AGENDA Governing Body Meeting

Wednesday 6th July 2016 (Public) Time: 1500-1730

Location: Queens Hall, Ealing Town Hall

General Business

1. Welcome, Introductions & Apologies (Mohini Parmar) Attendees: Mohini Parmar (MP-Chair), Clare Parker (CP), Tessa Sandall (TS), Vijay Tailor (VT), Jonathan Webster (JW), Eva Horgan (EH), David Ashby (DA), Arjun Dhillon (AD), Philip Portwood (PP), Alex Fragoyannis (AF), Carmel Cahill (CC), Sally Armstrong (SA), Allison Bennett (AB), Fionnuala O’Donnell (F’OD), Neha Unadkat (NU), Jackie Chin (JC), Alan Hakim (AH), Jackie Pigott (JP), Naseem Isaq (NI-Minutes).

Dr. Mohini Parmar (MP), Elected GP from North North Network, Chair of the Governing Body

Dr. Alex Fragoyannis (AF), GP Clinical lead, Ealing CCG

Ms. Clare Parker (CP) Accountable Officer, CWHHE CCGs

Neha Unadkat, Deputy Managing Director, Integrated and Primary Care, Ealing CCG

Ms. Tessa Sandall (TS) Acting Managing Director, Ealing CCG

Allison Bennett, Head of Strategic Delivery, Ealing CCG

Mr. Jonathan Webster (JW) Director of Quality, CWHHE CCGs

Dr. Jackie Chin Public Health Representative, Ealing Council

Ms. Eva Horgan (EH) Deputy Chief Finance Officer, CWHHE CCGs

Ms. Naseem Isaq, Strategic Support Officer, Ealing CCG

Dr. Arjun Dhillon (AD) Elected GP from Central Ealing Network

Dr. Vijay Tailor (VT) Elected GP from Acton Network (Vice Chair)

Dr. Jackie Piggott (JP) Elected GP from South Central Ealing Network

Ms. Carmel Cahill (CC) Lay member leading on Quality

Dr. David Ashby (DA) Lay Member leading on Informatics

Mr. Phil Portwood (PW) Lay member leading on Patient and Public Engagement

Ms. Sally Armstrong (SA) Elected Local Nurse

Ms. Fionnuala O’Donnell Elected Practice Manager

Dr. Alan Hakim, Secondary Care Doctor

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Apologies: Keith Edmunds, Serena Foo, Mohammad Alzarrad, Ian Bernstein, Ian Robinson, Raj Chandok, Shankar Vijayadeva, Judith Finlay, Ben Westmancott, Philip Young & John McNeil

2. Declarations of Interest* (Mohini Parmar) There were no additional declarations of interest that were not already recorded.

3. Minutes of the Ealing CCG Governing Body, 18th May 2016 (Mohini Parmar) The minutes were approved as correct, with the following insertion on Page 7, second paragraph : “There are approximately 10 children a day who may need transfer to another unit to complete their care. Of those there are some who will be critically ill and will require an ambulance transfer with an 8 minute response time. This will be approx. 8 per month.” It was further clarified that London Ambulance Service will transfer all children who require immediate transfer ie within 8 minutes, for all other children who attend Ealing UCC and need to be transferred to see a specialist paediatrician we have a dedicated patient transport service, or if clinically appropriate the family can choose to take the child. As the service is dedicated, the child and their family do not experience a delay in transport provision. We are closely monitoring the response times of this transport service.

4. Matters Arising (Mohini Parmar) There were no matters arising not already covered on the agenda.

5. Chief Officer’s Report to the Governing Body (Clare Parker) CP highlighted the programme to develop and implement Accountable Care Partnerships (ACPs) across the CWHHE CCGs. The ambition to have ACPs is part of our five year strategy, which will become the Sustainable Transformation Plan (STP), and was reiterated and set out in our 2016/17 Commissioning Intentions. An interim / shadow ACP Programme Board has been established to help guide us through the initial phase of the programme. All CCG Clinical Chairs and Managing Directors are members of the Board, along with two lay member representatives and the CWHHE shared directors. This item will be brought back to the September 2016 Governing Body to discuss further. David Freeman has been appointed to lead this work across the 5 CWHHE CCGs. Ealing CCG Chair’s Report (Mohini Parmar) MP highlighted the paediatric transition which took place on 30th June 2016. The new system planned has been enacted and a project and operations team is monitoring the transition very closely across North West London and individual Trusts. An update will be provided soon.

Presentation

6. Sustainability Transformation Plan (verbal update) (Clare Parker) The slide pack provided was discussed in further detail. CP commented the STP was still in draft, and the final document will be published in the autumn. The STP builds on all the strategies being worked across the last few years with some new strands; and therefore, the vision and outcomes should feel very familiar. The following slides were discussed:

• Slide 1 discusses the current landscape and that health and social care in NW London is not sustainable. Looking at three key factors, it is noted that for Health & Wellbeing, adults are not making healthy choices, there is increased social isolation and Poor children’s health and wellbeing. In terms of care and quality, there is unwarranted variation in clinical practise and outcomes, reduced life expectancy for those with mental health issues and a lack of end of life

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care available at home. In terms of finance and efficiency, there are deficits in most NHS providers, an Increasing financial gap across health and large social care funding cuts and inefficiencies and duplication driven by organisational not patient focus

• Slide 2 sets out the NW London Vision, helping people to be well and live well. This includes having a future system that is proactive focusing on self-care, wellbeing and community interventions.

• Slide 3 discusses working together to address a new challenge. To enable people to be well and live well, we need to be clear about our collective responsibilities. As a system we have a responsibility for the health and well-being of our population but people are also responsible for looking after themselves. Our future plans are dependent upon acceptance of shared responsibilities. Over the next few months, this conversation will be developed further.

• Slide 4 notes the five delivery areas: Radically upgrading prevention and wellbeing, Eliminating unwarranted variation and improving LTC management, Achieving better outcomes and experiences for older people, Improving outcomes for children &adults with mental health needs and Ensuring we have safe, high quality sustainable acute services. CP commented the statements noted were developed with patients and the care they would expect to experience by 2021.

• Slide 6 looks at the 16/17 key deliverables in further detail including what will be achieved and the impact these deliverables will have. Slide 7 looks at the enablers in supporting the 5 delivery areas which are estates, digital and workforce enablers.

• Slide 8 looks at the Overall Financial Challenge – ‘Do Something,’ and that if we do nothing, NWL will have a £1.3bn funding gap across health and care by 2020/21. In the status quo scenario, the gap reduces by £570m. The STP has identified 5 delivery areas that will both deliver the vision of a more proactive model of care and reduce the costs of meeting the needs of the population to enable the system to be financially as well as clinically sustainable. At an STP level there is an estimated surplus of £50m in 2020/21 if the plan is successfully delivered.

• Slide 9 looks at how the plan will be delivered – (1) Agree a joint NW London implementation plan for each of the 5 high impact delivery areas, (2) Shift funding and resources to the implementation of the five delivery areas, recognising funding pressures across the system and ensure we use all our assets, (3) Develop new joint governance to create joint accountability and enable rapid action to deliver STP priorities (4) Reshape our commissioning and delivery to ensure it sustains investment on the things that keep people healthy and out of hospital

JC asked if other Local Authorities were feeding into the Accountable Care Partnership (ACP) which is a deliverable of the STP. It was noted there could be a pooled budget to jointly commission across social and healthcare providers, and conversations were being held with the Local Authorities, to build upon current joint work such as the Better Care Fund. It was further noted that funding for commissioners, providers and social care to deliver services will flow differently and through a different model of care to deliver services. In final, it was noted the plan is still in draft form, and the final document will be published in the autumn.

Items for Approval

7. Health and Safety Annual Report and Plan (Allison Bennett) The Governing Body was asked to:

• Note the Health and Safety Annual Report for 2015/16; • Approve the Health and Safety Plan for 2016/17; and • Support the communications plan for the Chief Officer’s health and safety statement.

The Governing Body noted the report, approved the plan and supported the communication plan for the Chief Officer’s health and safety statement.

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8. Safeguarding Children Commissioning Policy and Procedure (Jonathan Webster)

The Governing Body was asked to: • Approve the Policy and Procedures document on behalf of NHS Hounslow CCG

JW noted the policies and procedures were here for approval at the Governing Body meeting. This document has been discussed at Quality & Safety Committee, and was approved in April 2016. In summary, this document sets out the policy on safeguarding children. JW noted the PREVENT training is a key requirement for providers and the CCG have also undertaken this training. JW noted the importance of training and how this is closely monitored on a quarterly basis at commissioned provider Clinical Quality Group Meetings - where appropriate/ additional assurance is required a 'deep dive' may be asked for. CP asked what the mechanism is to ensure providers compiled with this policy. JW replied this is a key expectation from providers, and fits in with the contract with these organisations. A quarterly report comes to the CCG’s Quality & Safety Committee meetings. There is a very clear triangulation of what providers are expected to report, and what is reported at Q&S committees. A key area will be to take this forward as part of the Co-Commissioning agenda. The Governing Body approved the Policy.

