REPORT TO THE MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY

Date of Meeting: 24th March 2016 Agenda No: 9.1 Attachment: 17

Title of Document: Approved Minutes of Committees of the CCG Governing Body

Rationale: To update the CCG Governing Body on the areas of responsibility covered by the following Committees.

Committee

Date of Meeting

Finance Committee 14.12.15; 20.01.16

Clinical Quality Committee 18.12.15; 15.01.16

Audit and Governance Committee 17.09.15

Clinical Transformation Committee 07.01.16

South West London Primary Care – Joint Committee 12.11.15; 04.02.16

Recommendation: That the Governing Body is asked to note the attached Minutes.

Date, author details: As per details on each attachment.

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Merton Clinical Commissioning Group

Finance Committee

Minutes of the meeting held on Monday, 14th December 2015

Chair: Peter Derrick

Members Cynthia Cardozo (CC) MCCG Chief Finance Officer Peter Derrick (PD) Lay Member (Chair) Adam Doyle (AD) Chief Officer Dr Tim Hodgson (TH) GP Governing Body Member Dr Andrew Murray (AM) Clinical Chair Attendees Faiza Waheed (FW) Deputy Chief Finance Officer Caroline Farrar (CF) Deputy Director of Commissioning and Planning

(attending as deputy for David Freeman) Tony Foote (TF) Minute taker

1. Welcome, introductions and apologies Peter Derrick (PD) welcomed all present to the meeting.

Apologies were received from Dr Carrie Chill and David Freeman.

2 Declarations of Interest The Register was approved as a full and accurate record of declared interests. No additional interests were declared in relation to items on the agenda.

3 For Approval

3.1 To approve the notes of the meeting held on 19th November 2015 The minutes were approved as an accurate record of the meeting.

3.2 Action Log and matters arising There were no actions for review this month.

3.3 Finance Report Format Review Faiza Waheed (FW) presented this item and asked the Committee members for any suggested changes they would like to see to the Report’s format.

After some discussion, during which the development of the report was noted and that it now clearly addressed all the relevant areas, it was agreed that the current format did not require any further changes at present.

3.4 CCG Financial Position – update on recovery plan CC reminded the Committee that the CCG began to see a deteriorating financial position in July 2015. The paper now presented, similar to one considered at the September meeting, sets out the financial challenges and risks to the financial position and identifies a number of actions, either already taken or awaiting implementation, to mitigate these. Specifically:

All GP practices asked to review their top 5 practice speciality referrals.

Clinical decision support tool piloted from November with 5 practices

Database showing Practices the cost of using the Nelson vs. acute

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providers.

Agree dashboard to regularly share first and follow up outpatient activity and cost data at CCG, Locality and GP practice level.

Share local directory of services information with all GPs

Agree pathway redesign priorities with GP locality groups

Visit high referring practices for guidance and support to reduce inappropriate referrals and identify suitable local alternatives.

New acute clinical directors to challenge SECSU (SUS) data quality improvement plans.

The Committee then discussed the issue of low levels of activity at the Nelson; specifically, that St George’s has been issued with a contract Activity Query Notice calling for the Trust to work together with the CCG to address the lower than expected direct referrals to the Nelson Health Centre. CC stated that the CCG is currently negotiating the value of the conditional minimum income guarantee (cMIG) to be paid in 2015/16. CC added that she was confident the CCG will be able to claw back a proportion of the cMIG. PD asked about the size of the claw back and AD said that whilst £700k was notionally possible it was more likely to be £400k for the first six months. However, AD added, it was a complex situation: that on certain lines St George’s had delivered but, on others, not and there was also the significant issue of the member practices not referring to the Nelson. In light of this latter issue, during quarter 4 and especially during the month of January, the CCG would be making a “huge” effort to emphasise the shorter waiting times for patients referred to the Nelson. Highlighting the right to “patient’s choice” TH said that, whilst he had heard only positive feedback from patients who had attended the Nelson, the main problem was persuading patients to change their habits and make that initial appointment.

The Committee strongly supported the planned efforts of the CCG, and AD explained that if all the member practices referred two patients per week (for the duration of quarter 4 to the Nelson rather than St George’s, the CCG would be able to make savings of circa £0.3m. If referrals were made to community services the savings could increase by a further £0.7m giving a total of £1m saving. PD stated that this put the onus very much on GPs and asked how they could best be supported. TH stressed the importance of GPs being made very aware of importance of their role and then kept up to date on the situation.

PD requested that another report with more activity information be presented to the January meeting and that it required “continual and intense monitoring” by the Committee.

The Finance Committee agreed to note the actions taken to date.

FW/CF

In a change to the running order of the agenda, the Committee next considered the Finance Report Month 8.

3.5 Finance Report M8 FW provided a summary of the highlights of the report:

For the eight months to 30th November 2015 the CCG is reporting a year to date and full year surplus performance to target.

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Acute commissioning is reporting a year to date over spend of £2.4m and a full year forecast over spend of £3.1m. Including: - St George’s: year to date over spend of £1.9m and full year over

spend of £2.9m. - Epsom and St Helier’s: year to date over spend of £0.3m and full

year over spend of £0.5m - Kingston: year to date over spend of £0.4m and full year over

spend of £0.8m FW explained that an in month year to date adverse variance of £0.5m was reported for St George’s owing to high levels of discharged critical care activity, the discharged activity was 20% higher in Month 7 compared to months 1 to 6. It was also reported that the over spends at St George’s and Epsom and St Helier were in the same areas as reported in previous months, namely, outpatients and critical care. The full year over spend at Kingston Hospital related to outpatients and maternity.

Non acute commissioning is reporting a full year forecast under spend of £1.3m. The two main areas where an adverse variance is reported compared to previous month are mental health placements and continuing healthcare. Four additional placements have been seen in mental health in November and continuing healthcare is showing an upward trend in spend.

Prescribing is reporting a full year forecast over spend of £0.5m.

QIPP: year to date over performance of £0.3m and a full year achievement of target is forecast.

FW explained that the CCG had assumed return of their contribution from the SWL risk pool in order to report the surplus position to target for Month 8.

PD commented that the financial situation was “very tight”.

The Finance Committee reviewed and noted the report.

