health Analysis of Local KPIs Client Digest to colleagues at the Integrated Commissioning Unit and contracting team at NHS South, Central and West Commissioning Support Unit

MS ASAP Completed. Mental Health analysis has been shared with CSU.

10 Send the Evaluation of External Audit Form to Audit Committee members

MS ASAP Completed.

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5. External Audit

a. External Audit Progress Report

Kate Handy reported that their planning procedures are substantially complete, and the result of them was the audit plan, which was discussed under the next agenda item. The Audit Committee noted the verbal update on the External Audit Progress Report b. 2015/16 External Audit Plan David White presented the External Audit Plan for 2015/16 which was to provide the Audit Committee with a basis to review Ernst & Young’s proposed audit approach and scope for the 2015/16 audit. The plan summarised Ernst & Young’s initial assessment of the key risks driving the development of an effective audit for the CCG and outlines the planned audit strategy in response to those risks. The External Auditors identified the following three significant risks: 1. Risk of fraud in revenue recognition – Under ISA240 there was a presumed risk that

revenue may be misstated due to improper recognition of revenue. Ernst & Young would keep their approach under review, pending further guidance from NHS England, the National Audit Office, PSAA, and information included in the final CCG Manual for Accounts.

2. Risk of management override – management is in a unique position to perpetrate fraud because of its ability to manipulate accounting records directly or indirectly and prepare fraudulent financial statements by overriding controls that otherwise appear to be operating effectively. Ernst & Young would identify and respond to this fraud risk on every audit engagement.

3. Better Care Fund – is a major new policy initiative between local authorities, CCGs and NHS providers with the aim of driving closer integration and improving outcomes for patients, services users and carers. Local BCF arrangements may be complex involving a number of different commissioning, governance and accounting arrangements that raise risks around misunderstanding, inconsistencies and confusion between partners. David White indicated that he had had a useful meeting with Nikki Burnett and representatives from Portsmouth City Council to gain a further understanding. Ernst & Young would look specifically at the proposed accounting treatments for the Better Care Fund and review the disclosures made under IFRS11 and 12 relating to the arrangements.

Page 4: Value for money risks – The approach to the value for money conclusion for CCGs for 2015/16 was anticipated to be based on criteria specified by the National Audit Office. To help auditors to consider this overall evaluation criterion, the following sub-criteria are intended to guide auditors in reaching their overall judgements. However, these are not separate and auditors are not required to reach a distinct judgement against each one:

1. Informed decision making 2. Sustainable resource deployment 3. Working with partners and other third parties

The risks relevant to the value for money conclusion have been considered, taking into account the National Audit Office guidance and at this stage, there were no significant risks to bring back to this Committee. However, this risk assessment will be kept under review during the course of the audit. Page 8: 4.4 Materiality – the initial work for the year end had been completed; however, these will be updated when the draft financial statements in April 2015 were received.

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The planning stage has been determined that overall materiality for the financial statements of the CCG is £5.151m based on 2% of gross expenditure. Ernst & Young will communicate uncorrected audit misstatements greater than £257,000. Julie Cullen suggested that it would be useful to have some more details around the value for money risks (page 4) in the form of a table/diagram. Kate Handy said that she would feed this back Action for Kate Handy: Use of a table/diagram in the value for money risks section in future External Audit Plans The Audit Committee noted the contents of the 2015/16 External Audit Plan c. Audit Committee Health Sector Briefing The briefing produced by the CCG’s External Auditors, to inform the Audit Committee of general issues affecting the health sector, was noted. These briefings were considered extremely useful and helpful. The Audit Committee noted the contents of the Audit Committee Health Sector Briefing

6. Internal Audit

a. Internal Audit Progress Report 2015/16 Will Barnard presented the Internal Audit progress Report which provided information on the progress against the 2015/16 Internal Audit Plan and to provide assurance through the final reports issued. Progress against the Plan was set out in Annex A and the Executive Summary from these reports were attached at Annex B. Will Barnard reported that the following reports had been finalised:

• Payroll and Human Resources Systems – substantial assurance, with no recommendations or operational matters

• QIPP – reasonable assurance, with one important recommendation relating to changes to the GP telephone line; one routine relating to project falling behind plan and two operational relating to Covalent and reporting KPIs

• Financial Accounting – substantial assurance, with one routine recommendation relating to segregation of duties discussed with Chief Finance Officer/Deputy Chief Finance Officer. The risk had been accepted and the relevant controls were in place. There was one operational recommendation relating to the review of Oracle. Management had accepted risk involved

The issues identified at other CCG clients, but not included in this CCG’s audit plan, will be brought to the Committee’s attention. Recent issues identified elsewhere included:

• Governance arrangements • Safeguarding Adults • ICT risks

The CCG’s Governing Body were given a presentation on the ‘risk appetite’. This has resulted in further work around risk and the assurance framework being developed. A summary briefing on recent sector developments in risk and governance were given at Annex C. The Audit Committee noted contents the Internal Audit Progress Report 2015/16

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b. Previous Internal Audit Actions progress report/Client Portal – Terms of Reference

Will Barnard presented a report on the progress made against Internal Audit recommendations and to present the TIAA Client Portal which incorporated the facility to record and track progress on recommendations. The four remaining recommendations are all in progress and have been given revised implementation dates as they relate to the Portsmouth Blueprint. TIAA Client Portal (the portal) is included as part of our standard service provision to NHS Portsmouth Clinical Commissioning Group. The portal has been designed to meet the needs of our clients, providing a central repository to view audit recommendations and reports. In addition, the portal provides an oversight of progress against the annual audit plan and gives access to the latest TIAA publications. The Audit Committee noted the contents in Previous Internal Audit Actions progress report/Client Portal – Terms of Reference c. Interim Head of Internal Opinion

Will Barnard presented the Interim Head of Internal Opinion and asked the Audit Committee members to note that reasonable assurance had been given that there were adequate and effective management and internal control processes to manage the achievement of the CCG’s objectives and that there were no major issues to identify.