Items for Discussion

9. Like Minded Programme: Update and discussion on progress and next steps in Ealing (Tessa Sandall) The Governing Body was asked to:

• Note this paper, discuss and comment TS noted this document was to update the Governing Body of the Like Minded programme. The programme have now gone live with the single point of access service, perinatal mental health services, and 32 GPs across NW London attended the GP Diploma in Primary Care Mental Health training, 4 GPs from Ealing were part of the cohort. In regards to children’s services, the eating disorder service is now operational as is the out of hours CAMHS services which is operating across 3 boroughs. Approval for The Learning Disabilities & the Transforming Care Plan (TCP) for people with learning disabilities, autism, and/or challenging behaviour was received in May 2016. The Serious & Long Term Mental Health Needs (SLTMHN) will be discussed at the next Governing Body in September 2016. MP commented it was important to note the work and changes in Mental Health services since the start of the Like Minded Programme. The strategy was developing well in bringing together and addressing the needs of children and adults. CP further commented it was important to bring mental health as well as physical heath together through the STP.

Items for Noting

10 Finance, Quality and Performance Reports: a. Ealing CCG Month 2 (16-17) Integrated Performance Report

JW noted work was being undertaken with WLMHT around the mortality data, and were also working with the Trust to follow up actions. A Board to Board Meeting with the Trust took place 3 weeks ago, and issues discussed included the CQC action plan, the Serious Incident Reporting and the current backlog which is being worked through. Looking forward, risks in some areas were also discussed. JW further noted the CQC report of the LNWHT had been received; overall progress noted as good with

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three areas for improvement identified. There will be a LNWH CQC Summit held later in July. JW summarised by saying from a WLMHT perspective, work was being undertaken with the Trust and across NWL looking at pathways of care as part of the mortality pathway review process, which is very positive.

b. Finance Report Month 02 (2016-17) EH noted the overall surplus target is being met. Main risks are acute performance and QIPP, and work is being undertaken with providers to bring this back on track. Finance will continue to monitor progress.

c. SaHF Month 12 (2015-16) Finance Report This report was noted.

11 Report of the NWL CCGs’ collaboration board (Clare Parker) This item was noted.

12 Board Assurance Framework (Allison Bennett) The Governing Body was asked to:

• Note the latest iteration of the Board Assurance Framework (BAF – at Annex A),which incorporates the risk owners and management team’s controls and assurances to mitigate the key risks to delivering our strategic objectives;

• Comment and amend (as necessary), with a view to approving; and • Note that the relevant Committees of the Governing Body and CWHHE Senior Team will subject

the BAF to scrutiny and further development before bringing it back to Governing Bodies in September for scrutiny and approval.

AB commented a workshop had taken place to identify the risks which prevent/delay the CCG from meeting its strategic objectives. Some of the risks will be mitigated through successful delivery of the Sustainability & Transformation Plan, but this document will contribute in identifying programmes of work to mitigate the risks identified. This item was discussed at the joint Quality and Performance Committee meeting in July (joint with the other CCGs in the CWHHE Collaborative). A paper went to CWHHE SMT with options identified re: next steps - Directors and MD's were asked for feedback by e mail. MP summarised by saying the document defined the risks well. The report was noted, including the mitigations identified in the BAF.

13 Strategy & Transformation Annual Report 2015/16 (Matt Hannant) This item was noted.

14 Q4 Ealing CCG Patient & Public Engagement Report (Zereen Rahman- Jennings) This item was noted.

15 Minutes for noting This item was noted.

Public Questions and Answers on agenda items

A member of the public asked the following questions: • In engaging and supporting healthier living, how will the gaps be closed? More practical pathways are

needed (for example investment in children centres). • Response: Our antenatal clinics are located within children centres so that that the health, education and

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prevention agendas go hand in hand

• Could clarification be provided on the skin dermatology service as this has a waiting list of 22 weeks? • Response: In terms of the dermatology service AF clarified the lead consultant is the clinical lead for the

service, and this includes being responsible for audit (as per the specification of the service) and the development of consultants in his clinics. His waiting list not directly relevant to this CCG. In terms of the waiting times, this has been recognised and the CCG will be meeting with Concordia next week to discuss waiting times, data and practices receiving delayed reports.

• AF further commented that the evaluation of the service is in progress, and therefore an informed judgement would be possible once this information was received. We will not know how effective the service is (in terms of preventing hospital outpatient attendances), and how satisfied patients are until the evaluation is complete .

• What is the current situation with staff recruitment? It was commented there is not enough staff to deliver the seven day service standard. An example was provided of the Radiology department at Northwick Park Hospital, whereby 25% of patient reports over the weekend needed revision by a consultant on Monday, due to junior staffing levels

• Response: In terms of Seven Day Service, NWL is an early implementer of this with a clear programme. The NWL report has been received by the Clinical Senate, and the standards are now in place across health and social care. MP recognised there were staffing issues at North Middlesex, and noted the limitations of this. It was further noted. CP added it was recognised there are not enough staff at the moment to deliver a seven day service which was not acceptable. The SaHF programme recognises this, hence the implementation of having fewer hospitals with specialised units so care can be delivered consistently.

• In terms of the Self-Care Strategy, this was finalised by the Self-Care Group on 22nd September 2015. The Self-Care Strategy and workplan was approved by the CCG Exec on 7th October 2015.The strategy has not been formally published to the public, but is used by commissioners and the Self-Care Group to inform the work commissioned to support the delivery of the Self-care Agenda in Ealing

James Guest raised the following points:

• Could the STP presentation discussed earlier be published on the website? • Can the full IPR report also be published on the website? Can this include the West Middx data?

CP commented the STP is still a draft document, and there is a plan of communications which is being drawn up. There will be engagement events help with further information to follow. In terms of the IPR report, this will be published on the website. Michael Geoghegan asked the following question:

• In light of the paediatric transition, what has been the transfer rate and what systems in place for self-presenting children?

• Response: It is very clear what the pathways are, and a substantial number of children will not require ambulance transfer. These patients can be taken by parents to an alternative unit or use escorted patient transport. For those children that are critically unwell, they will be moved by ambulance transfer.

• As the transition has happened recently, more information will be provided at the next Governing Body. However, MP is able to give the assurance that there have only been a small amount of ambulance transfers and LAS is responding well

• CP further commented the number of children seen so far have been less than what was modelled for, and there is an increase of staff

• In the initial weeks of the transition there were a couple of occasions when London Ambulance were called for a non-urgent transfer. It was entirely appropriate that clinicians were cautious in the first few weeks and London Ambulance Service confirmed they were able to answer all calls without detriment to

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their service in general. Since that time the doctors in the A&E and the Urgent Care Centre have worked closely together to ensure these children are directed correctly to the dedicated patient transport service. Any call for an ambulance is made directly from the A&E and not through the UCC.

A question was asked about management costs. CP responded due to the reconfiguration and implementation of several new programmes, it was recognised consultancy fees were approx. £20m in 2014/15. In 2015/16 this was brought down to £5m, and within our current budget for 2016/17 this is £1.5m. CP further commented the STP work was being implemented by staff. In final, a member asked what the CCG were doing about childhood obesity which is a national problem with 1 out of 5 children overweight. JC responded that we were working closely with children centres, and maternity services. There is a national weight programme for 10+, and parents are being followed up. SA noted there is a strong link between maternity services and midwives delivering support in children centres where Early Start are also based, and provide lifestyle advice. NWL will continue to raise awareness.

Date of Next Meeting: Wednesday, 7th September 2016, Ealing Town Hall

*All governing body members and attendees may have interests relating to their roles. These should be declared in the register of interests. While these general interests do not need to be individually declared at meetings, interests over and above these where relevant to the topic under discussion should be declared.

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1- Ealing CCG Board Assurance Framework 2015-16 CCG Objective Description of Risk Identified

Objective 1: Enabling people to take more control of their health and wellbeing

1 – If we do not successfully empower patients and change behaviours, activity will continue to grow and the system will become unsustainable.

Objective 2: Securing quality healthcare services and improved outcomes for the people we commission services for

2 – Safeguarding children: Risk that we do not comply with the Children Act and the NHSE assurance framework, due to complexities of multi-agency working, especially in the case of looked after children placed out of borough, as well as the way tier 4 child and adolescent mental health services (CAMHS) are commissioned, leading to a child being seriously harmed.

3 – Safeguarding adults: Risk that we do not sustain compliance with the Care Act and the NHSE assurance framework across all the services that we commission, leading to an adult being seriously harmed.

4 - Chelsea and Westminster: Risk that during the acquisition of West Middlesex Hospital, standards are not maintained leading to less optimal care. Particular focus on unified policies, procedures and training across the Trust including safeguarding arrangements.

5 – Imperial: Risk that the Trust does not deliver quality and performance requirements and strategic change to the require timescales, particularly in relation to:

• Accident & Emergency performance • Non-elective pathway changes • Referral to Treatment performance • Outpatients

6 - London North West NHS Trust: Risk that the Trust (incorporating Ealing Hospital) does not deliver quality and performance requirements to the required timescales, particularly in relation to:

• Cancer • Staffing levels • Trust finances

7 - West Middlesex: Risk that during the acquisition by Chelsea and Westminster, standards are not maintained leading to less optimal care. Particular focus on unified policies, procedures and training across the Trust including safeguarding arrangements, temporary leadership and financial position.