3.5 Primary Care Infrastructure Application

In January 2015, NHS England invited GP Practices to submit investment bids for 2015/16 from the Primary Care Transformation Fund (PCTF), a four year (£1bn) investment programme to help Practices make improvements in premises and technology. However, in November 2015, NHSE wrote to CCGs telling them to fund the revenue consequences of the successful bids.

The Finance Committee is now asked to consider supporting bids in 2015/16 and subsequent years for General Practice to the PCTF that are below average conditions and therefore have a CQC impact.

AM was unhappy that NHSE had decided, in year, to pass on the responsibility for the revenue consequences; something for which the CCG was not currently funded. Accordingly, AD continued, the CCG should robustly push back to NHSE on the grounds that due diligence had not been followed, that it did not hold a budget for this and had not been involved in the initial decision making. AM said the CCG would need to give sound

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reasons to the practice for not supporting the bid. NHSE have asked CCGs to approve Primary Care bids for 2016/17 before submission AD stated that these will have to be considered in light of the Estates Strategy that is being developed and also asked for a clear process to be put in place for the submission of 2016/17 bids.

This approach was agreed by the Finance Committee

CC/FW

4 Standing Items

4.2 QIPP Report M8 CC explained that the QIPP report was similar to previous months. AD agreed and that the one area in which major work remained to be done was planned care.

There were no further questions or comments from the Committee.

The Finance Committee reviewed and noted the QIPP report.

4.3 Business Cases There are no business cases this month

4.4 Tender Waivers (above £100k) There are no tender waivers this month.

5 For Note

5.1 Approved Minutes There were no approved minutes to be reported this month.

6 Any Other Business

6.1 There was no further business for discussion.

7 Date of Next Meeting

20th January 2016, 3.30 – 4.30pm, Rm. 5.1m, 120 The Broadway

The Minutes are an accurate record of the meeting held on 14th December 2015 …………………………………………………………. Peter Derrick – Chair, MCCG Finance Committee ……………………………………. Date:

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Merton Clinical Commissioning Group

Clinical Quality Committee

Minutes from the meeting held on 18 December 2015

Meeting Room 6.3, 120 the Broadway, Wimbledon SW19 1RH

Members Clare Gummett (CG) Lay Member Patient and Public Involvement (Chair) Dr Tim Hodgson (TH) GP Locality Lead – West Merton Lynn Street (LS) Director of Quality & Performance In attendance Angela O’Connor (AO’C) Head of Health Systems Performance & Business Caroline Farrar (CF) Asst. Director of Commissioning & Planning James Holden (JH) Commissioning and Service Improvement Manager Yasmin Mahmood (YM) Equality & Diversity Manager (SECSU) Aniko Szucs (AS) Commissioning Manager Annette Bunka (AB) Senior Commissioning Manager Debbie Lindon-Taylor (D L-T) Associate Director, Sutton & Merton Community

Services Jane Topping (JT) Integrated Locality Team and Night Nursing Manager

Raynes Park (SMCS) Emma Harvey (EH) Student Nurse (SMCS) Yvonne Hylton (YH) Committee Secretary, SECSU (Minute taker) Apologies Sally Thomson (ST) Independent Nurse Member Dr Karen Worthington (KW) Locality Lead East Merton David Freeman (DF) Director of Commissioning & Planning David Parry (DP) Head of Quality Anjan Ghosh (AG) Public Health Consultant, London Borough of Merton

Welcome and Introductions

1 The Chair welcomed all in attendance to the meeting and agreed that whilst the meeting was not quorate it could go ahead with the minutes circulated to the absent Members prior to the next meeting to approve the decisions made at the meeting today. Declarations of Interest

The Register of Declared Interests was agreed as an accurate record and no further interests were declared in relation to items on the agenda.

Notes, action log and matters arising

2 Draft minutes of the meeting held on 13 November 2015 The minutes were approved without amendment. Matters arising SGH response letter

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Following discussion with SGH at the November meeting a letter was sent to the Trust to ask for assurance of:-

- The internal systems in place to ensure that all patients who breach targets are clinically safe;

- Assessment and review process of patients to understand physical and mental health issues for patients waiting longer than 18 weeks or breach cancer targets;

- Assurance that patient choice is fully informed and patients understand the impact of their choice

- The Trust’s response to workforce issues to meet demand Following full review and discussion the Committee felt that whilst the letter provided some assurance more information was required to evidence that internal systems and assessment processes were working; patient choice was informed and information on how the Trust is pro-actively promoting itself and advertising vacancies to address the workforce issues. In response to discussion LS agreed to ensure that the areas of concern raised by the Committee were added to the CQRG agenda for response by the Trust and brought back to the MCQC to provide the assurance required. Providers Monitoring Protocol The amended monitoring protocol for planned visits to Providers was reviewed and approved by the MCQC. LS advised that a visit to ESH by CG, ST and DP will take place the week commencing 4th January supported by the template. DP to co-ordinate the visit and the outcome of the visit will be reported back to the MCQC.

LS

DP

3 Assurance Reporting

3.1 Director of Quality and Performance Update The DoQ&P provided an update on the key areas of focus of the Quality Directorate over the last month. Expert Patient Programme LS advised that following the department of the PPE Lead, the team is being re-modelled and will comprise of two EPP Co-ordinators. A video of one patient’s experience of the EPP service was played to the meeting. The Committee felt that the video was very good but commented on the presentation style which LS agreed to feedback the comments to the Communications Team. London Ambulance Service CQC inspection of LAS report was brought to the meeting for information. LS said that the key highlight of the report is the need for a co-ordinated joined up SWL approach to address the on-going capacity and achievement of response time issues.

LS

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SGH Risk Summit A risk summit is to take place on 22 December focussed on Health Education and Training. The summit will comprise of NHSE, MCCG, WCCG and SGH and aims to reach a shared understanding and approach to resolving the issues. TH asked how SGH’s response will be monitored. LS advised that an action plan will be developed and monitored through the CQRG.