The Audit Committee noted the contents of the Interim Head of Internal Opinion d. Draft 2016/17 Annual Internal Audit Plan

Will Barnard presented the Draft Internal audit Plan for 2016/17. It is the responsibility of the Audit Committee to determine that the number of audit days to be provided and the planned audit coverage are sufficient to meet the Committee’s requirements and that the areas selected for review are sufficient to provide assurance against the key risks within the CCG. TIAA are currently reviewing the progress against the days purchased in order to get value for money in respect of the audits undertaken. TIAA will be looking at the following key areas which are significant to year end process: Page 5: - Information Governance Toolkit – to provide assurance on the CCG’s self-assessment against the national toolkit requirements Payroll and Human Resources Systems – review the key controls in place to manage to manage recruitments and the process of changes to standing payroll data. There is provision for a contingency which would allow Internal Audit to respond to any emerging risk issues during the year, without having an impact on agreed plan areas. The rolling strategic plan set out in Annex B will be subject to ongoing review and could change as the risks change for the CCG and would formally be reviewed with senior management and the Committee mid-way through the financial year or should a significant issue arise. It was suggested incorporating the information within the rolling strategic plan (page 7) into a table/grid to make the information easier to understand. The Rolling Strategic Plan for the 3 year period would be taken to the next Clinical Executive Committee being held on 23 March, with the final document being brought back to the next Audit Committee meeting.

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Action for Michelle Spandley/Jane Cole: Rolling Internal Audit Strategic Plan for the 3 year period to be taken to the next Clinical Executive on 23 March, with the final document being brought back to the next Audit Committee meeting The Audit Committee approved the Draft Internal Audit Plan for 2016/17 e. Internal Audit Briefings Will Barnard presented the following Internal Audit Briefings for the Audit Committee members to note:

• NAO Report on Managing Conflicts of Interest • Management of Adult Diabetes Services

The Audit Committee noted the contents of the Internal Audit Briefings

7. Local Counter Fraud Services

a. Local Counter Fraud Services Interim Report

Heather Greenhowe presented the Local Counter Fraud Interim Report for the period 26 November 2015 to 12 February 2016. There were no significant issues/investigations to report; however, there were 6 local fraud patient alerts/warnings to report. NHS Protect are currently restructuring and part of this process are to streamline their training aspect, and this will affect how Local Counter Fraud Specialists can be trained. The quarterly counter fraud newsletter, ‘Fraud Matters’, provides detail of local and national NHS fraud cases along with advice to protect both the organisation and its employees against fraud. Michelle Spandley said that she would contact the CCG’s Communications team to ensure that this newsletter is disseminated to the correct people. Action for Michelle Spandley: Contact Communications Team to ensure that the newsletter, ‘Fraud Matters’, is disseminated to the correct people

The Audit Committee noted the contents of the Local Counter Fraud Interim Report

b. Anti-Fraud, Bribery and Corruption Policy Heather Greenhowe presented the revised Anti-fraud, Bribery and Corruption policy for approval by the Audit Committee. The following amendments were to be made to this policy:

• Add the following sentence to section 3.4 - The Human Resources function is currently administered by Portsmouth City Council.

The changes in the care act (offence of false or misleading information) were discussed and the re-structure of NHS Protect and how both affect the CCG, together with how to improve the Local Counter Fraud’s ability to measure and monitor the effectiveness of counter fraud. An e-learning package has been developed for the CCG and Heather Greenhowe would speak to HR / L&D and progress this from their end. Initially the intention would be to offer it to staff as a refresher training, if uptake is too low then the Local Counter Fraud Service will revisit whether it can be made mandatory or not.

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The Audit Committee approved this Policy subject to the minor changes and would be made available to all staff via the organisation’s intranet and internet sites. A review has been undertaken of the roles and responsibilities of our CCG's lay members. However, it was confirmed that Dr Elizabeth Fellows would remain in the role of the CCG’s Caldicott guardian at the moment. The Audit Committee approved this Policy subject to the minor changes

8. Financial Matters

a. Finance Report for the period ending 31 January 2016 (Month 10)

Jane Cole presented the finance report for the period ending 31 January 2016 (month 10) and was pleased to confirm that the CCG remains on track to meet its surplus position of £3.1m. The CCG continues to liaise with Portsmouth Hospitals NHS Trust around the Contract Performance Notices issued in November to assure recovery plans. Withheld funding will be released when plans are approved. As part of the process, the CCG had provided a remedial action plan which had to be agreed by both parties; however, at the present time PHT have failed to agree. A recent revised Recovery Action Plan (RAP) was raised and the CCG is currently working with PHT in respect of RTT, A&E, Cancer and cancelled operations but if there is failure to agree the remedial action plan, a view to permanently withholding funding may be taken. The Audit Committee noted the contents of the Financial Report b. Use of NHS Portsmouth CCG Trust Seal

None to declare. c. Record of Chair’s Actions / Single Tender Action

None to declare.

9. Governance Matters

a. Information Governance Update Angela Sumner joined the meeting to present the Information Governance update which related to the actions in connection to the IG Toolkit and the wide Information Governance work programme and supports the CCG to fulfil its requirements under the Information Governance toolkit and information related legislation. Evidence in respect of Version 13 of the Information Governance toolkit is currently being uploaded in readiness for the 31 March. TIAA were currently reviewing the 10 requirements ahead of this submission. However, initial feedback has been received from TIAA which is being worked through by the Michelle Spandley (SIRO) and Angela Sumner (Information Governance Manager), in order that the recommendations are incorporated into the final submission. There were no data breaches attributable to the CCG. Angela Sumner emphasised that this was due mainly to the rigorous approach that staff have in recognising incidents of data breaches and recording these to the appropriate way.