8 - Central London Community Healthcare NHS Trust: Risk that the organisation is not delivering strategic change and operational performance, with a focus on safe services during the procurements of care home services, and transformation of community nursing

9 - West London Mental Health Trust: Risk that the organisation is not well positioned to deliver strategic change and operational performance.

10 - Central & North West London Trust: Risk that the Trust does not deliver quality and performance requirements and strategic change to the required timescales, particularly in relation to:

• Staffing levels • Financial position • Service transformation and capacity to deliver change • Bed capacity – Care Quality Commission Report

11 - LCW and Care UK (111): Risk that the 111 service does not support overall plans to improve urgent and emergency care services leading to difficulties in delivering the A&E access targets.

12 - London Ambulance Service: Risk that the workforce is not in place to deliver the high quality, value for money service required, leading to delays in attending patients and risk of serious patient harm.

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13 – Hounslow and Richmond Community Healthcare: Risk that the organisation is not well positioned to deliver strategic change and operational performance.

14 – Care homes and care packages: Risk that quality and financial challenges in care providers (such as care homes, supported housing, domiciliary care or other care packages commissioned by CCGs) leads to patient harm and/or safeguarding concerns, as well as to pressure on Accident & Emergency and non-elective activity.

15 – Federations: Risk that Primary care is unable to deliver increased activity due to organisational and workforce issues (includes implications of working at scale and establishing GP federations).

Objective 3: Enhancing the organisation's culture – developing people, processes and systems to help deliver high quality commissioning

16 – Primary care co-commissioning: Risk that the structures and behaviours established to jointly commission primary care with NHS England:

• do not enable us to commission the change required to deliver our strategy • adversely affect relationships with member practices • create significant conflicts of interest • there is not the finance or capacity to deliver

leading to challenges in delivering the change to services in our plans.

17 – Organisational and Leadership Development: Risk that we cannot attract and retain excellent staff to deliver the CCG’s plans.

Objective 4: Establishing a collaborative and proactive culture with partners and the people we commission services for

18 - If we do not engage member practices, the LMC and other partners in the change programmes, we will not be able to realise the intended quality improvements.

19 - Risk that working arrangements with colleagues in local authorities (through such structures as the Health and Wellbeing Board and the Better Care Fund) are unclear, leading to lower likelihood of achieving improved outcomes.

Objective 5: Planning, developing and delivering strategies and actions that reduce inequalities and improve health outcomes

20 – Conflicts of interest: Not managing conflicts of interest adequately leaves us open to challenge and reputational damage.

21 – Strategic change (workforce) : Risk that we do not have the required resources in place across the system to deliver strategic change including:

- workforce to deliver new models of care - training and development for future workforce - organisational development programmes that challenge the status quo, communicate

the change needed, shape the culture and values needed and empower staff - finances to fund transitional change - IT systems that make good use of technology

22 – Strategic change (organisations): Risk that provider organisations are not able to support implementation of the strategic changes to acute services.

23 – Strategic change (reputation): Risk that if an adverse event happens that might not be related to strategic change, then there could be a perceived or real attribution of a link leading to negative impact on our reputation and subsequent risk to delivery.

Objective 6: Empowering staff to deliver our statutory and organisational duties

24 – Information governance: Risk that lack of awareness of how to apply information governance rules leads to a breach or lack of flexibility to support delivery of new models of care.

25 – Finance: Risk that we do not achieve our financial duties in 2015/16, as well as ensuring the longer term financial stability and security of the system, whilst remaining within the management spend budget.

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Voting Members of CCG Governing Body Name Role Arjun Dhillon Elected GP from Central Ealing Network

Carmel Cahill Lay Member

Clare Parker Accountable Officer

David Ashby Lay Member

Fionnuala O'Donnell Elected CCG Member Practice Manager

Jackie Pigott Elected GP from South Central Ealing Network

Jonathan Webster Nurse, Director of Quality and Patient Safety

Keith Edmunds Chief Finance Officer

Mohammad Alzarrad Elected GP from North Southall Network

Mohini Parmar Chair, Elected GP from North Network

Phil Portwood Lay Member

Philip Young Lay Member, Governing Body Deputy Chair

Raj Chandok Clinical Vice Chair, Elected GP from South Southall Network

Sally Armstrong Elected Local Nurse

Serena Foo Elected GP from South North Network

Shanker Vijayadeva Elected Sessional GP

Tessa Sandall Acting Managing Director

Vijay Tailor Clinical Vice Chair, Elected GP from Acton Network

Alan Hakim Secondary Care Consultant

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Governing Body Meeting Wednesday 7th September 2016 (Public)

Time: 14:45-17:30 Location: Queens Hall, Ealing Town Hall

Mr. Philip Young (PY) Lay Member leading on Audit

Ms. Fionnuala O’Donnell (FOD) Elected Practice Manager

Ms. Clare Parker (CP) Accountable Officer, CWHHE CCGs

Dr. Ian Bernstein (IB), GP Clinical lead, Ealing CCG

Ms. Tessa Sandall (TS) Acting Managing Director, Ealing CCG

Dr. Alex Fragoyannis (AF), GP Clinical lead, Ealing CCG

Mr. Jonathan Webster (JW) Director of Quality, CWHHE CCGs

Jason Antrobus (JA), Deputy Managing Director- Contracts, Ealing CCG

Ben Westmancott (BW) Director of Compliance, CWHHE CCGs

Tara-Lee Baohm (TLB), Deputy Managing Director-Service Redesign.

Mr. Keith Edmund (KM) Chief Finance Officer, CWHHE CCGs

Neha Unadkat (NU), Deputy Managing Director, Integrated and Primary Care, Ealing CCG

Dr. Vijay Tailor (VT) Elected GP from Acton Network (Vice Chair)

Dr. Jackie Chin (JC) Public Health Representative, Ealing Council

Dr. Raj Chandok (RC) Elected GP from Southall (Vice Chair)

Ms. Judith Finlay (JF) Local Authority Representative, Ealing Council

Dr. Jackie Piggott (JP) Elected GP from South Central Ealing Network

Mr. James Guest (JG), Chair of Healthwatch, Ealing

Dr. Arjun Dhillon (AD) Elected GP from Central Ealing Network

Shrey Thakran (ST), PMO Support Officer, Ealing CCG

Dr. Serena Foo (SF) Elected GP from South North Network

Ms. Naseem Isaq (NI), Strategic Support Officer, Ealing CCG

Dr Mohammad Alzarrad (MA) Elected GP from Southall

Dr. Abbas Khakoo (AK), Medical Director, The Hillingdon Hospitals NHS Foundation Trust

Dr. Shanker Vijayadeva (SV) Elected Sessional GP

Ms. Juliet Brown (JB), Programme Director, Strategy & Transformation, CWHHE CCGs

Dr. Alan Hakim (AH) Secondary Care Doctor

David Freeman (DF), Programme Director Director for Accountable Care Partnerships (ACP), CWHHE CCGs

Ms. Carmel Cahill (CC) Lay member leading on Quality

Ed Cox (EC), Associate Director for Local Services, CWHHE CCGs

Dr. David Ashby (DA) Lay Member leading on Informatics

Mr. Phil Portwood (PW) Lay member leading on Patient and Public Engagement

Ms. Sally Armstrong (SA) Elected Local Nurse

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1. Welcome, Introductions & Apologies: In attendance: Philip Young (PY- Chair), Clare Parker (CP) Tessa Sandall (TS), Vijay Tailor (VT), Jonathan Webster (JW), Ben Westmancott (BW), Jackie Pigott (JP), Serena Foo (SF), Mohammad Alzarrad (MA), Carmel Cahill (CC), Philip Portwood (PP), James Guest (JG), David Ashby (DA), Keith Edmunds (KE), Arjun Dhillon (AD), Alan Hakim (AH), Fionnuala O’ Donnell (FOD), Sally Armstrong (SA), Raj Chandok (RC), Shanker Vijayadeva (SV), Ian Bernstein (IB), Alex Fragoyannis (AF), Judith Finlay (JF), Jackie Chin (JC), Unadkat (NU), Tara-Lee Baohm (TLB), Jason Antrobus (JA), Shrey Thakran (ST-Minutes), Naseem Isaq (NI- Minutes) Guest Attendees: Abbas Khakoo (AK), Juliet Brown (JB), David Freeman (DF), Ed Cox (EC) Apologies: Dr Mohini Parmar (MP). PY welcomed everyone to the Public GB Meeting. PY welcomed James Guest and congratulated him on his appointment as Chair of Healthwatch Ealing. PY extended his congratulations to Tessa Sandall who has now been appointed to the substantive post of Managing Director Ealing CCG, and also welcomed Jason Antrobus as the Deputy Managing Director – Contracts, and Tara-Lee Baohm, Deputy Managing Director-Service Redesign, Ealing CCG.

2. Declarations of Interest * There were no additional declarations of interest noted.

3. Minutes of the Ealing CCG Governing Body- Wed, 6th July 2016 Having received feedback from Governing Body members, and members of the public, these will be revised and brought for approval at the next GB.

4. Matters Arising There were no matters arising not already covered on the agenda.

5. 5(a)Ealing CCG Chair’s Report (Tessa Sandall) TS drew members attention the following items noted in the Chair’s Report:

• Item 1- Ealing Improving Access to Psychological Therapies (IAPT) service - Ealing has been successful in meeting its Access and Recovery Targets for IAPT services in the first quarter of this year, following intensive work by the IAPT service, WLMHT and primary care.