3.2 Performance and Quality Report The Quality and Performance Report presents performance of the key performance indicators demonstrating progress towards the five domains outlined in Everyone Counts. The month 6 report includes exception reports on A&E, diagnostics, RTT, Cancer 2week wait, cancer 62 days, HCAI, LAS, DTOC, Weekend Discharges, Reduction in Antibiotic prescribing, Electronic prescribing, and IAPT. The format of the report has changed to highlight areas to note by exception and concern across the health economy. At month 6 Merton CCG did not achieve A&E 4 hour waits, Referral to Treatment Incomplete, Diagnostics, and Cancer 2week wait. IAPT is below plan YTD. London Ambulance services continue to breach response time standards due to on-going staff capacity constraints. Comments HCAIs gaps in assurance (Page 12) CG asked if this was addressed in the new Community Services Contract. AO’C the gap relates primarily to GP Practices seeing patients with an existing CDI who are unknown to Community Services. It is anticipated that delegated commissioning will go some way to addressing the gap as GPs are supported to undertake RCAs and share learning. IAPT (Page 19) Temporary staff are in place to make up the shortfall seen between October and December due in part to a high number of staff choosing to leave the service. Recruitment to substantive posts will take place during December and January. Dementia diagnosis significantly increased in August, September and October (Page 18). This is due to lower dementia prevalence than originally calculated and changes to data collation which has resulted in increases for all CCGs. CQUIN Q1 and Q2 was achieved 100% by ESH. KHFT has partial achievement for the dementia CQUIN for Q1 and Q2 due to the Trust not

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having staffing in place to support the programme. The Trust is confident that this will be rectified for Q3 and Q4. All other national and local CQUINs were achieved. Dr Foster Mortality data was noted by the meeting. In future it was agreed that only data ‘refreshed’ annually would be included in the report. Patient Safety Thermometer for Acute and Community Services was received and noted. Friends and Family Test. SGH is reporting below the England average in the percentage of patients recommending A&E. Nine Complaints were reported in November 2015. Four of which were CCG and Five were non-CCG. Serious Incident reporting for Acute and Community Services was reported. Comments CG asked that data for Community Services and SWLSTG be included in the Quality & Performance Report. AO’C confirmed that Community Services performance data will be reported next month. SWLSTG performance reporting is in train. Performance meetings are taking place and discussion at CQRG to agree the annual work plan. LS advised that she has been invited to 18.1attend the Internal SWLSTG Safeguarding Assurance meeting which will provide an additional level of quality monitoring to the MCQC. Recommendation The MCQC is asked to approve the Month 6 report. Approved

3.3 Equality & Diversity The Chair welcomed Yasmin Mahmood, Equality & Diversity Lead to the meeting. The annual public sector equality report highlights progress made in respect of Equality and Diversity responsibilities between January and December 2015. Under the Equality Act 2010, public bodies must publish information by January 31 of each year showing how they are meeting the general equality duty. A summary of positive examples of strategy, policy and practice in Merton CCG were reported including the development of the new vision and strategy and organisational development plan which included equality and diversity action needs, gathering of information to inform the EDS improvement plans for 2015-16, ensuring Equality & Diversity was considered as part of the re-

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procurement of Community Services process and delivery of statutory and mandatory face to face training to staff and Governing Body Members. Workforce Race Equality Standards The Workforce Race Equality Standard is a benchmarking tool introduced by NHS England to assess the progress of race equality within NHS organisations annually. This report is based on the evidence gathered against the nine WRES metrics. It is not mandatory for Merton CCG to publish its WRES report as it currently employs less than 150 employees. The WRES report is an internal assurance report. YM advised that bullying and harassment has been highlighted as an area for action. An action plan will be developed at the next EDS meeting to align with the CCG organisational plans and EDS report to be published in March 2016. Recommendation The MCQC is asked to approve the reports prior to presentation to the Governing Body in January 2016. Approved

3.4 Low Vision Services The Chair welcomed Aniko Szucs, CCG Commissioning Manager to the meeting. The report provided a summary of the low vision community services currently commissioned by the CCG; specifically the Merton Low Vision Service and the Diabetic Eye Screening Programme (DESP) Surveillance Service. Low Vision Service The current Low Vision Service offered at Merton Vision has the potential to offer many people with visual impairment the chance to have increasing independence with the many benefits this brings. It is a valuable service for a vulnerable group of people and although the service utilisation has improved since 2014/15 the service is still relatively underused.to date in 2015/16 six domiciliary visits have been invoiced and 46 patients received assessments in clinic settings. CG commented on the low attendance given that it was a free service which would be very beneficial to patients. AS responded that the service is not well known and work is taking place to raise awareness and promote the service. TH said that as GPs are able to refer directly, it is important they are aware of the service and the process for referring patients. Diabetic Eye Screening Programme (DESP) Merton CCG agreed to fund a pilot Surveillance Clinic service with SMCS, the previous provider of the DESP, which commenced February 2015. The CCG has now agreed to continue this Surveillance Clinic Pilot with Medical Imaging

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(who will be providing the DESP from November onwards until the end of March 2016.) The service reports that 230 Merton CCG patients were seen by the service between 05/03/2015 and 09/10/2015, representing a saving of £38.5K for this time period. Recommendation The MCQC is asked to note the report. Noted

3.5 Sexual Health and Termination of Pregnancy Service The report provides a summary of the current Termination of Pregnancy, HIV Respite and IVF services for adults directly commissioned by NHS Merton CCG. Services for NHS terminations for Merton patients are accessible through a Central Booking Service (CBS) hosted by BPAS. This service is available 7 days per week, 364 days per year. In 14/15 there was a slightly higher demand for termination services compared to the previous year. Demand continues to be closely monitored and there are peaks and troughs in women accessing the services, and the type of procedures carried out. NHS Merton CCG is currently assessing the feasibility of taking part in the potential PAN London AQP procurement of Termination of Pregnancy (ToP) Services which will be taking place in 2016/17 with a view to start providing the ToP services via AQP contracts from 1st April 2017. Throughout 2014/15 there was no HIV respite activity, therefore MCCG terminated the contract with Mildmay but agreed with Mildmay that Merton patients can still be referred for HIV respite to their facility and invoicing will happen on the individual basis for these patients. In response to a question on referring ToP to the ECI Framework, AS said that this is being investigated. Recommendation The MCQC is asked to note the report. Noted

3.6 Continuing HealthCare Update The Chair welcomed James Holden to present the report highlights to the meeting. The update in November reported on continued challenges with the operational delivery of the CHC service and that the matter has been escalated to the SWL Director of Commissioners (DoCs) Network. A chief officer and lead director working group has now been established with representation from all CCGs that commission CHC and quality, commissioning and finance director representation.