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The CCG is currently 98% compliant with mandatory Information Governance training and has demonstrated the necessary 95% compliance. The Portsmouth Information Sharing Group have reviewed the citywide Information Sharing Protocol which was now available for adoption and signature by the CCG. After discussion, the CCG were happy to adopt the Portsmouth Information Sharing Framework and Angela Sumner said that she would arrange for Dr Elizabeth Fellows (Caldicott Guardian) to give agreement to this document. The final Data Custodian Work Programme report has been completed and presented to the SIRO for consideration and action. It has been attached to this report for information as Appendix 3. Andy Silvester thanked Angela for such a comprehensive report. The Audit Committee noted the contents of the Information Governance Update b. Governing Board Assurance Framework In line with the CCG’s Risk Management Framework, the Audit Committee reviews quarterly the Governing Board Assurance Framework (GBAF) which in turn reports to the next meeting of the Governing Board. Governing Board members reviewed the Governing Board Assurance Framework risks and process at a development session on the 10 February 2016. A number of issues were identified with the current process and concern noted that the Governing Board Assurance Framework process needs to be more dynamic, timely and responsive. Changes to the process will be incorporated into an update of the CCG’s Risk Management Framework which will be presented to the May Audit Committee meeting for approval. The Audit Committee approved the proposed Governing Board Assurance Framework in preparation for its presentation at the Governing Board meeting on 16 March 2016 c. Register of Gifts/Hospitalities Michelle presented the register of gifs/hospitalities for the period 1 October to 4 March 2016) which recorded the following:

• Goodie bag received by Chief Operating Officer to the value of £25.00 from Silver Linings Global who had arranged a learning tour of the UK for government officials and aging industry leaders from Taiwan (specifically from the Social and Family Administration team within the Ministry of Health and Welfare)

• Gift voucher received by Chief Operating Officer to the value of £25.00 for presenting at an HFMA Commissioning Finance Forum on Integration on 18 November 2015

• 5 x boxes of chocolates received by the Medicines Management team to the value of £15.00 from GoldChem pharmacy on 14 December 2015

The Audit Committee noted the contents of the Register of Gifts/Hospitalities d. Register of Interests – potential conflicts of interest

None to declare.

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10. Prescribing and Medicines Management Update – Simon Cooper Simon Cooper, Head of Prescribing Support, presented a summary report of GP practice prescribing within the CCG. This report employed both the local and BSA (British Services Authority) method for the year-end outturn for comparison. Forecasting methods provided by the BSA are averaged nationally and do not always accurately reflect an individual CCG’s position. The BSA forecast outturn for prescribing spend is based on previous national prescribing patterns of expenditure and the number of dispensing days in any particular month. This method has been amended for November 2015 to take into account the national Category M price changes that will come into effect in January 2016. The current forecast budget overspends is reflected to some part by the national picture and locally CCGs within SHIP are describing similar budgetary positions. The actual level of overspend needs to be reviewed in the light of the individual rebate schemes that each CCG has adopted and income from Public Health as these are not included within the BSA prescribing data. The majority of the impact on the prescribing budget can be assigned to the uptake of newer more expensive medications that have been approved by NICE as an option in treatment. Whilst this growth has been in place for a period of time, its effect has been negated by the savings within Category M. The recent changes in pricing of Category M have led to a reduction in savings to a point where it is no longer offsetting the other budgetary cost pressures and is now expected to become a cost pressure in itself. The change in Category M pricing from January will offset some of this cost pressure although longer term into 2016/17 Category M is expected to continue to cause a cost pressure. Current work on the initial prescribing savings programme is ahead of the original planned activity and is expected to over deliver the planned £200k savings. Additional opportunities for savings within the prescribing budget have been identified and this work is continuing. While these actions will not completely redress the projected overspend, they will go some way to ensuring it is contained.

11. Any Other Business

Michelle Spandley reminded Audit Committee members that CCGs are required to select and appoint their own auditors and directly manage their contracts for audits for the financial year starting in April 2017. The Audit Committee will be Portsmouth CCG Auditor Panel. The ‘SHIP’ CCGs are discussing procuring this service jointly (as undertaken to appoint Internal Audit). The Audit Panel will advise on appointment following procurement exercise. An external auditor (to audit the annual accounts) must be appointed by 31st December 2016 for the 2017/18 financial year. Andy Silvester concluded the meeting by once again thanking Tom Morton, on behalf of the Audit Committee, for the excellent work he had undertaken over the years in his role as Audit Chair.

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12. Dates and Times of future meetings The next meeting will be held on Wednesday 25 May 2015, 10:00am to 12:00 midday, in the Committee Room, NHS Portsmouth CCG Headquarters. Wednesday 7 September 2016 10:00-12:00 CCG Committee Room Wednesday 14 December 2016 1:00-3:00 CCG Committee Room Wednesday 1 March 2017 10:00-12:00 CCG Committee Room

There is a meeting scheduled on Wednesday 4 May 2016, 3:00-5:00pm, in the Committee Room, NHS Portsmouth CCG Headquarters, to review the draft annual accounts.

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HEALTH AND WELLBEING BOARD MINUTES OF THE MEETING of the Health and Wellbeing Board held on Wednesday, 2 December 2015 at 9.00 am in Conference Room A, Civic Offices, Portsmouth.

Present

Dr James Hogan (in the Chair)

Councillor Donna Jones Councillor Gerald Vernon-Jackson Dr Janet Maxwell Innes Richens Di Smith Rob Watt Patrick Fowler Healthwatch Portsmouth Dianne Sherlock Sue Harriman Ursula Ward Jackie Powell

Officers Present David Williams Matt Gummerson Reg Hooke Rachael Roberts Lee Loveless Mary Shek

34. Welcome, apologies for absence and declarations of members' interests (AI 1) The Chair, Dr Jim Hogan, welcomed everyone and asked for introductions around the table. Apologies for absence had been received from Cllr Luke Stubbs, Cllr Neill Young and Ruth Williams. There were no declarations of members' interests.

35. Minutes of previous meeting - 16 September 2015 - and Matters Arising (AI 2) RESOLVED: The minutes of the meeting held on 16 September 2015 were approved as a correct record.

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The following matters arose regarding minute 30 'A Proposal for Portsmouth: A Blueprint for Health and Care in Portsmouth'

(i) The joint PCC/CCG/PHT and Solent letter to the secretary of State - Matt Gummerson confirmed that this had been sent and a response had been chased.