• Item 2- Ealing Integrated Model of Care - The Care Coordination Service has now received over 400 referrals since November 2015 and has a current case load of 282 patients. This demonstrates the work being undertaken to ensure care provision is joined up.

• Item 3(b) - Joint Working with Ealing Local Authority, Self- Care - The Healthy Ealing website http://www.healthyealing.com/ is now live and hosts useful video resources on topics such as respiratory health and dementia. Many of these are available in languages other than English and there are plans in place to make more of these available.

• Item 6- Launch of the Wheelchair Service - The new Integrated Wheelchair Service went live on 1st July 2016, and is delivering well.

• Item 7- Community Education Providers Network (CEPN) – All education events so far, have been very well taken up, with most being fully booked in a matter of days. This demonstrates the need for a comprehensive programme of education events that caters to whole workforce. An example is the Care Certificate roll out for all Health Care Assistants which has been extremely well taken up with over 60 booked into the 3 cohorts.

• Item 8- Patient & Public Engagement - Ealing CCG held a number of engagement events with patients and public, including a specific bespoke event in Ealing Town Hall to discuss the Sustainability & Transformation Plans STP), held on 13th June 2016.

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5(b)Chief Officer’s Report to the Governing Body (Clare Parker) CP drew members attention the following items noted in the Chief Officer’s Report:

• Implementation Business Case (ImBC) - To support future clinical improvements in NW London, work continues on the ImBC. The business case details the capital investment needed to implement the clinical changes of Shaping a Healthier Future (SaHF). A first draft of the ImBC – the Strategic Outline Case (SOC) Part 1 was submitted to NHSE on 3rd August and is currently being assured by colleagues from NHS England and NHS Improvement. An updated version of SOC part 1 was shared with CCGs and Trusts on Friday 26th August, for review and comment. Assuming the successful completion of the assurance process, SOC part 1 will be considered for approval at a public Governing Body. Further updates will be provided at the next meeting.

• 2017/18 Contracting Round- NHS England released guidance in late July that requires us to agree two-year NHS contracts with our providers by 23rd December 2016. These contracts are for activity to be undertaken from 1st April 2017 – 31st March 2019. Contracts will be based on the deliverables outlined in our NWL London Sustainability and Transformation Plan and will, therefore, be developed as a collaboration between commissioners and providers. It has been agreed to approach this contracting round collectively as the eight CCGs of NW London as this maximises our opportunity to both align with the STP and deliver change at scale. The contracting round is expected to be completed by December 2016.

JG raised his concern about the IMB SOC1, and that Healthwatch had no sight of these documents. This means Healthwatch cannot provide any feedback or comments on the STP which the IMBC inherently relies on. CP responded with the following two comments:

1- The IMBC business case is a capital business case, detailing the capital investment needed to implement the clinical changes of Shaping a Healthier Future

2- The document cannot be currently shared as it is going through the assurance process, and is being updated and changed, and therefore we cannot risk confusing the public with several iterations of this document.

It was also noted there will not be a Public Governing Body at the end of September (28th September for Ealing CCG) to discuss the IMBC.

Items for Approval

6. Programme Initiation Document (PID) for Accountable Care Partnership (ACP) Development & Implementation (David Freeman) The Governing Body is asked to:

• Approve the Accountable Care Partnership (ACP) Programme PID and thus confirm the CCGs commitment to support ACP delivery against the timelines described.

• Approve the direction of travel for governance set out in the PID, in particular to provide a mandate for the Initial ACP Programme Board to proceed as described

• Approve the Scheme of Delegation (Authority to Act) and assurance mechanisms outlined in the governance section of both the PID Executive Summary Pack (slides 27-29) and in section 6.2 , page 32 in the main PID document

DF pointed out the coversheet had been updated and replaced in the packs, but would speak to the original document as members may not have had enough opportunity to review the revised coversheet. Across NWL we have agreed that ACPs need to be developed to play in enabling and supporting sustainable service transformation. The ambitions to create ACPs were set out by Ealing in their Commissioning Intentions last year. The Project Initiation Document (PID) sets out the approach that is being taken to develop and implement ACPs across the CWHHE CCGs. The PID reflects the size and complexity of the programme and we have sought to be thorough and comprehensive in our planning, recognising the additional requirements required with such a complex change programme. A PID is a critical part of any programme, providing a vital source of information and assurance about what the programme is aiming to achieve and how it aims to achieve it.In particular the enclosed PID seeks to answer the following key

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questions: • Does the ACP programme have clear goals and aims? • Is it clear why it is important to achieve them? • Is there a clear plan for who needs to be involved and what are their responsibilities are? • Are there plans in place that describe how and when ACPs will happen? • Are controls in place to support assurance and performance management? • Are governance, risk management and reporting structures clearly defined and fit for purpose?

GB members are being asked to approve the PID today, so that the current work being undertaken can become more detailed and moved forward. DF stressed there are still a number of issues that need to be defined and agreed, including the size and scope, the contract route, which providers will be involved and the outcomes and priorities. The PID sets out the ambition of what we want to achieve by 2018 and the scope. Slides 27-29 sets out the authority to act for this current phase of work. CC noted the slide on phased working notes the PID to be completed by June and we are now in September. Does this mean the programme is running late? DF replied the first phase was the start-up phase, and then the PID established in draft form and being asked for approval today is a more structured document defining the work that now needs to happen. CC requested clarity for understanding the early parts of the document, which refers to procuring a supplier. Will we have one provider, even if there are many ACPs? In January 2017, we will go out to procure or decide to procure a supplier, and this process needs clarifying. DF clarified when looking to procure ACPS, multiple partners will come together and create new ways of working so a single supplier will not be sought. PY commented due to the breadth of this, it cannot be resolved today, but flagged a number of questions for which answers will be required at the November Governing Body meeting:

• What the impact will be for residents of Ealing if London North West Hospitals and Hillingdon Hospital (managed by BHH) do not sign up for the ACP programme, and the issues that may arise around this

• The risk of challenges if the providers refuse to comply • Where in the process is there scope for public engagement and consultation • Whether ACPs are legal • On the governance issue, if there will be governance by majority or is their right of veto for

individual CCGs PY also said he would welcome an explanation of working examples of an ACP in England. DF commented ACPs are not in operation in England or UK, as the accountable care models are still being developed, but there are plenty of examples around the globe, in the US and Europe. There is an evidence pack to support the implementation of ACPs, which draws upon current literature, research by the Kings Fund and key colleagues, and this has shaped the programme. In terms of legality, ACPs are legal, as Commissioners, we are responsible for budgets and outcomes, and within our rights to reprocure and organise services in different ways to get better services. Formal legal advice has been sought, and the legal advice from NHSE and our legal team has been consistent. In addition, as more legal advice will be sought once the Team are able to get into the detail of ACPs, there will be built-in checkpoints, and therefore this has been built into the programme. JG noted the below:

• Thanked DF for the briefing provided. • If this entity is being delivered, there ought to be command and control, and further clarity was

needed as so much of healthcare depends on the different contracts • JG was taken by the NWL commitment, but we have an extremely large and challenging

demographic in Ealing, and a few token representatives providing input will most likely not lead

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to the most satisfactory outcome. There will need to be deep and wide scale involvement with a range of stakeholder representatives, as patients should not be left behind

JF noted the LA would like to be involved in the development of the ACPs. PY summarised the discussion, and noted that everything that was being requested could not be agreed. The Governing Body supported the direction of travel, approve the mandate so that the team have authority to progress the work, get on with work and under slide 29, part c, approved the scheme of delegation, other than the one that relates to contract approval, and asked for this to be removed and to come back in November GB meeting. The PID was not agreed as this was too complicated, and a more salient version should be provided at the November GB meeting.

7. Emergency Preparedness, Resilience and Response (EPRR) Annual Report (Jonathan Webster) The Governing Body is asked to:

• There is a statutory requirement for an EPRR Annual Report to be presented to the CCG Governing Body. The Governing Body is asked approve EPRR Annual Report 2015/16.

As part of the NHS England Assurance Process 2015/ 2016 all 8 NWL CCGs were assessed and assured by NHS England (London), and deemed compliant with the National EPRR Core Standards. JW noted CCGs are Category 2 responders under the Civil Contingencies Act 2004 – our main role is to provide ‘reasonable’ support to Category 1 responders rather than respond or manage an incident directly. Of particular note for the year 2015/ 2016, in view of the Category 2 responder status, the Memorandum of Understanding (MOU) with the City of Westminster with regard to the provision of an Emergency Response/Incident Response Room has been renewed. The City of Westminster has three Borough Emergency Control Centres across the borough and has agreed to provide space and equipment for the NWL CCG On-Call Director and Loggist in the event of a Major Incident. The following are key areas for development during the next year:

• On-call Directors must meet identified competencies and key knowledge and skills for staff as outlined in the NHS England (London) assurance process. Work will be undertaken to ensure that all staff have undertaken the appropriate training to meet this requirement. This will include completing Strategic Leadership in a Crisis Training.

• CCGs to have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response. The annual training and exercising programme 2016/17 will incorporate measures to meet the requirements in the EPRR Assurance Process.