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Senior management from SECSU have since attended the November DoC/CFO meeting to outline how they believe the service is delivering a number of functions that are not within scope of the current service level agreement. They therefore have requested that either CCGs provide large amount of additional investment or they will instruct the service from the 1 December to deliver what they regard as the core ‘in scope’ services. The SECSU have begun to withdraw those functions that they believe are above and beyond what they are commissioned to deliver. This has been undertaken without any notice, planning or co-ordination with CCGs or the wider system. For example CHC Nurse Assessors no longer form part of the MDT meeting at St George’s Hospital and St Helier Hospital. SECSU are no longer delivering the weekly report about the number of reviews undertaken and progress against the trajectory. They also have not provided key performance indicators for October. We now have even less assurance about the quality of the service in comparison to last month. It is clear that all SWL CCGs are now considering their position regarding the SECSU continuing to deliver the CHC service. All CCGs recognise the need to work together in identifying next steps so not to further destabilise the service. LS agreed to share the Patient Experience Report with the MCQC. Recommendation The MCQC is asked to note the monthly update report. Noted

LS

3.7 Holistic Assessment and Rapid Investigation Service (HARI) 6 month report The HARI service commissioned from the Sutton and Merton Community Services commenced at the Nelson Health Centre in April 2015. The numbers of referrals appear to be steady, with scope for capacity to expand to enable urgent referrals to be received in a controlled and managed way. All except one practice have referred into the service. There is a data quality issue relating to discharges which needs to be improved upon The CCG is meeting with both SMCS and St George’s, following the unsuccessful recruitment to the interface geriatrician post to work in HARI. A positive meeting was held with St George’s, where it was agreed to assign the same consultant for the three sessions they have committed to deliver in the HARI service and provide access to the consultant team over the phone at other times. A further meeting has taken place to build on this and scope out the urgent pathway. Weekly updates have been requested regarding outstanding actions to enable the urgent pathway to be available. The community navigator post has been recruited to and will start in post in January and that together with the pharmacist that has recently started should help to increase the number of referrals to the service and the range of services available.

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In response to a question on the reason that Sutton CCG were referring to the service, AB said that this will be rectified as part of the disaggregation process and a change will be seen from 1 April 2016. LS commented on patient experience and CG asked that this be shared with the Committee. AB agreed to liaise with SMCS and ensure that the patient experience report is circulated. Recommendation The MCQC is asked to note the update report. Noted

AB

3.8 Quality Risk Register LS introduced the quality risk register advising that no risks have been added to the register. Risk 1012 has been escalated to the Governing Body Assurance Framework, following the removal of risk 1009 and it’s amalgamation to cover safeguarding children. Risk 1009 was previously on the Assurance Framework, meaning risk 1012 is an alternate rather than a new area of risk being added. The committee are asked to review and discuss risk 1002 in detail for this months’ deep dive, which relates to Transforming Care. The committee should consider whether the risk accurately describes the current position of the CCG and whether they are assured by the controls and actions in place to mitigate the risk. CG asked that given the number of apologies that the deep dive is deferred to the next Quality Risk Register review to ensure a wider audience.

4 Key Focus – Sutton and Merton Community Services Pressure Ulcers

4.1 Commissioner perspective of performance CF said that Pressure Ulcers data collection and improvement was a CQUIN for SMCS in 2014/15. The CQUIN was achieved and good progress made both in quality and reporting which is continuing into 2015/16. CF said that reporting to the CQRG is good as the number of new lessons learned through RCAs is exhausted and the focus is now on ensuring that the learning is implemented and embedded into business as usual.

4.2 SMCS Pressure Ulcer Presentation and Patient Story The Chair welcomed Debbie Lindon-Taylor (Clinical Director), Jane Topping (Integrated Locality Lead, Raynes Park) and Emma Harvey (Student Nurse) to the meeting. DL-T presented and talked through the report. Pressure Ulcers was a CQUIN in 2014/15 and whilst it is not a CQUIN this year the work has continued. To raise awareness to staff, SMCS took part in the National Pressure Ulcer

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awareness day and posters of PU categorisation was distributed to all staff. A breakdown of attributable and non-attributable to SMCS was discussed. Pressure Ulcers reporting is good, in particular in Raynes Park where high numbers are reported. This reflects both good reporting and the number of Residential and Nursing Homes in that area. The Safety Thermometer provides a ‘point in time’ and is helpful in identifying trends. DL-T said that Christmas is a ‘peak time’ for increased PU reporting due partly to non-residents of Merton who visit families and friends over the Christmas period and also patients discharged from hospital to spend the holiday at home. All Category 3 and 4 Pressure Ulcers are declared as a Serious Incident and DL-T described for process for investigating a Serious Incident, including RCA and panel meetings led by the Tissue Viability Nurse. The panel aims to determine whether the Pressure Ulcer was avoidable or not and where it is avoidable an action plan is put in place and reported to the Trust Integrated Risk Management Board, chaired by the Chief Nurse. Learning from the investigation is shared with all Teams and cascaded to all staff. DL-T then handed over the Jane Topping, Raynes Park Integrated Locality Team Manager to tell the patient story of a patient in the community with a Category 4 pressure ulcer. The patient had been visited by Community Services for a number of years and there had been no change in circumstances to indicate why a pressure ulcer had developed. When the reason did become clear it was explained to the patient and suggestions to relieve the pressure ulcer were made but declined by the patient. As the patient had full capacity his decision was respected. Jane advised that a number of meetings were held with the patient, family and professionals but no progress was made. The nurses were becoming increasingly concerned as the pressure ulcer was not healing and the patient was discussed at the monthly integrated locality team meeting. The meeting is attended by Podiatrists, Tissues Viability Nurses and other professionals and the case was discussed in detail. At the meeting a Podiatrist suggested a bone x-ray. The result of the x-ray showed that the patient was suffering from a serious bone infection caused by the pressure ulcer and this was explained to the patient who then agreed to the suggestions made and his pressure ulcer is now almost healed. Jane said that the story is just one example of the benefits of integrated locality leading where nurses have access to other health professionals, training and knowledge sharing opportunities. The Chair thanked Debbie and Jane for an informative and interesting presentation.

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5 For Information Only

5.1 MCQC Workplan The Workplan was noted by the Committee.

5.2 Medicines Management Committee Minutes The approved minutes of the MMC meeting were noted by the Committee. LS asked for clarification of the Joint Chair arrangements following the departure of Mary Clarke. Subsequent to the meeting Sedina Agama (Chief Pharmacist) advised that LS was appointed Joint Chair of the MMC and had Chaired the meeting in November.