(ii) Ursula Ward had fed back into this process having discussed this with

the PHT Board.

It was noted that the Blueprint was later on this meeting's agenda for a progress update.

36. The Blueprint for Health and Care in Portsmouth (AI 3) The report by Innes Richens and David Williams had been circulated to members the day before. Copies were available at the meeting and on the website. David Williams presented the paper which was for noting as this was to advise on the development of thinking for the way forward for the integration. He stressed the importance of the whole spectrum of activity (as evidenced in the diagrams within the report). So far progress was in line with government and the King's Fund guidance, and had been commented on within the Chancellor's autumn statement the previous week. Pages 3 to 4 of the report set out how implementation was taking place with investigation of the powers invested to the boards and to see how much progress Health & Wellbeing Board can make without the need for external permission. The governance arrangements at PCC and the CCG were also being looked at as well and the role of the Health & Wellbeing Board. David Williams further reported that:

There would be a series of steps for each organisation to ratify.

There are areas of commissioning currently reserved to NHS England or Public Health England.

There will need to be a decision made regarding accelerating the process and how the role of the Health & Wellbeing Board can be strengthened.

Innes Richens drew attention to page 11 of the report which set out how the changes would be delivered, such as:

How PCC/CCG undertake commissioning together an how the funding for this could be joined up.

The scope of the Health & Wellbeing Board.

Looking at commitment to a single provision for a frontline delivery and regarding the impact on the organisations.

Discussions were taking place on backroom support functions such as HR.

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It was noted that all the organisations had pressures around the finances so this should not be decided in isolation but should be planned together. Questions were raised by members regarding the legal and financial implications and how influence could be placed on the council's social care budgets but it was confirmed that Health & Wellbeing Board could express views to the council but authority on the actual budget lay with the council. Councillor Donna Jones wished to record her disappointment that she had not been involved in consultations on this paper, so she was pleased it was an information and not decision item at this stage. As Leader of PCC she welcomed the direction of travel for the Blueprint and asked that she and her Cabinet Member for Health & Social Care were kept involved in the process. In response David Williams apologised for the late delivery and stressed that the report was for noting and this was part of a long journey for which members would be kept involved and there would be papers brought back to the Health & Wellbeing Board, with each of the organisations having the opportunity to be appropriately briefed before decisions were taken. In response to other questions it was noted that the autumn budget had put more pressure on the budgets of the member organisations involved but each area should still develop its proposals. With regard to the ring-fencing of monies for adult social care, Councillor Donna Jones as Leader reported that PCC had launched an online consultation regarding a proposed extra 2% on the Council Tax to ensure protection of services. The government were not provided extra funding for the implications of the living social wage which could mean £1.5-2 million which was not funded by the government and was for the local authority to find. Dr Hogan as Chair stressed that the papers were for noting and there were lessons learned in taking partners forward and being briefed appropriately. This area would continue to be developed with reports being brought back to the Health & Wellbeing Board (as well as the Cabinet and CCG Board).

37. Portsmouth Safeguarding Adults Board Annual (PSAB) Report (AI 4) This report was presented by Rachael Roberts, from PCC Adult Social Care, who went through the headlines from the report. The PSAB was preparing for the implementation of the implications of the Care Act and met on a regular basis, as did the sub-groups, to working on their priorities. There was also close work with Hampshire County Council for a pan-Hampshire approach e.g. on fire safety, workforce development etc. There had been a couple of adult safeguarding reviews, the main themes emerging from these were regarding communication, with the action plans being taken forward on these. The reviews were published on the PSAB website which also set out its policies and procedures. There were approximately 1,300 referrals each year with a higher proportion of these needing a greater response, including those concerning financial abuse, physical harm and neglectful care by providers.

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In response to questions it was noted that the number of referrals was comparable with similar sized boards and there was more awareness leading to increased referrals and these were then signposted appropriately and the multi-agency "MASH" in Portsmouth (under the Safer Portsmouth Partnership) was helpful in improving communication. It was noted that there was member training on safeguarding awareness which was combined for children and adults. This was welcomed by the councillors present and it was felt it was particularly important for the spokespersons and group leaders to have this training. Discussion took place regarding the possible cuts to domestic violence funding within the council's budget although it was noted that other schemes such as the Iris scheme in primary care would be continuing and the work of the police whose budgets had been more protected by the Chancellor. Councillor Jones reported that a letter would be going from Councillor New (as Cabinet Member for Environment & Community Safety) to the Police Commissioner to ask for funding and she stressed that the cuts to domestic violence were at the moment for 2017/18 and with efforts to secure future funding. Rachael was thanked for her report which was noted.

38. Portsmouth Safeguarding Children's Board (PSCB) Annual Report (AI 5) Reg Hooke presented this report as chair of the PSCB and reiterated the functions of the board to protect children by holding agencies to account, holding training sessions for professionals and upholding the standards by review. There was integration with the Safer Portsmouth Partnership, the Children's Trust and the Health & Wellbeing Board. There were also links with the Tackling Poverty strategy and the Mental Health strategy. Priorities: Page 3 of the report set out the four strategic priorities for 2014-17: firstly to ensure that the voice of the child was heard, tackling neglect and the risk of neglect, improving communication between bodies and lastly the board to challenge itself and scrutinise its own effectiveness. An emerging theme for the city was the tackling of child sexual exploitation. Reg Hooke was pleased to report that the Ofsted inspection findings as set out in the report had given a "good" result for the PSCB. There were a number of areas of challenges which included female genital mutilation, tackling radicalisation, supporting care leavers and mental health provision. There was also the scrutinising of restructuring around less budget provision. Questions and matters arising from the report:

It was asked which areas would be helpful to have further funding if it were available? In response Reg Hooke felt that the analytical capability was crucial for the accessing of multi-agency information and the capacity of officers to develop this as well as the capturing of the voice of the child.

It was noted that the report showed that all partners were involved and agencies were participating within the audit process.