• CCGs have an overarching framework or policy, which sets out expectations of emergency preparedness, resilience and response. In order to achieve this, the relevant policies will be reviewed in June 2016.

• 6 monthly update to each CCG QPS Committee. • Embed joint working and alignment across the 8 CCGs in NWL Inc. confirmation of one SRO for all

8 CCGs. • Table top review of on call arrangements across NWL CCGs on the 7th September 2016 led by NHS

England – NWL EPRR Lead. • Reconvene the NWL CCGs Resilience Forum commencing the 5th September 2016.

JW notified GB members that he had been appointed as the Senior Responsible Officer (SRO) for all all eight CCGs, and had been appointed on 1st Sep 2016. PY congratulated JW on his appointment. The Governing Body approved the EPRR Annual Report 2015/16.

8. NW London Local Services Transformation (Ed Cox) •Progress, Action plans and Governance (June – Dec 2016) •Planning and initiatives (Mar-June 2016)

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The Governing Body is asked to: • Approve the recommended governance structure for Local Services Transformation for NW

London; • Note progress to date within the initiatives; • Approve initiative action plans going forward; and, for completeness, • Endorse for the record the initial Local Service plan (at Annex B), which has been discussed in

detail at Governing Body seminars over recent months. EC noted he provided some background to local services, summarised as below:

• To date, Local Services Transformation has been discussed at the Executive Committee on the 8th June and then presented by Mohini Parmar at the Ealing governing body seminar on the 15th June.

• The Local Services programme brings together two previous transformation strategies (Primary Care & Whole Systems Integrated Care). Local Services brings these together to build on how we can transform community healthcare services.

• There are six key workstreams- New Models of Local Services Care, Self- Care, Wider Determinants of Health, Expanding Common Discharge, Rapid Response & Intermediate Care, Right-Care

• The Local Services Transformation Programme has been developed to focus on key out of hospital areas, in order to deliver significant aspects of the STP and support sustainable care models. The programme is working at-scale and at-pace.

• This paper follows on from the Local Services Transformation planning paper March – June 2016. Since the time of writing the planning paper, endorsement from NW London Collaboration Board was achieved in order to initiate the planning for delivery process, and begin setting up Project Delivery Groups (Working groups) for the initiatives, with membership across the sector.

• The next steps will be to continue to set up working groups for each initiative with clinical and commissioning leads from each CCG, refining the governance and completing the diagnostics phase of the programme, in conjunction with key stakeholders across the sector. Following this, detailed financial analysis can begin in earnest.

Some of the slides were discussed, as summarised below:

• Slides 6&7- shows the engagement and the governance meetings attended to date, and that this will continue as the programme moves forward

• Slide 9- discusses the initiatives with the project lifecycle, and define key gateway points • Slide 11- sets out the governance delivery structure, and how the delivery groups will work • Slide 16- shows the Scheme of Delegation provides a structure and process that enables the

programme to achieve the key STP objectives relating to Local Services without compromising delivery and confirms the sector has gained sufficient assurance.

EC noted this paper requests approval of a refined governance structure for the Local Services Transformation across the sector. BW commented this was a complex piece of work as governance is complicated, and if there are ways it can be simplified to maximise success and improve outcomes. BW noted the following:

- Too many layers in governance and decision making, and this needs to be more simpler - There needs to be more clarity about the escalation process if an issue needs resolving, and at

what Committee/Level - Are we comfortable that where we are delegating authority, are we doing this within our internal

governance rules - Where progress is being made, are we getting enough assurance back, and is a quarterly report

to GBs enough? - The Scheme of Delegation needs to be clearer as to where decisions are being made and where

issues are escalated EC noted the above points and said he would be keen to work with BW and his team.

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VT posed the question that as Local Services is a combination of whole systems and new models of care within primary care, how much engagement has there been with GP practices in primary care in developing the Local Services model. EC replied a working group has been set up, and this comprises membership from a number of different provider groups, including CCG, GPs and Federation Leads. SF asked if the Local Services team were in discussion with the ACP Team as the two areas are extremely interlinked. EC replied David Freeman sit on the new models of care working group. CC noted that on self-care (under BCF), there has been a lot of progress at local level, and how is this being incorporated so as to not duplicate work? EC replied self-care was a really good example of where local work is being drawn upon to deliver for Local Services. PY noted he was struggling to understand what the deliverables are from this programme, and requested this item be brought back to the November GB meeting. PY asked for clarification around what is it that the people of Ealing can expect at the end of the programme, how things will different, how will their care improve and how much will it cost. CP noted PY’s queries, but also that we need to progress with the Local Services Deliverables. It was noted that we have been trying to shift hospital activity for some time, and have made some progress, but this programme has been borne from the concept that we can achieve more and faster by working across NWL rather than 8 times over. The critical questions to consider are do we think the 6 focus areas are the correct areas and do we agree working across NWL as we will get better pace and delivery. CP further noted the team needs to be given the mandate to move ahead, noting more clarity is required about what the individual project groups are working on. The key point to note is that anything that is programme and project based, authority should be delegated to the team on the proviso that updates are provided to GBs. Financial spend, QIPP, clarity around deliverables and any material changes to the programme should be brought to the GB for approval, and engagement will be maintained going forward. CC asked regarding joint areas of work with Local Authorities, is there a joint funding for the next 2-3 years about how this will be taken forward? CP replied there is a joint programme of work with our Local Authority Partners, and these links will be expected to be maintained. However, it will be really important to be clear about the money being spent, savings, return on business case and any funding implication for partners are understood, and these should come back to GB for further discussion. PY concluded the discussion in saying there is broad Consensus that the 6 areas listed in the Local Services programme are the correct 6 areas, and there is a consensus that we need to start working across the 8 CCGs. The Governing Body noted the proposed governance structure and detail of travel. Whilst the principle was approved, the financial issues need to be brought back to GB and any changes to deliverables to be brought back to GB. Where appropriate, reporting needs to be consistent so that the GB is endorsing the overall way forward. Further clarity is requested, and this item to be brought back in November GB.

9. Ealing Urgent Care Centre Verita Report (Tessa Sandall) The Governing Body is asked to:

• Note the final report from the Independent Review carried out by Verita • Accept the recommendations from the review • The Governing Body is asked to note the progress against the Action Plan and that the CCG will

continue to work with Greenbrook to embed the recommendations from the review. 7 of 18

An ITV programme entitled ‘NHS Out of Hours Undercover’ was broadcast on 22nd July 2015 using covert footage obtained by an undercover reporter posing as a work experience student at the Ealing Urgent Care Centre (UCC). Following broadcast, Ealing CCG undertook an immediate clinical review which determined that there were no immediate safety concerns and commissioned Verita, an independent organisation, to carry out a review of the allegations made and the management of the UCC provider contract by Ealing CCG. The final report and recommendations have now been received. As of 26th April 2016 a consortium led by Greenbrook Healthcare (includes London North West Hospital Trust (LNWHT) and London Central and West Unscheduled Care Collaborative (LCW) took over the running of the UCC in Ealing following a procurement process. It is important to note that while the report was being finalised, the CCG were taking action to address and resolve the draft findings identified by Verita with Care UK whilst they were operating the UCC. Verita, in the course of its review, did not find any immediate safety issues but did develop a number of recommendations at the end of phase one and two of the review. Care UK, the CCG and the new provider of the service have made good progress in implementing these recommendations ahead of final publication of the review. An action plan has been developed which shows progress against the 34 recommendations made in the Verita report. The CCG worked with Care UK and a draft set of recommendations from Verita at the end of the first phase of the report. Care UK worked to address the draft recommendations and progress was made against these whilst they were still providing the service. The commentary on the action plan demonstrates this. The CCG informed Greenbrook of the independent review from Contract Award and agreement was reached that the draft recommendations would be reviewed and action taken to meet these over time. Greenbrook, and its partners, have worked on the draft recommendations and will continue to do so post publication. The action plan highlights that work is underway against all the recommendations and although progress has been made against them the actions remain open. The CCG and Greenbrook will continue to review and test recommendations have been delivered and embedded through the on-going quality and performance meeting. The CCG has started the work to look at how its Contract management can be strengthened across all Contracts it holds. The CCG will work with the other Commissioners and providers of Urgent Care Centres to set up a forum where the learning from the review can be shared and on-going best practice can be shared. TS noted that 37 people were interviewed as part of the process, and this included CCG staff, GB members and Care UK staff. VT noted one area that was highlighted in the report was the lack of robust monitoring especially clinical monitoring being carried out by the CCG as lead commissioner, and asked what actions we have taken going forward. TS noted we have strengthened our contracting arrangements, and have a clinical lead present in all contracting discussions. A recent example is both VT and RC being closely involved in the mobilisation of the UCC. This included revised assurance checkpoint to be assured the service was ready to go live, Clinical leads also worked very closely with the CCG with the paediatric transition, and the clinical presence continues. Gordon Turner, Assistant Director, Quality Improvement & Clinical Assurance attends meetings to provide clinical and quality scrutiny. Clinical Leads are also now going into services, and noted VT and RC had today visited the UCC. From a system perspective, it is intended to set up a group across NWL with all providers of UCCs to share learning and best practice. JW noted the Verita report had been shared with all CCGs across NWL, and had received briefings ahead of the Ealing GB today. JW further commented from a Care UK perspective, who have a portfolio of other services such as care home provision; assurance had been seeked to see how the learning has been transferred. The Governing Body noted the final review, accepted the recommendations from the review and noted

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the noted the progress against action plan and that the CCG will continue to work with the GB. Items for Noting

10 Update on NW London Sustainability and Transformation Plan (STP) (Juliet Brown/Clare Parker)

The Governing Body is asked to note: - The work to date in developing the Sustainability and Transformation Plan (STP) for NW London - The work to date in mobilising for the delivery of the STP

The Governing body is asked to feedback:

- On the June submission to the STP Programme Team by 9th September so that all feedback can be reviewed and incorporated where possible for the final submission of the plan in October.