5.3 Date of Next Meeting Friday 15th January 2016 – 12.00 to 2.30pm.

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Merton Clinical Commissioning Group

Clinical Quality Committee

Minutes from the meeting held on 15 January 2016

Meeting Room 6.3, 120 the Broadway, Wimbledon SW19 1RH

Members Clare Gummett (CG) Lay Member Patient and Public Involvement (Chair) Dr Tim Hodgson (TH) GP Locality Lead – West Merton Lynn Street (LS) Director of Quality & Performance Sally Thomson (ST) Independent Nurse Member Dr Karen Worthington (KW) Locality Lead East Merton Sue Hillyard (SH) Interim Director of Commissioning & Planning In attendance Angela O’Connor (AO’C) Head of Health Systems Performance & Business Hannah Pearson (HP) Commissioning and Service Improvement Manager Margaret Benbow (MB) Complaints Manager, SECSU Yvonne Hylton (YH) Committee Secretary, SECSU (Minute taker) Apologies David Parry (DP) Head of Quality James Holden (JH) Commissioning and Service Improvement Manager

Welcome and Introductions

1 The Chair welcomed everyone to the meeting. Declarations of Interest

The Register of Declared Interests was agreed as an accurate record and no further interests were declared in relation to items on the agenda.

Notes, action log and matters arising

2 Draft minutes of the meeting held on 18 December 2015 The minutes were approved as an accurate record of the meeting. As the December meeting was not quorate the Chair asked KW to review and confirm approval of the actions. Action Log The action log was reviewed and updated and will be re-circulated to the meeting.

KW

3. MCQC Terms of Reference (revised) The ToR has been updated to reflect comments and changes requested by the Committee at its meeting in November 2015, in particular that all Statutory Reports must be formally approved by the CCG Governing Body. The Chair has reviewed and approved the ToR.

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Recommendation The Committee is asked to approve the ToR for submission to the next meeting of the Governing Body on 26.1.15 Approved

4 Assurance Reporting

4.1 Director of Quality and Performance Update

1. SGH Risk Summit LS provided a verbal update. At the end of last year Health Education England (South London) raised concerns about the training environment in two specialities with SGH, the outcome of which was the withdrawal of trainees from these areas. NHSE called a Risk Summit which took place in December. Attendees included NHSE, MCCG, WCCG, CQC, Monitor and the Trust. All parties were given the opportunity to put forward their views and this was followed by a discussion, in the absence of the Trust, to consider the outcomes and next steps. The summit identified a number of areas for improvement and the Trust is working to produce an action plan to resolve these. Actions from the summit will be monitored through an extended CQRG and the DoQ&P meets regularly with the Chief Nurse providing an extra level of assurance to MCCG.

2. Annual Statutory Obligations Report 2014/15 Formal feedback on the PPI deep dive and the annual report has been received from NHSE with an assessment of Outstanding. Congratulations on behalf of the MCQC were extended to the team.

3. Serious Case Review The SCR involving a Merton Child and her mother is on-going. A meeting to review the agency reports will take place at the end of January 2016 followed by a round-table meeting.

4.2 Quality & Performance Report AO’C presented the report. The Quality and Performance Report presents progress towards the five domains outlined in Everyone Counts. The month 7 report includes exception reports on A&E, RTT, Cancer 2 week wait, Cancer 62 days, Healthcare Acquired Infections (HCAI), London Ambulance Service (LAS), Delayed Transfer of Care (DTOC), Weekend Discharges, Reduction in Antibiotic prescribing, Electronic prescribing, Improved Access to Psychological Treatment (IAPT) and Community

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Services. Key Points A&E The CCG did not meet the A&E target in October with performance at 92.8% due to performance at SGH (91.9%) due to bed pressures and specialist waits and ESH (94.2%) due to bed capacity issues. A two day event is to take place at St. George’s in the week commencing 18 January 2016 which will focus on escalating discharges for medically fit patients. RTT 18 weeks The CCG failed to meet the RTT Incomplete standard with the performance at 91.2% primarily due to performance at SGH. A key focus at the Trust has been the validation of the waiting list and getting a clean PTL which is expected to be available in reporting in November. Cancer 2 week waits The CCG failed to meet the standard with performance at 87.4% in Month 7. This was due to 53 breaches out of 422 patient pathways. CG asked for a breakdown of the number of days breached to be included in reporting. Following the contract query notice issued by WCCG a remedial action plan has been agreed with the focus on improving capacity, pathway management and includes planning for 7 day working. HCAI Four new cases of C.Difficile Infection were reported at ESH in November. The exact site/s is not known, however further details will be available in the Quarterly Infection Control report. Delayed Transfers of Care (DTOC) Figures show that DTOC has increased by 173 days in October compared to August primarily due to increases in Non Acute Trusts, for example Community Services. AO’C advised a new software package is being developed to improve the quality data reporting at SGH will identify if there are internal or external provider delays. IAPT ST provided a verbal update on the service. A trajectory for 1800 new contacts was agreed with the new Provider, however issues over higher number of patients transferring to the caseload and staff exiting the service have resulted in the new Provider advising that

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the 1800 will not be achieved. Discussions on a recovery plan to meet the trajectory have taken place and a plan to deliver the 1800 is expected today (15.1.16). Action SH agreed to bring the recovery plan to the next meeting of the MCQC in February. Comments SH gave assurance that the quality of care is very good and there have been significant increases in the number of recoveries reported. KW referred to the new Complex service in terms of the reported increase in recovery. LS said that the service is now seeing the correct cohort of patients. CG expressed concern for people unable to access the service and ST asked if there was any evidence of harms for people waiting. SH said that the recovery plan will include a trajectory to clear the waiting list and LS advised that there was no evidence that harms had increased. Community Services The key focus for MCCG is now on mobilisation of the new service provider from 1 April 2016. The existing contract will continue to be monitored through the Contract Monitoring Meeting and CQRG until 31 March. Comments CG asked about how the CCG are ensuring that there is no impact on the quality of patient care during the change to the new Provider and how this is being managed. LS said some staff will transfer over and the new Provider TUPE list has now been received. The risk is known and has been discussed with the Provider and mitigating actions have been agreed. Serious Incidents SGH reported 3 SIs in December involving MCCG residents. There are some issues regarding reporting at the Trust and is being robustly managed. . SWL&STG reported 5 SIs in December involving MCCG patients. As the new host commissioner of SWLSTG an updated MCCG model for managing SIs will go live on 20 January mirroring the Acute Provider model. The service will be managed by the SECSU with subject matter experts to provide an extra level of assurance.