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Cllr Jones stated that the council budget savings of £11 million did not target adult and children's social care but they were asked to come within their previous cash limits.

It was reported that the radicalisation of young people was being tackled through the Prevent programme and future funding for this would be through the Home Office's support rather than from the city council. There was a strong involvement via schools in Portsmouth in the Prevent agenda.

It was also noted that the schools councils were being encouraged to engage and schools were participating in the 'capturing of voices'.

It was also reported that the Child Death Overview Panel was now having a more local arrangement for Portsmouth but they were still sharing annual data from across Hampshire.

Reg Hooke was thanked for his presentation. RESOLVED Members of the Health and Wellbeing Board received the Portsmouth Safeguarding Children Board Annual Report and noted areas of progress and challenges identified in the context of services being planned and commissioned.

39. JSNA - annual summary and progress with outcomes in JHWS (AI 6) Dr Janet Maxwell as the Director of Public Health gave a presentation on the JSNA annual summary, identifying areas in which there were improvements or where things had worsened in the city. She displayed maps profiling the deprivation levels by wards; those in the 1% highest deprivation areas would be where work would be targeted. The displayed graphs illustrated the diseases that were linked to preventable deaths, the highest being circulatory followed by cancer, respiratory and digestive (see page 11 of the JSNA report). Trends: There was improvement in childhood obesity, teenage conception, new cases of TB and infant mortality. However there were worsening trends for alcohol related hospital stays and hip fractures. It was noted that road injuries was a big issue for Public Health and there were more efforts being made to influence road safety. Dr Maxwell reported on the work of City Deal funded programmes to support those with health issues maintain their employability, early years work, integrating health visitors and the importance of the Portsmouth Together volunteering work. The chosen areas concentrate on strong community links were Fratton and Somerstown. Public health officers were also involved in the refresh of the Portsmouth Plan looking at the economic development and infrastructure changes to promote walkability and breathability in Portsmouth and were working closely with the University of Portsmouth and making a national bid for 'urban living' funding. Questions: In response to questions from Health and Wellbeing Board members, the following extra information was given:

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It was noted that female mortality rates had previously been better than male mortality rates.

Housing There were other issues that were affecting the most deprived wards such as social housing. It was noted that more people were going into the private rented sector. Councillor Vernon-Jackson reported on the building of fewer council houses in the Hampshire area. Councillor Jones felt that lead developments would be mostly outside of Portsmouth, and developers in Portsmouth would say it was not viable for social housing to be provided within the city although the major developments outside of Portsmouth in the Solent PUSH area would have a large proportion of social housing. Janet Maxwell stressed the integration with the housing services and with those visiting the vulnerable to do risk assessments.

Training on JSNA It was suggested that online training be given to group leaders and any other interested parties by Joanne Kerr (the Head of Public Health Intelligence) to show how to get the greatest value from the online tools that form part of the JSNA.

40. Mental Health and Wellbeing Strategy (AI 7) Lee Loveless presented this report which requested the adoption of the Mental Health and Wellbeing Strategy 2016-2021 which had been brought together by a multi-agency group, setting out 11 pledges through the topic 'experts'. In consultation with each of these a pledge group had been formed. Once the strategy was adopted by the HWB there would be the developing of an action plan which would be brought back to HWB for approval in June 2016. Janet Maxwell stressed there was a new approach for mental wellbeing being seen as an integrated part of people's lives and it was felt that Portsmouth were leading the way in this cultural shift. Councillor Jones was interested in the pledge to change and challenge attitudes and behaviour in turn reduce the stigma and isolation. Councillor Jones stressed that that the city council as a whole was very interested in the subject of mental health and had recently passed a cross-party Notice of Motion on the subject. The action plan should be in place by the 1st April and would be reported back to the Health and Wellbeing Board after that. The Chair thanked Lee Loveless and Matt Smith for this report. RESOLVED that the Board adopted the proposed Mental Health and Wellbeing Strategy 2016-2021.

41. Progress of the Wellbeing Service (AI 8)

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Mary Shek presented this report which gave an update to the Health and Wellbeing Board on the progress since the previous report in June and the launch of the Service on 1st October. The Service was to give support to residents on alcohol, smoking and diet advice for their wellbeing, taking a holistic approach working with Housing and other departments. There had been a smooth handover of clients in the transition and there had been a quiet launch so they would not be overwhelmed by requests initially but there would be the use of national branding from March. A majority of staff were in place (see paragraph 4.4 of the report) and she was pleased to report that this included apprentices. Of the 419 referrals, half of these were from GPs. Training was taking place for staff regarding safeguarding and it was hoped there be a migration to a single IT system that was also used by the GPs. In response to questions Mary Shek gave additional information:

Staff going into homes already received safeguarding training.

Dialogue was taking place with other services to try and ensure there was not duplication - there were locality teams sharing information and there was liaison with the Children's Centres.

It was hoped that there would be demonstrable outcomes by April. Dianne Sherlock appreciated working with Mary Shek from the voluntary sector angle. It was noted that Mary had been approached to give advice by other local authorities. Mary was thanked for her report and it was asked that all partners feedback to her in relation to the capability and capacity of the Wellbeing Service e.g. referrals, waiting times and any barriers. The HWB noted: (1) the progress of the new integrated wellbeing service (2) the role and strategic priorities of the Wellbeing Service within the

wider health & social care system.

42. Dementia - HWB Priority Update (information report) (AI 9) Matt Gummerson reported this was a regular item and any questions could be forwarded to Preeti Sheth. This report was noted.

43. Public Health Annual Report (AI 10) Janet Maxwell presented this report. She reported on the refresh of the Portsmouth Plan which is an underpinning document for development in the city. It includes chapters dealing with transport and health, for which there was involvement in various issues such as:

The Hard redevelopment

The Park and Ride to reduce congestion and increase safety

The bid for Urban Living.

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Sustainability and Health were also included within work on flood defences and the food economy.