JB provide GB members with progress of developing the STP, what the next steps are in terms of agreeing the STP, and how do we start working/mobilising and linking ambitions in that plan. The STP was submitted to NHSE 30th June, and met with NHSE on 14th July. The STP describes our shared ambition across health and local government to create an integrated health and care system that enables people to live well and be well. There are five areas articulated: Radically upgrading prevention and wellbeing, Eliminating unwarranted variation and improving LTC management, Achieving better outcomes and experiences for older people, Improving outcomes for children &adults with mental health needs, Ensuring we have safe, high quality sustainable acute services The Plan is being worked on in terms of the various recommendation and improvement areas to produce the final draft. This will be brought back to GBs in November for agreement. Alongside this, there is a whole process of engagement and number of events across NWL. The plan is available online, and on 20th September, there is an Ealing event around STP. This will be a dynamic plan, and show the footprint over the next 5 years, and how we work across health and social care. The STP will be a live document. The Framework enables us to pull together with our social care colleagues- and have been working towards this, and seeing better traction with this, so for example, members of social care sit next to JB who are working on the same things. In terms of delivery, the deliverables are being mobilised for each of the 5 delivery areas, and all are jointly chaired by health and local government representatives. Within the delivery areas, there are a number of projects, with a view there is an outline of these by 21st October. Alongside this, we also have advisory groups, and the first meeting is 23rd September. CP noted the delivery plan is really important, as it builds upon strategic planning, and is our delivery mechanism. It is critical this happens in 2016/17, 2017/18, and that we have the project groups working with the right governance. There is a Joint Health Care Transformation group; however a Strategic Planning Group has also been established to oversee the development of the STP with representation from each organisation, comprising approx. 40 members. A smaller group will be established with less people to drive progress. This group has no decision making powers, and will be comprised of 7-8 people from Local Government, 2 lay members, and CCG representation. Both CP and Mohini Parmar will sit on this group.BW questioned if we need to take legal advice whether we are set up in line with our governance. CP replied we are currently not close to this, and this is about building relationships and working with our LA partners- no decision making powers. The next reiteration of the STP will be in October, and this will be brought back to GBs, social care governance and Trust boards. The intention is to make the document public as soon as possible. IB noted feedback from NHSE required further detail on primary and community services and impact on hospital based activity. Will these be slotted in the plan, in light of specific public health messages that can achieve some of those objectives- how can we strengthen the document and have sight before it is

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resubmitted? JC noted the prevention group met end of August, and particular areas looked at included alcohol, physical activity, children back to school and physical health. JB further noted that in respect of delivery area 1, there had been 2 meeting of the Programme Board convened, and directors of public health had met to discuss the priorities. In regards to community and primary care, some of the workstreams are already clearly articulated, and this is to move forward and have a greater impact, including what are we aiming for and the benefits. JG noted his concern about Healthwatch ‘being outside the room’ whilst this has evolved, and that unlike some of the other CCGs (such as Hillingdon where the STP is published on the Healthwatch website) there has been very little sight of the Ealing document. In addition, the finances show a 6% drop in spend in acute provision, and only 1% increase in primary care. Whilst this may be part of SaHF, and reconfiguration of hospitals, there are many large pockets of depravation and these residents cannot access alternative hospitals by an alternative method. How is the local GP provision going to be enhanced so there is a bare minimum service, and that it will not get worse? In addition, given the issues of Ealing Hospital (IMBC capital plans) - Healthwatch are not impressed by the engagement process, closer working should be happening anyway, and there is a legal obligation to ensure residents (100k+) are aware of healthcare. CP noted that the pie charts in the paper were not a very effective way of demonstrating the data, and in fact there had been 20% increases in community spend, and 30% increase in primary care spends to mitigate the hospital pressures. It was further noted there had been an engagement event held regarding local priorities, and a further one on 13th June attended by patients and carers. CP noted the STP public engagement event on 20th Sep that Healthwatch is welcome to attend. The Governing Body noted the STP work completed and mobilisation, and welcome further updates.

11 Update on the transition of children’s services which took place 30th June 2016 (Abbas Khakoo/ Juliet Brown) The Governing Body is asked to: • Note the report The key elements covered in the paper are: • Clinical benefits • Activity in Ealing • Rapid Access Clinic • Next steps The Governing Body members are asked to note that the new models of care have been implemented safely. They are also asked to acknowledge that the next steps for the CCG are to assess the Rapid Access Clinic pilot, ensure the monthly monitoring of the community nursing service and review the Patient Transport Service to ensure capacity matches demand. AK noted he was the SRO for the paediatric transition from Ealing Hospital. The transition of Children’s inpatient and A&E service from Ealing Hospital occurred safely on 30th June 2016. The paediatric transition has brought a number of improvements across North West London to the quality of care children receive, the capacity and capabilities of the workforce and the environment in which children receive their care. NWL is the only area in the whole country that has met fully the London quality standards by having a consultant paediatrician on site. JB noted it was right to reflect this has been a safe and well managed transition. What has been demonstrated is leadership from all our providers, whether that was LAS, Trusts, and the joint working. In terms of the activity assumptions, despite all sites in London reporting unseasonably busy demand all units managed the transition effectively with no serious incidents reported. The activity seen at all sites has been within the capacity modelling. A&E performance at the major acute sites across NW London has remained the same or improved since the transition. Robust operational management arrangements

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were in place throughout the transition across the sector and continue to provide oversight and support as the new model of care embeds. The Urgent Care Centre (UCC) at Ealing Hospital has continued to see children although they have stopped being treated in A&E. Activity information indicates that families and children are continuing to access the UCC appropriately with activity levels mirroring those seen in 2015/2016. JB talked through the table on page 4, and noted the patient flows were in line with what was modelled, and less than anticipated. Weekly monitoring continues, and data is discussed at the CCG Quality & Safety Committee. The Patient Transport Service has seen significantly lower activity than has been commissioned, the service was commissioned to manage an average of 12 patients per day, but have seen an average of 3 per week. The numbers of transfers by London Ambulance Service were higher than expected in the first week immediately after transition with 7 transfers in total, as clinicians were being understandably cautious. Partners have continued to work together to ensure the appropriate transport arrangements. The number of London Ambulance Service transfers has subsequently dropped to a lower level than anticipated, with an average of 1 per week. The Rapid Access Clinic (RAC) continues to work well, and is projected to see approximately 500 children per year given current activity levels. The service ensures early specialist paediatric input to children where appropriate; provides GPs with an alternative to referring children to Accident and Emergency; and improves children’s experience of care by ensuring that they receive treatment in a setting more appropriate to their condition. There will be a review of the service prior to the contract end date in November 2016. IB commented he had used the RAC service, and had been very impressed as this had avoided an unnecessary A&E attendance for the child in question. In terms of next steps, the remaining priorities for Ealing CCG are to:

• Assess the Rapid Access Clinic pilot • Ensure monthly monitoring of the community nursing service • Review the Patient Transport Service to ensure capacity matches demand

JG asked the following questions as noted below:

• JG asked for clarification in writing about the 4 hour wait for self-presenters. He has been advised that when a child comes to Ealing Hospital and seen arrives at the UCC, the 4 hour clock starts. This is then stopped if it deemed a child needs to be transferred elsewhere, and then starts again when the child is received at the receiving unit. This potentially exceed the waiting time of 4 hours. JB noted that once a child leaves the UCC to go to a receiving unit, they should be seen immediately, and are directly transferred to the PAU. Clinical standards dictate a child should be triaged within 15 minutes, and seen by a doctor. The waiting times are being audited.

1- If a parent decides to transfer the child themselves, who will provide support on this transfer, and how is this monitored and checked that the child has arrived at the receiving unit. JB replied that all referrals are noted and if a child doesn’t arrive, a phone call is made back to Ealing to say that the child did not attend. There is also a liaison safeguarding team to pick this up and to make sure vulnerable children do not slip out of the net. In addition it is the clinician who has the decision as to whether it is safe for a parent to transfer the child.

• The London Clinical Senate has observed NWL focuses on a definition of 0-16 as a child, whereas the national perception is 0-18. The two year gap cohorts need to be thought about, especially regarding safeguarding issues. JB noted there is a 16-18 Paediatric Delivery Board, looking at this age cohort. There are a number of services (i.e. CAMHS) that focus on this age group, and more issues are being looked at and taken forward.

RC asked if the data was available around inter hospital transfer time. CP noted yes we do have these figures, but the patient numbers are very small. A review will be conducted after the winter period.