SH

5

In addition all Serious Incidents over the past year are being reviewed. Comments KW raised concern about the Home Treatment Team and highlighted a risk where it is reported that the team were unable to gain access. KW gave an example of a patient who chose not to be at home at the time of a visit which is a risk given the vulnerability of this patient group. LS said that where there are issues they should be reported as a quality alert to provide visibility of the issue. SH commented that the number of SIs reported appears to be very low and asked if under reporting is suspected. LS advised that the reporting culture needs to be improved and this is being progressed. Southern Health NHS Foundation Trust As background the report was commissioned by NHS England (South) following the death of a patient in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. Both Southern Health NHS Foundation Trust and the clinical commissioning groups that commission services from them have accepted the recommendations. A copy of the report and recommendations and SWLSTG response was included in reporting to provide assurance to the MCQC and to note the monitoring arrangements. Primary Care Report to be presented to the MCQC in February. Recommendation The Committee is asked to approve the report. The Committee noted the report and requested that for future reports more detail is included to give assurance that appropriate actions have been taken and to provide an overview of the up to date position.

Complaints and PALS 6 month report The Chair welcomed Margaret Benbow (MB) to the meeting. MB presented the report covering the period 1 April to 30 September 2015. The report details the number of Complaints and PALS enquiries relating to MCCG and in addition provides performance and quality assurance data of the service provided on behalf of MCCG by the SECSU. During the reporting period 29 complaints and 48 PALS enquiries were received on behalf of MCCG. The average time taken to acknowledge a Complaint was 1 day which is within the 3 day target. The statutory requirement for Complaints and PALS responses has been removed but the SECSU still work to the 25 day standard or the time which has been agreed with the Complainant.

6

ST asked for the reason that some responses take longer than 25 days. MB said that the vast majority relate to Continuing Healthcare which are complex and in some cases the response received does not have the level of information required to effectively respond to the Complaint. To address this Complaints Management training for the CHC team took place in September and MB is working closely them to improve the responses received. Regularly weekly meetings are held with MCCG Executive Assistant to discuss Complaints and any outstanding issues. Non-CCG complaints which are received are re-directed to the appropriate service. The Complaints team are looking to move to a new database, SharePoint, which is already used for FOIs to improve the processing and monitoring of complaints. Feedback from patients is very difficult to receive with very low numbers responding to the questionnaire. LS advised that she is working with the Complaints Team to provide assurance to the MCQC that the lessons learned are happening. The Chair asked that an example to demonstrate the Patient’s experience of the Complaints process is included in reports. Recommendation The Committee is asked to approve the report. Approved The Chair thanked MB who then left the meeting

4.4 Carers Support Contracts Update January 2016 The Chair welcomed Hannah Pearson to the meeting. This paper provides national and local contextual information, sets out key information about the carers support services that are provided by organisations with which the CCG holds contracts, and outlines relevant next steps. Two engagement events took place during September 2015. The outputs of these events will inform the development of the new joint Carers Strategy for Merton. Contracts for Carers Support Services in Merton are held with the following organisations:-

- Carers Support Merton - The Alzheimer’s Society - St Raphael’s Hospice – Hospice @ Home

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- Marie Curie Night Sitting Service The report provided an overview of each service and developments during 2015 and developments for 2016. Next Steps Development of the new joint Carers Strategy for Merton with LBM and involving voluntary sector organisations. Reviewing people’s experience of the Memory Clinics and working with GP Practices to provide training Hospice for Home to be promoted to widen the benefit from the additional investment including communication to Practices and linking with discharge Marie Curie Night Sitting service to be reviewed to widen the access including dedicated staff in Merton to ensure that those most in need have access to the service. Comments CG welcomed the progress made and asked how the gaps will be covered. HP said that the new Community Services Provider gave the CCG an opportunity to review how services are provided as will discussions with the Local Authority as Contracts expire being mindful of the cuts in adult social care. As the joint Carers Strategy for Merton is developed the aim will be that services both health and social care, whilst separate contracts, will be linked. Recommendation The Committee is asked to note the update. Noted The Chair thanked HP for presenting to the meeting. HP left the meeting.

4.5 Continuing Healthcare Complaints Report and CHC Update

The MCQC in December requested sight of the Complaints and Patient Experience report provided by the SECSU. A number of patients have raised complaints or concerns about the ease and quality of communication from the CHC service with difficulty getting through on the phone and no responses to emails as well as not enough notice when assessments and reviews are scheduled. There have also been a number of complaints which demonstrate that the service has failed to deliver all functions within the national framework some of which have been highlighted by patients and carers and include delays in

8

receiving outcome of assessment; next of kin having to remind about due reviews and assessments and copies of documentation following review not received. LS said that the CHC patient experience report reflected themes identified within the complaints reports. CHC monthly update LS provided a verbal update in respect of CHC performance. The CCG has significant concerns with the service and is continuing to monitor with the CHC team and explore options for future delivery of a safe and effective service.

4.6 Workforce and Learning LS provided an update on workforce and learning in MCCG which is led by the Chief Officer. An OD plan and working group with HR is in place. Following feedback from the staff survey, Staff Well-being had been added to the Staff working group agenda to help make staff feel supported.

5 Key Focus – Epsom & St Helier Trust

5.1 This item has been deferred to April 2016.

6 For Information Only

6.1 MCQC Workplan The Workplan was noted by the Committee. MCQC Meeting April 2016 to March 2017 will take place on the 1st Wednesday of the month from 10am to 12.30pm.