Dr Maxwell was working with other directorates such as Housing and Education regarding employment for mental health support for people to keep them in work and also regarding the Healthy City Team to bring in funding. The information report was noted.

44. Future work programme of HWB for 2016 (AI 11) Matt Gummerson reported that during the year the workstreams had shaped the work programme and now a lot of work was taking place on the Blueprint and so future items would be brought back relating to this. There would continue to be the statutory annual reports and the intention was to share the work programme before the next meeting of the 17th February.

45. Date of next meeting (AI 12) It was noted that the next meeting would take place on the 17th February at 10 am. Additional business was raised in that:-

(1) It was Matt Gummerson's last meeting, so the Chair thanked him on behalf of the HWB for his help and support in establishing and progressing the work of the Board. Councillor Jones extended her good wishes to him in his new position working with Health and the University.

(2) In response to a question regarding the publicity for these meetings it

was noted that these are public meetings and information was on the Portsmouth City Council's website and the HWB newsletter.

The meeting concluded at 11.00 am.

Dr James Hogan Chair

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Minutes of the NHS Portsmouth Primary Care Commissioning Committee meeting held on Wednesday 16 March 2016 at 2.30pm – 4.00pm in Conference Room A, 2nd Floor, Civic

Offices, Portsmouth

Present: Dr Linda Collie - Clinical Executive Dr Julie Cullen - Registered Nurse Ms Katie Hovenden - Director of Primary Care Mr Tom Morton - Lay Member Ms Jackie Powell - Lay Member Mr Innes Richens - Chief Operating Officer Ms Tracy Sanders - Chief Strategic Officer Mr Andy Silvester - Lay Member Mrs Michelle Spandley - Chief Finance Officer In Attendance Dr Dapo Alalade - Clinical Executive Mrs Jayne Collis - Business Development Manager Mr Paul Cox - Practice Manager Representative Dr Elizabeth Fellows - Clinical Executive Mr Patrick Fowler - Healthwatch Representative Dr Jim Hogan - Clinical Leader and Chief Clinical Officer Dr Janet Maxwell - Director of Public Health, Portsmouth City Council Ms Suzannah Rosenberg - Director of Quality and Commissioning Dr Tim Wilkinson - Chair of Governing Board/Clinical Executive Mr David Williams - Chief Executive, Portsmouth City Council Apologies Dr Tahwinder Upile - Secondary Care Specialist Doctor

1. Apologies and Welcome

Apologies received from Dr Tahwinder Upile. Tom Morton welcomed everyone to the first meeting of the newly constituted stand-alone Primary Care Commissioning Committee. He reminded those present that although the meeting was being held in public it was not a public meeting and therefore no participation from members of the audience is allowed during the formal business of the Committee.

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The CCG undertakes primary care co-commissioning under delegated powers from NHS England. As a GP membership organisation we are open and transparent in how we handle perceived or potential conflicts of interest in all aspects of our business. In line with our policies the chairing of the Committee is a lay member representative. In addition there is only one representative from member practices, the Clinical Executive lead for primary care, who is a voting member of the committee. All other Clinical Executives and the practice manager representative are non-voting members of the committees which means they will normally be able to participate in discussions but not decision making. Where members (voting or non-voting) are felt to have a direct potential conflict of interest they will be excluded from our discussions as well as decision making. However in order to retain the voice of local primary care the Clinical Executive lead for primary care, Dr Linda Collie, will be allowed to participate in discussions for such items unless they are directly about their practice.

2. Declarations of Interest

Dr Linda Collie, Dr Dapo Alalade, Dr Elizabeth Fellows, Dr Jim Hogan, Dr Tim Wilkinson and Paul Cox declared possible conflicts of interest relating to agenda items 4, 5, 6 and 7. It was agreed that they would be excluded from discussion and decisions making from all 4 items except Dr Collie who would be invited back to join discussions regarding items 6 and 7 as the items were not directly related to her practice and a primary care view would be welcomed by the committee. Andy Silvester declared a possible perceived conflict of interest relating to agenda item 4 due to his membership of the Labour Party, a subset of which had submitted a petition. It was agreed that Mr Silvester would remain for the item as he was not directly involved.

3. Minutes of Previous Meeting The minutes of the Primary Care Commissioning business part of the Governing Board meeting held on Wednesday 20 January 2016 (Items 8 and 9 only) were approved as an accurate record.

An update on actions from the previous meeting was provided as follows:

Agenda Item

Action Who By Progress

10 Primary Care Commissioning Governance Arrangements – Share updated diagram of Committee structures with Jackie Powell.

T Wilkinson Mar 16 Complete.

12 Review of Lay Member Portfolios – Portfolio for Andy Silvester to include Voluntary Sector.

T Wilkinson Mar 16 Complete

Tom Morton asked Dr Linda Collie, Dr Dapo Alalade, Dr Elizabeth Fellows, Dr Jim Hogan, Dr Tim Wilkinson and Paul Cox to leave the table for the following agenda items. 4. Guildhall Walk Healthcare Centre Petition

Innes Richens presented a paper which explained that the CCG had received petitions with regard to the proposals for the future of NHS services at Guildhall Walk Healthcare Centre.

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The Primary Care Commissioning Committee noted the petitions.

5. Future of NHS Services at Guildhall Walk Healthcare Centre Tom Morton noted that all clinical executives and the practice manager representative have been excluded from discussions and decision making. Innes Richens presented a paper which summarised the feedback received from earlier engagement activities as well as the response to the formal consultation which closed on 19 February 2016. It also detailed a set of revised proposals regarding the future of NHS services at Guildhall Walk Healthcare Centre and how these take account of the impact of the proposed changes and feedback that has been received. Innes Richens said that from the consultation and other engagement work it is clear that people do have problems accessing their GP service and it is therefore understandable that they do not want to see walk-in capacity changed in the City. One of the CCGs main priorities is to improve access to Primary Care for the whole of the City, not just one location and we have other schemes already being delivered that try different ways of doing this. Other practices are also seeking to increase their opening hours and trial different ways of triaging people when they call in so they get the help they need more quickly. Innes Richens referred to the 3 proposals detailed on the front sheet of the paper. Katie Hovenden went through the paper in detail and highlighted the following points:

Strong views about the need to retain GP services in the city centre have been expressed.