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VT asked about any untoward incidences relating to the transition and care of children. AK noted one of the key areas of the transition was that if a sick child presents at Ealing, they should be stabilised before being transferred. UCC staff have received training around paediatric life support and safeguarding, and this had been well received. AK further noted the weekly performance monitoring and monthly quality metrics which are reviewed by the Programme Delivery board, which can pick up trends and/or any specific issues very quickly. VT mentioned he and RC had conducted a site visit to the UCC, and one of the areas looked at was the paediatric pathway and the triage element of children entering the UCC, in particular the paediatric observation bay and the 24 hour paediatric nurse who monitors children whilst they are being monitored, transferred or discharged. Both VT and RC noted the relationship between the UCC and London North West is working well to ensure any sick child gets a rapid early assessment and transfer to one of the units across NWL. The Governing Body noted the report and that the new models of care have been implemented safely.

12 Finance, Quality and Performance Reports: (Tessa Sandall/Keith Edmunds) a. Ealing CCG Integrated Performance & Quality Report- Month 3 b. Finance Report – Month 4 c. SaHF Finance Report- Month 4

Ealing CCG Integrated Performance & Quality Report- Month 3 West London Mental Health NHS Trust (WLMHT):

- Care Quality Commission (CQC) Improvement Action Plan. As of June 2016, the Trust-wide actions numbered 84, of which 6 were overdue and had not yet passed through the Process stage. The Trust remains confident that they are on track to achieve all the required process and practice changes outlined within the timescale set.

- Planned pre-CQC re-inspection peer reviews have taken place, and commissioners and stakeholders have participated in the reviews. A full programme has been produced and representatives (both clinical and non-clinical) from lead and associate commissioners and other stakeholders will join further visits during September 2016.

- Serious Incident (SI) reporting. The Trust reported that there continued to be a number of overdue SIs as of mid-July 2016. The Trust has now met with Ealing CCG, CWHHE and NHS England to discuss the outstanding SI reports and agree the best way of supporting timely submission of overdue SIs. The Trust has set a trajectory of the end of October 2016 to clear the backlog of overdue SIs, and is confident that they are on track to meet this target.

- Mortality Review Update. Since the 1st April 2016 the Trust Nursing and Medical directors have met on a weekly basis to review mortality data / reports. The aim of the meeting is to ensure that the correct level of review is undertaken. An exploratory meeting has been held between stakeholders to identify areas where a North West London (NWL) system-wide response can be successfully introduced to improving the investigation and learning processes, where the deceased was under the care of a number of providers at the time of death.

- Performance. The main areas identified for further monitoring and review were: Care Plan Approach Reviews, Delayed Transfer of Care, Re-admission Rates, Under 18 Admission and Children and Adolescent Mental Health Services out of Hours provision.

London North West Healthcare NHS Trust (LNWHT):

- CQC Inspection. The Trust provided their draft CQC Improvement Action Plans along with their Board Report Summary to the August LNWHT CQG. It was agreed that the Trust would present a rolling monthly review by area (Quality and Safety, Workforce, Patient Experience, Governance and Risk, Pathways, and Estates) at each CQG to allow an acceptable level of monitoring by commissioners. In addition, a full summary overview of progress and evidence will be presented at each quarterly Joint CQG.

- Critical Care Capacity. The Northwick Park Hospital (NWP) site has challenges providing sufficient

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critical care beds required to meet the activity they receive. Extensive work is being undertaken by Brent Harrow and Hillingdon CCGs to further understand requirement, capacity and cost. The additional requirement may mean a substantial investment is required from both the hospital and the commissioning CCGs. Brent CCG, as Lead Commissioner, has written to LNWHT expressing the concerns held by commissioners around the Trust’s capacity plans.

- Performance. The main acute areas identified for further review were: Referral to Treatment, Re-admissions, 2 Week and 62-day Waits – Cancer Urgent Referrals and Diagnostics. The main community areas identified in M03 for further review were: Children’s Physiotherapy, Falls, MSK Waiting Times, Diabetes Did Not Attend Rates and Safeguarding Level 4 training.

- RTT performance. NHS England (NHSE) has written to both LNWHT and Imperial College Healthcare NHS Trust (ICHT) in order to fully understand their internal Demand and Capacity plans, and they have also written to Ealing CCG to understand complimentary management schemes to reduce activity that would support the trusts’ activity and continued reduction. The providers and CCG have submitted plans to NHSE outlining all schemes with timeframes for delivery and monetary values.

- NHSE and Hammersmith & Fulham CCG are closely monitoring ICHT due to a decline in achievement and progress, specifically around cancer and RTT

- ICHT have a trajectory to meet their RTT target by March 2017. They have taken robust steps, including having a RTT turnaround team in place, which is directly reporting to the Trust Board in order to rectify the situation.

Emergency Care:

- Ealing Urgent Care Centre (UCC). Previous electronic medical record difficulties and under-staffing challenges have now been addressed, and performance is improving. This has led to a low (0.6%) 4-hour breach rate and improving triage times for both adults and children. 98.2% of adults were triaged within 20 minutes, and 96.3% of children were triaged within 15 minutes. The triage times will continue to be closely monitored.

Finance Report – Month 4 KE noted this report shows the financial position of the CCG as at M4. The position overall continues to deteriorate and the Governing Body should be aware that there is now a real risk that the current control total will not be delivered. The CCG is £1.5m off plan year to date, and although the full year forecast is to deliver the planned control total of £7.6m, the CCG reported a net risk to this position of £2m as at M4. The Governing Body should also note the deterioration to the Underlying Position, which is significantly behind plan at a £6.4m surplus (forecast). The main cause of the year to date over-spend is over-performance in the acute sector (£5.6m), including QIPP under-delivery. This is being offset by use of non-recurrent items including reserves. This over-spend largely relates to LNWHT (£2.4m), Imperial (£1m), THH (£0.7m) and Chelsea & Westminster FT (£0.8m). In addition, pressures are reflected due to the national change to funded nursing care contributions, and due to number of care homes in Ealing. IB queried if the acute overspend was related to the 18 week catch up programmes., and this seemed a heroic aspiration, as if the current £5m overspend is based on 3 months data, this could potentially be £20m by the end of the 4th quarter. KE noted he did not have this information to hand, and in any case, it is difficult to identify this with any real certainty. KE provided an example that for Imperial, the overspend of £4.5m was due to RTT catch up. For North West London, some of the overspend is related to QIPP. KE noted that in terms of the methodology, we have 3 months of data, and use our understanding as well as previous experience and seasonality to extrapolate YTD and full year forecast. At the moment, there is a high level of judgement due to time of year. Considerable efforts are being made to turn this position around. A Recovery Team has been set up to address the QIPP gap and potential opportunities to cover this; actions are in place to drive delivery of

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existing QIPP schemes. The CCG is working closely with contract management teams and provider trusts on this. SaHF Finance Report- Month 4 This finance report covers the SaHF teams running costs and the various elements of provider support committed to. There is an overall overspend across the work streams for M4 of (£2.0m) but overall the S&T year-end position is breakeven. This is in line with expectations and is due to budget phasing and does not, at this stage, reflect an underlying problem. JG mentioned that for the various performance reports it would be really helpful where an activity is delivered on more than one site, there are separate reports. An example is the maternity dashboard. TS replied that although she could recognise the value of site specific information (and that maternity data is currently aggregated under ChelWest), she could not commit to this further at this time. CP further noted thee separate data reporting exists for maternity and paediatric services due to the data being captured explicitly for the transition of both services; however it was usual to not have site specific information. Where this information exists, it could be reported, but cannot commit to this for all services. The Governing Body noted the reports.

13 North West London Financial Strategy 2016/17 (Keith Edmunds) The Governing Body is asked to:

• Note the NWL Financial Strategy 2016/17 • Ratify the decision from the Governing Body Seminar to approve the NWL Financial Strategy

2016/17 The North West London (NWL) Financial Strategy is in its 3rd year. The principles for the2016/17 financial period were discussed and agreed at the NWL Collaboration board and discussed at Ealing CCG’s Finance & Performance Committee. This paper was debated at some length at the Governing Body Seminar on the 29th June 2016, and the proposals for 2016/17 were agreed with the following caveats:

• The costs for Urgent Care Centre paediatric transfers (additional staffing and transport) associated with the paediatric transition will need to come out of the pooled budget arrangements

• There needs to be a clearer process and governance for 2017/18. It would be important to articulate a process for how we take the planning process forward for 2017/18, starting in September 2016

• While no decision has yet been taken on 2017/18, it is unclear as to why all CCGs would not contribute equally in 2017/18 to the NWL financial strategy ‘Part A’

These issues are now being addressed with CWHHE and BHH partners. The caveats were noted, especially caveat A, and concern for the UCC paediatric transfers (additional staffing and transport) costs. CP noted this was some of the reason for some of the financial pressure and overspend on budget. The Governing Body ratified the decision to agree the Financial Strategy for 2016/17, subject to the points noted above and look forward to 2017/18 planning process.

14 Board Assurance Framework (Ben Westmancott) The Governing Body is asked to:

• Note the latest iteration of the Board Assurance Framework (BAF v4.1 - top levelRAG ratings at Annex A, and BAF 4.1- CWHHE Board Assurance Framework v4. atAnnex B),

• Provide any comments regarding further assurances or clarification needed & on how this information is best presented to enable effective discussion to the CWHHE Governance team,

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with a view to approving; and • Note that the relevant Committees of the Governing Body and CWHHE Senior Team will subject

the BAF to scrutiny and further development before bringing it back to Governing Bodies for scrutiny and approval.