6.2 Date of Next Meeting Friday 12th February 2016. Key Focus: Dementia Patient Experience

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Merton Clinical Commissioning Group Audit and Governance Committee

Notes of the meeting held on Thursday 17th September 2015 Present:- Members

PD Peter Derrick MCCG Lay Member (Chair) CG Clare Gummett MCCG Lay Member, Patient & Public Involvement SP Stephen Powis MCCG Secondary Care Consultant

In attendance AM Dr Andrew Murray CCG Chair AD Adam Doyle Chief Officer CC Cynthia Cardozo Chief Finance Officer FW Faiza Waheed Head of Finance and Business SE Sue Exton External Auditor – Grant Thornton NA Nick Atkinson Internal Auditor – Baker Tilly CG Gemma Higginson Counter Fraud – Baker Tilly

MC-S Martin Campbell-Smith

Head of Accounting, Reporting & Control - SECSU

BV Ben Vinter Partner Business Advisory Services (Governance) – SECSU

YH Yvonne Hylton Note Taker – SECSU

1. Introduction and Apologies Peter Derrick (PD) welcomed all to the meeting.

Apologies were received from Sally Thomson, MCCG Independent Nurse Member.

2. Declaration of Interest The Register to be updated to reflect the change to the Independence Nurse Member. No additional declarations were received in relation to items on the agenda.

3. Notes of the meeting held on 24th June 2015 The notes were approved without amendment.

4. Action Log of the meeting held on 24th June 2015 The action log was reviewed and updated and will be brought to the next meeting.

5. For Approval

5.1 Financial Control Environment Self-Assessment NHS England is in the process of rolling out a financial resilience toolkit and as part of this process all CCGs were required to complete a financial control environment self-assessment checklist. The final completed checklist was submitted on the 1st September 2015

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and reviewed by the Chief Officer before submission. The draft checklist was also reviewed by the Chair of the Audit and Governance Committee and the Head of internal audit before submission on the 24th August 2015. The Governing Body is required to sign off the checklist on the 24th September 2015. PD invited the Auditors to comment on the self-assessment.

- NA said that feedback from Internal Audit was received prior to submission and that the self-assessment was sensible.

- SA said that the range of scores was correct and reflected the

feedback from the External Auditors.

CC commented that the CCG compared well with other CCGs in South West London. Recommendation The Audit & Governance Committee is asked to approve the Financial Control Environment Assessment. Approved

5.2 Report on Internal Controls (Type II) – Information Technology 2014/15 and South East London CSU response Martin Campbell-Smith (MC-S) introduced the Internal Control Report for Information Technology and the SECSU response to the identified exceptions. MC-S explained that NHSE has engaged a reporting accountant to prepare a report on internal controls to provide assurance in a cost effective manner for the NHS through reducing the duplication which would likely arise from multiple CCG internal and external auditors separately assessing CSU controls. MC-S advised that issues specific to NHSE will be investigated and exceptions will be reported to the NHSE Audit Committee. Comments PD asked if there were any concerns in the control environment for action by MCCG. MC-S said that there was an action plan for the control weaknesses identified. CC commented that it was challenging for the CCG as a service user to be assured as reports were not received despite a number of requests. MC-S said that he would feed this back to SECSU and come back to CC with a response. NA asked about the process for follow-ups as another report is not due. Following a short discussion and noting that the service is commissioned by NHSE and reports go to the NHSE Audit Committee, NA said that the

MC-S

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CSU could consider sharing their feedback to NHSE with CCGs to give CCGs assurance. MC-S said he would take this suggestion back to the CSU. Recommendation Approved

6. For Review

6.1 Reviewing MCCG Constitution Following the election of a new Clinical Chair and appointment of a new Chief Officer it is an ideal opportunity to review this key governance document which establishes the CCG’s governance framework and its relationship with its member practices. The Constitution has been reviewed in partnership with the South East Commissioning Support Unit (SECSU), in particular with the SECSU Corporate Affairs Team. AD outlined the key changes as described in the report in particular the creation of the Clinical Transformation Board. Next Steps Once documentation has been finalised, discussions will take place with the Membership and, following this, assuming their support, a request for ratification by the Governing Body in October. NHSE have requested sight of the changes in October in expectation of submission of the final documentation for approval in November. All changes to CCG Constitutions must be submitted to NHS England for final approval as one of the conditions governing every CCGs relationship with NHSE. The governance structure and the governance changes will be progressed with agreement to use Audit and Governance Committee Chairs action to progress the changes in the constitution. Comments In response to a question from PD on support for the Clinical Transformation Board, AD provided an overview advising that the Board will be Chaired by a GP Governing Body Member, and membership will comprise of the CCG Clinical Chair, GPs, Locality Leads, Practice Managers, Independent Nurse Member, Director of Quality, Director of Commissioning and Planning and Clinical Directors. In addition, the CCG’s key partners such as London Borough of Merton will attend the Board. CG welcomed the inclusion of the Patient Engagement Group as a vital part of the CCG Structure. Recommendation

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The Audit and Governance Committee agreed the recommendation to note the update that governance changes will be progressed with agreement to use Audit and Governance Committee Chairs action to progress the way changes in the constitution. The Committee agreed the recommendation

7. For Note

7.1 Tender Waiver for Intermediate Care Beds The Audit and Governance Committee were asked to note a single tender with Central and Cecil Housing Trust for the procurement of Intermediate Care Beds up to a total cost of £1,062.922.

This is a short term arrangement as the commissioning of intermediate care beds has been included within the community services re-procurement. Transition arrangements will be in place from 1st April 2016 to 30th September 2016 by which time the successful community provider will secure a service on behalf of the CCG.

The Finance Committee approved the tender waiver at its meeting on 16th July 2015.

Comments CG asked if the views of service users and carers had been taken into account. CC agreed to come back to CG outside the meeting.

Recommendation The Audit and Governance Committee was asked to note the tender waiver.

Noted

CC

8. Auditors’ Report

8.1 External Audit Report – Grant Thornton SE introduced the Annual Audit Letter for the year end 31.3.15 which includes:-

- Auditing of 2014/15 accounts - Assessing the CCG’s arrangements for securing economy,

efficiency and effectiveness in its use of resources - The result of these was an ‘unqualified opinion’

The letter is intended to communicate key messages to the CCG and external stakeholders, including members of the public.

Recommendation

The Audit and Governance Committee was asked to note the Annual External Audit Letter. Noted

8.2 Internal Audit Report – Baker Tilley

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NA introduced this report advising that two audits from the 15/16 Audit plan have been finalised and the remaining audit from 14/15.