In light of the public and professional feedback, a revised proposal is presented which takes into account key aspects of the feedback and concerns raised.

The proposal is in 3 parts and is recommended on the basis that it keeps the city centre practice currently at Guildhall Walk open, whilst enabling the CCG to continue with its strategic plans to redesign urgent care.

It is essential that the medical services and management of vulnerable patients, such as people who are homeless or alcohol and substance misusers continue to be delivered within the city and there is ongoing work and discussion with Public Health and local authority colleagues regarding the best model for the future.

Recommendations that the practice is retained in the city centre for registered patients who will be able to access GPs and or nurses without the need to make an appointment with services being available in the evenings and at weekends.

Recommendations that the walk in service at St Mary’s is enhanced by increasing capacity and providing access to GPs as well as nurses.

Recommendations that the eligibility criteria and scope of the Pharmacy First minor ailments service is expanded to ensure there is enhanced services offered in the city centre/Guildhall walk area.

In order to achieve the recommendations the following is proposed:

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Extend the current contract with the existing provider at Guildhall Walk Healthcare Centre until 30 June 2016.

Agree an interim contract from 1 July 2016 to 31 March 2017 with the current provider PHL, for the provision of general medical services for registered patients only.

From April 2017 the CCG will put a new contract in place for a city centre practice for those patients currently registered at Guildhall Walk Healthcare Centre.

Tom Morton thanked Katie Hovenden for a very clear analysis of a complicated paper. Patrick Fowler asked about the location of the city centre GP practice from April 2017. Katie Hovenden said that the location of the practice, once re-procured, will take into account feedback as the CCG wants to keep its options open so the location has not yet fully been decided. Patrick Fowler asked about access for cars at St Marys and what is the plan before the new car park is installed in July 2017. Katie Hovenden said that the majority accessing services is outside of GP core hours and over the coming year we need to improve access to GPs practices and the majority have arrangements to access GPs on the day if urgently required. In the main it is believed that the majority of access will be required in the evenings and at weekends when car access and parking arrangements are not generally an issue. Patrick Fowler asked about pharmacies and how the CCG planned to improve the trust of the public in using them for advice. Katie Hovenden explained that from communications work we know that some pharmacies are already providing a service and we need to work with GP practices on this as well as the general public to explain the options to them better. Tracy Sanders asked for clarification on the registered practice and whether the catchment was limited or not. Katie Hovenden explained that the proposal is that the boundary will be the city, that way if people working in the city want to take advantage of using the practice they can choose to register as an out of area practice which means they would not have access to out of hours provision but would have access to all other GP services. There are some practices in the city that already have broad boundaries operating such as this. Tracy Sanders asked about the capacity at St Mary’s treatment centre and confirmation that capacity would be expanded to accommodate the full walk in activity to be transferred to the treatment centre. Katie Hovenden confirmed this and that there was a very clear expectation on resources and plans would be in place to ensure this was the case. Andy Silvester asked about students and if the same rule applied regarding registration. Katie Hovenden explained that patients can only be registered at one practice at a time and therefore if they were registered elsewhere (such as their home address) they would not be able to register in the city. However if they were taken ill they can go to any GP practice as they would have to treat them for urgent care as a temporary resident. Suzannah Rosenberg commented on Portsmouth Hospitals Trust Emergency Department 4 hour waiting time performance issues and stated that any decision needs to offset the pressure. An enhanced walk in GP presence at the Treatment Centre is an opportunity to tweak the model as it is not seemingly currently having the desired impact. Katie Hovenden said that we have very positive relationship with Care UK who are a flexible provider if we found that we wanted further changes to the model. Work was already in

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hand with discussions on a balanced service to encourage more patients to be conveyed to the treatment centre rather than ED as well as work to simplify the description of what ailments the centre can and cannot treat. Katie also noted that this is not the sole solution and there are other actions being considered to improve urgent care model so that we ensure that patients are seen in the right place. Dr Julie Cullen commented that it makes sense to put everything together in one place and avoiding confusion is the key. Can we be assured that there is capacity at St Marys as it is likely to be equal or greater to what we have at the moment? Innes Richens explained that the activity put into St Marys is what there is currently however the contract allows us to monitor and review as we do with others so it is not a fixed point. Dr Julie Cullen said that maintaining the staffing levels would be essential to enable people to be seen quicker and we need to ensure we do not underestimate the potential activity. Innes Richens said that at the moment we have nurses working at one location and GP working at one location and by joining them up it makes it a more efficient service. Jackie Powell asked if the nearest pharmacy to the Guildhall Walk Healthcare Centre would become part of the Pharmacy First scheme. Katie Hovenden confirmed this noting that it was important those pharmacies closest to the centre were part of the programme as soon as possible and we would work with those that are interested to put arrangements in place for the July deadline. Jackie Powell asked about bus routes to St Marys and if the multi-story carpark at St Marys required planning permission. Katie Hovenden said that she did not know the answer about planning permission. With regards to the bus route the CCG has met with both bus companies and there has been a slight reduction in one service with buses stopping slightly earlier however it is still quite a comprehensive service from the city centre to St Marys but it was appreciated that services going east to west is not so good. Bus companies had indicated willingness to changing services if demand increases to the site. Dr Julie Cullen asked if we would need to wait for approval from NHS England. Katie Hovenden said that she can reassure members that discussions with NHS England are well under way and we do not anticipate any delays. Tom Morton asked about support for the homeless and asked how well they are supported at the moment and how will it change. Dr Janet Maxwell explained that there are approximately 200 people who are homeless and some people in some sort of housing but they have complex needs and we need to be mindful that we need to do more. The current arrangements provide a walk in service for homeless but we think we can do better with better pathways and we want to develop the service and offer better integration with other services for the population. Current contracts for drug and alcohol services etc are all coming to an end at the same time and we are realigning tenders to get more coherent provision. There may be a shift of focus for services to St Marys but there is an extension to ensure we get the work done. Katie Hovenden clarified the three phases to the next steps as mentioned previously and as detailed in the paper. Innes Richens reminded members of the Committee that during the options appraisal process we assessed quality and safety and the financial impact and there will be a small saving. Tom Morton commented that it was a complex paper which he felt the Committee had devoted a significant amount of time to.