Since the last iteration of the BAF that was presented to the Governing Body in June the CWHHE governance team has worked with risk owners to ensure that the narrative that is included for each risk provides a more robust reflection of the current position and plans for the management of the risks going forward. The BAF summary page now outlines clearly any variation in risk score in line with the agreed risk appetite and brings this to attention using the RAG system, for which a key can be found on the first page of Annex A. The BAF sets out the key risks to achieving our strategic objectives, the controls in place to reduce the risk and the assurances we have to let us know if the controls are having the desired effect. Mitigating actions and current performance information are also summarised for each risk. The document is reviewed throughout the year by senior management and Governing Body Committees to enable Governing Bodies ‘scrutiny at each public meeting (i.e. every two months). Proposed changes from this rolling review process are captured and presented at each stage. The Governing Body has been central to the development and consideration (at seminars) of this BAF and this is the first formal version for 2016/17 presented for approval. It is, therefore and in places, still a work in progress. Further work is planned between now and September to develop not only the BAF entry but also the lines of assurance that underpin it – the CWHHE Senior Team and Governing Body Committees will be integral to that process. BW noted that since the last iteration, the process has changed in terms of how the BAF is updated. A notable change is using the RAG (Red, Amber, Green) rating, the green signifying where a risk has reduced, amber where it has stayed the same, and red signifying where a risk has increased. The BAF has been through a rigorous critiquing process and BW noted he felt assured this was moving in the right direction to highlight risks to the CCG’s strategic objectives. BW drew members’ attention to risk 9 ‘Data & Information’, (rating increased from 16 to 20) as this is a risk that has increased. This is mainly due to the procurement of the BI informatics service. It was noted there is a risk register that sits underneath this document and BW posed the question as to how we scrutinise the risks so that all risks are managed appropriately. CP and IB queried risk 5 ‘ Primary Care’ as this has dropped from a rating of 20 to 12, as they were not sure if this risk had reduced as much as the figures noted. PY asked this risk be reviewed, and considering the regulations have not reduced, it should be reviewed and clarified as to if it has changed at all. Risk 3 ‘Long Term Conditions Prevention & Management’ was also noted, as this had reduced from a rating of 16 to 12, and it was suggested this could be looked at Quality & Safety Committees. KE noted it may also be worth considering scoring financial risks in the not too distant future, and this is something the Committees could possibly action. BW noted he was asking the GB today to note this latest iteration of the BAF (4.1), would appreciate any further comments from GB members as this is a continual process, and the risks noted today would be looked at by the Governance Team and GB members. The Governing Body noted the latest iteration of the BAF report, with a view that the above risks would be reviewed.

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15 Conflict of Interest- Revised Statutory Guidance (Ben Westmancott) The Governing Body is asked to:

• Note the Audit Committees will oversee the development of a revised policy that combines CWHHE and BHH’s current policies and creates a unified one for NWL CCGs;

• subject to the Audit Committees’ approval, a small reference group will be created to support the policy development;

• CWHHE’s Audit Committees will be considering the proposals in the briefing at their meeting on 15th September; and

• The final version of the policy, along with a detailed update and implementation plan, will be tabled at the November Governing Body meeting for approval.

On 28th June 2016 NHS England published Managing Conflicts of Interest: Revised Statutory Guidance for CCGs. It was first published in a draft form for discussion on 31st March 2016.The guidance supersedes Managing Conflicts of Interest: Statutory Guidance for CCGs which was published in December 2014. CWHHE’s current Conflicts of Interest Policy was revised late last year and approved in January 2016. BW noted there is an increased requirement for CCGs to be aware of conflicts of interest, as this is statutory guidance and therefore regard needs to be given to this document. BW drew members attention to page 1, which notes the key revised requirements/ changes for declarations of interest (and gifts etc.) are, potentially administratively onerous across the eight CCGs; declarations have to be captured from ALL staff (whether temporary, permanent or otherwise) and any constituent GP practice partners / directors that have a link to decision-making in the CCGs. It also notes the requirement to have a minimum of three Lay Members, but Ealing already has four. There is a training package being planned, and will form part of the mandatory training. This will be published in November 2016, to be completed by January 2017. There is a proposal to set up a working group across all the 8 CCGs in NWL, which would also help with any COI requirements of the STP and other common plans. BW asked the GB to note this paper. PY expressed concern about how much extra work this will involve. It was felt that there is a real risk of becoming a major piece of work and being clear about the benefits that will arise. BW noted one of the objectives of the working group will be to make sure the COI is managed effectively. The Governing Body noted the report, with concerns raised as above.

16 Report of the NWL CCGs’ collaboration board (Clare Parker) The Governing Body is asked to:

• Note the report for information. This summary update details the business that has been dealt with in recent meetings of the Collaboration Board, which took place in July. There were no formal meetings in August. Other areas of collaboration continue to be developed in a consultative manner before being taken to governing bodies for local decisions and /or adjustments. The Governing Body noted the report.

17 BCF 16/17 Planning Update (Neha Unadakat) The Governing Body is asked to:

• Note the approval by NHSE of Ealing’s BCF plan for 2016/17 • Note the BCF Q1 2016/17 Report due for submission to NHSE on 9th September • Note the improvements made in the Delayed Transfer of Care (DTOC) metrics in Q1 2016/17 • Note the progress on the WLA Discharge Plan

PY thanked the CCG and the Local Authority for the amount of work and effort that goes into working

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together on this and was very impressed. The BCF 16/17 Planning Update was noted.

18 Minutes for noting- ECCG and CWHHE Committees The minutes for the ECCG and CWHHE Committees were all noted.

Public Questions and Answers on agenda items Q&A 1: More and more abbreviations are being produced, with over 20 in one document. To ordinary members of the public, we have found it almost impossible to understand what the organisation is doing. CP apologised for the complex papers, and noted the point made. Q&A 2: Regarding ACPS, and GPs being at the hub of all activity, there are insufficient GPs appointed by NHSE, with more retiring, and may also not want to cooperate with a ‘super organisation’ with the new contracts. CP noted a lot of workforce modelling has happened around GP numbers, ad what we have is the correct amount. It was recognised that some GPs will be retiring, and the organisation is working with HENWL to resolve some of these issues. What the maternity and paediatric transition have shown is that if we can make NWL an attractive place to work, staff will remain. In terms of the contracts, this will need to be worked through as we are asking GMS/ PMS practices to come into the ACP which can involve financial reward, but also risk. In addition, there is a lot of activity outside GP contracts, and how that will link into the ACP will need to be considered. Q&A 3: If no children are going to A&E, and diverted to the UCC, and then admitted to different hospitals, do they spend more time as inpatients in the receiving hospitals? What impact does the transfer have on the duration of stay? AK/JB responded that all children will be assessed at the UCC before going into A&E if necessary. There were a lot of communication messages sent out to advise parents to not take children to the UCC if the child needed to go to A&E, and the numbers are relatively small. In addition, many children do not attend Ealing Hospital anyway, but other hospital site; hence there is no anticipation that children going to other hospitals will get a longer stay. In addition, we do not expect to see any difference in stay for those children who present at Ealing Hospital and are then transferred to a receiving site. A review will be conducted, and this will include length of stay, as hospitals are monitoring this. In addition, for those children with chronic care conditions, the consultants are well aware of these children and their health needs. Q&A 4: What advice do the UCC give to parents once their child needs to be transferred to another unit? Do they recommend the child is not taken in the parent’s car? JB responded that we have performance indicator that the child needs to be picked up within hour, and we have 2 ambulances on site so that the transfer happens quickly. In terms of self-transfer, this is not about a specific set of criteria. The UCC staff are used to working with children, and in which conditions it is safe if parent wishes to take their child to another unit. The clinician will have a discussion with the child and adult so the decision is made in an informed way. There have been training sessions with UCC, and if a clinician believes the child too ill to be transferred or at risk of detoriating, they will advise patient transport- and we have different levels of transport. In final, GPs make these decisions in their own practices – so these are not new ways of working for people in the UCC, and could confirm children not sitting around, and will be transferred quickly. Q&A 5: The Chief Officers Report mentions that a ‘Joint Health and Care Transformation Group will have representation from across local government and health, including commissioners, providers and patient representatives.’ Who is going to be included as a patient representative? CP noted one of the two is the Harrow Healthwatch Chair, and the second may be a Lay Member. This will be confirmed in the next Chief Officer’s report. Q&A 6: In regards to the West London Mental Health Trust (WLMHT) peer review visit, will the relevant healthwatch organisation be involved in the pre- CQC visit? It was noted that WLMHT would be asked, and

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were sure Healthwatch would be welcomed. It was noted the CQC has emailed Healthwatch regarding the forthcoming inspection, and Healthwatch will be participating with inspectors alongside representatives from Healthwatch Hounslow and Central London. As part of preparation for any CQC visit, they contact all stakeholders across the system for feedback.

Date of Next Meeting: Wednesday, 2nd November 2016 15:00-17:30, Venue TBC

*All governing body members and attendees may have interests relating to their roles. These should be declared in the register of interests. While these general interests do not need to be individually declared at meetings, interests over and above these where relevant to the topic under discussion should be declared.

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