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Andy Silvester asked about the 4 strategic priorities for the CCG and if the Committee felt that this recommendation would meet one of those priorities. Innes Richens said that he felt it did and is why he reminded the Committee about improving access for Primary Care in the City. Jackie Powell asked if the new practice would have extended hours. Katie Hovenden said that it was not likely to have the same extended hours as the current model if it was only for a registered list of patients as it will not be needed and this is why the CCG asked patients what they wanted. In response to feedback it is likely to be open evenings and Saturday mornings as a minimum and this is what some other practices do. We have a number of schemes in the City extending the hours of service provided. The CCG is trying to get equality across the City however not all the practices are open but it is about patients being able to access services. The Primary Care Commissioning Committee considered the contents of the paper, including the feedback received and approved the recommendation as set out in Section 7 of the paper. Innes Richens highlighted to Committee members that the paper had been considered by the Portsmouth Health Overview and Scrutiny Panel and some of the comments at the meeting were as follows:

The consultation was thorough, extensive, fair and clear.

Some concerns around the potential loss of walk-in access for unregistered patients in the city centre location.

Some concern regarding parking and traffic congestion at the St Mary’s site.

Putting GPs into the St Marys Centre is a good proposal. Innes Richens explained that following today’s meeting the Chair of HOSP will be informed of the outcome. Innes Richens said he would like to recognise the work of David Barker, Nick Brooks, the Communications team, Mark Compton and Nikki Burnett on this issue and personally thanks Katie Hovenden for her work on this.

Dr Linda Collie re-joined the meeting in order to contribute to the next items but will not take part in any decision.

6. Locally Commissioned Services 2016/17

Katie Hovenden presented a paper which details plans to re-invest PMS monies into amalgamated and new Locally Commissioning Services (LCS). This has previously been presented to the Governing Board under Primary Care business. Practices are currently doing a lot of work that is not within their core contract. The CCG has worked with the LMC and practices and it is proposed that they are pulled together and commissioned as an outcomes-focused basket of services, rather than individual LCSs. It is proposed that some local services are included in the “basket” and these are detailed in the paper. The paper details proposals for the Diabetes Locally Commissioned Service and the Respiratory Locally Commissioned Service. Dr Linda Collie said that this has been discussed as clinicians and a lot of practices commission some of the services already but it is good to standardise and she welcomed

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the change. She clarified that to get to Level 3 you do not have to have done Levels 1 and 2. Katie Hovenden said this was correct and the same applied to Respiratory. Dr Janet Maxwell said that it is very important and supported the proposal wholeheartedly. She said there were a number of public health initiatives that were at risk of being cut or removed and said that she would be discussing these further to see if LCS offer any assistance. Dr Julie Cullen commented that the “basket of services” is a lot of nursing activity and asked, in relation to the next paper on the agenda, if this was the same that was included in the “basket”. We need to clarify between longer term care and leg ulcer care that is included in the basket. She asked where the clarity was and how can the CCG be sure it is not paying for the same thing 3 times. Katie Hovenden explained that the services listed on Page 1 of the paper are the current locally commissioned services and are not necessarily what will go into the revised “basket”. The items proposed for the “basket” are listed on page 2 of the paper which do not include leg ulcer care. There will be a specification that underpins the “basket” which she is happy to share and then it will be clear there is no overlap. The Primary Care Commissioning Committee approved the required non-recurrent investment for 2016/17 (to be funded recurrently from freed up PMS monies) and agree the overall investment plan.

7. GP Leg Ulcer Service Provision Katie Hovenden presented a paper which provided an update on the plans for leg ulcer provision across the city and to seek authorisation for the new investment associated with it. She explained that this had been discussed at the Clinical Strategy Committee but because it required additional investment it has been presented to the Primary Care Commissioning Committee. A service has been commissioned from some practices for a number of years. From April 2014 a Leg Ulcer Support Service has been commissioned by the CCG utilising the skills and experience of a nurse specialist to provide training, advice and a referral route for ongoing complex leg ulcer cases requiring on-site assistance. Assessment of leg ulcers is a time consuming process for practices and we need to recognise where primary care are taking on additional service and we need to define what we require to a set of consistent standards and to resource the services appropriately. The CCG has worked with the LMC on the financial framework who felt the funding previously offered was below that which was recommended. In light of this the CCG is looking to bring the payment model broadly in line with the LMC guidance and a summary of the proposal changes is detailed in the paper. Dr Julie Cullen commented that this activity is very important and needs to happen. It is not included in the contract and therefore needs funding. It was asked how the CCG can be assured of quality of service and that the funding reaches the right place for training and that patients are treated pro-actively with a quality service. Katie Hovenden said that this is activity based payment and it will be closely monitored and the nurse specialist will do regular rounds. If you compare this service to the other services we commission it is robust and has a robust assessment and monitoring processes of the service being delivered.

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Dr Julie Cullen asked if payment kicked in at the 6 week point if it was not complex but because of the time and registered nurse involvement. Katie Hovenden explained that practices can only claim funding after 6 weeks and at the Doppler stage. In terms of how the funding works she would need to check. Michelle Spandley said that we would need to make sure appropriate KPIs were in place. The Primary Care Commissioning Committee approved the investment required for Leg Ulcer Services.

8. Date of Next Meeting in Public The next Primary Care Commissioning Committee meeting to be held in public will take place on Wednesday 18 May 2016 at approximately 2.30pm in the Conference Room A, 2nd Floor, Civic Offices. Tom Morton thanked everyone for attending the meeting and reminded members of the public that feedback and comments would be welcomed. Jayne Collis 7 April 2016