- Safeguarding Adults at Risk - Board Assurance Framework - Governing Body Assurance Framework Assurance Map

All outstanding audit actions due for implementation have been completed apart from one low priority recommendation. Control weaknesses identified during the Safeguarding Adults review and the associated action plan to resolve the weaknesses have been identified. Comments AD referred to Adult Safeguarding actions and said that the Head of Quality would be in post from 1 October to progress the action plan. BV questioned the use of ‘amber’ in the GB Assurance Map. NA explained that this represented where further assurance was required. AD said that the assurance map reflected the proposed CCG governance arrangements. Recommendation The Audit and Governance Committee is asked to note the update. Noted

8.3 Counter Fraud Report – Baker Tilly GH introduced this item. The Counter Fraud Team has completed a review of the National Fraud Initiative 2014/15. 64 matches have been reviewed, for which no further investigation is considered necessary. Self-Review Tool (SRT) was completed and returned to NHS Protect on behalf of the CCG. The return was submitted within the deadline agreed with NHS Protect. The SRT process forms part of NHS Protect’s Quality Assurance programme. The SRT is a RAG-rated document and the overall rating for Merton was GREEN. The Counter Fraud Team, in consultation with the CFO, has selected Medicines Management as the focus for a Local Proactive Exercise during the next quarter. The LCFS has begun to draft a scope for this exercise, which will involve a detailed review of the current procedures in place with respect to Medicines Management. The LCFS is seeking an opportunity to meet with key personnel in order to ensure the scope is reflective of the CCGs’ concerns within this area. Following review of the Fraud Risk Profile changes the Committee requested narrative to explain the changes in future reports. Recommendation

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The Audit and Governance Committee is asked to note the update Noted

9 Any Other Business

9.1 Date of the next meeting The Committee agreed that the next meeting on 10th December will start at 3.30pm to 4.30pm. An email will be sent to all Members to confirm the change. The change is to facilitate a meeting of the Audit and Governance Chair with the Auditors.

Agreed as an accurate account of the meeting held on the 17th September 2015

Mr Peter Derrick – Chairman

Date:

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Merton Clinical Commissioning Group Clinical Transformation Committee

Thursday, 7th January 2016

Chair: Dr Carrie Chill Present: CC Cynthia Cardozo Chief Finance Officer CChi Dr Carrie Chill GP Governing Body Member AD Adam Doyle Chief Officer VG Dr Vasa Gnanapragasm Clinical Lead for Community Services TH Dr Tim Hodgson GP Governing Body Member/Locality Lead for West Merton

(left meeting at 3.50pm) AM Dr Andrew Murray Clinical Chair AO Dr Andrew Otley Clinical Lead for Mental Health SP Prof. Stephen Powis Secondary Care Member KW Dr Karen Worthington Locality Lead for East Merton Participating Observers DF David Freeman Director of Commissioning & Planning SH Sue Hillyard Director of Commissioning Operations

Officer in Attendance TF Tony Foote Note Taker, South East CSU

ACTION

1. Welcome and Apologies for Absence

Dr Carrie Chill (CChi) welcomed all to the inaugural meeting of the Clinical Transformation Committee (CTC) and noted apologies had been received from Sally Thomson and Lynn Street.

2. Declarations of Interest

Two amendments to the Register were requested: Dr Vasa Gnanapragasm (VG) requested the entry “Wife job shares as Medicines Optimisation Lead in Sutton CCG” be amended to “Wife is Medicines Optimisation Lead in Sutton CCG” Dr Andrew Otley requested the following additions to his entry: “GP Trainer”; “Merton Representative on Local Medical Committee”.

TF

3. For Approval

3.1 Clinical Transformation Committee – Terms of Reference

Prior to the consideration of the Terms of Reference, CChi asked Adam Doyle (AD) to provide a brief overview of the CTC’s aims and responsibilities. AD explained that one of the guiding principles of the CCG was to have

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ACTION

demonstrable clinical leadership and that to facilitate clinical transformation new structures and processes were required. Accordingly, the CTC had been established as the fifth formal supporting committee of the Governing Body and would consider all future clinical transformational changes – such as the tendering process for new services - and, where appropriate, recommending these for approval by the Governing Body. The CTC would also have responsibility for shaping the overall transformation strategy.

Professor Stephen Powis (SP) stated that when the CCG was being formed there was a discussion about the merits of a committee like this. SP stated that he felt that now was the right time to put it in place.

CChi then noted the queries/comments raised about the Terms of Reference and these were discussed by the CTC.

Where the same CTC member fulfilled two roles (e.g. Dr Tim Hodgson (TH) as both GP Governing Body Member and Locality Lead for West Merton) there would be a more explicit clarification of their role on, and expected input to, the CTC. With regard to TH’s position, his role on the CTC was as a GP Governing Body Member and it would be for the CTC to seek the input the West Merton Locality via different sources.

That expert views on specific issues would be sought on an ad hoc basis rather than expanding the regular membership of the CTC.

That the representative of the Patient Engagement Group (PEG) would be nominated on an annual basis by Clare Gummett (Governing Body Lead on Engagement), and it was intended that such a representative would be in place for the first CTC meeting of 2016/17.

For the sake of clarity the phrase “The Committee will meet bi-monthly” to be changed to “The Committee will meet every other month.”

AD stated that there was a need to formalise Health and Wellbeing strategies within the CCG and the CTC would play an important role in this It was also noted that a number of CTC members were members of the Health and Wellbeing Board.

The phrase “The Committee will commission work that results in comprehensive services that are available to all the residents in Merton” be amended to “The Committee will request a programme of work that results in comprehensive services that are available to all the residents in Merton”

The phrase “The Committee will actively promote the highest standards of excellence and professionalism in the provision of high quality care that is safe, effective and focussed on excellent patient experience and outcomes” be amended to “The Committee will actively promote the highest standards of excellence and professionalism in the provision of high quality care that is safe, effective and focussed on excellent patient and people’s experience and outcomes”

The phrase “The Committee will ensure that appropriate consultation is carried out with all stakeholders” be amended to “The Committee will ensure that appropriate consultation is carried out with all relevant stakeholders”

With the incorporation of the above amendments, the Clinical Transformation

TF

TF

TF

TF

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ACTION

Committee’s Terms of Reference were approved.

4. For Discussion

4.1 MCCG Vision and Strategy Update

DF introduced this item and stated that the CCG has developed a revised vision – “Whole Merton” – that describes an enhanced clinically-led approach to the health and wellbeing of the people of Merton. To support this, the CCG has developed a strategy document to set out and guide our work towards implementing the Whole Merton vision. The purpose of the paper presented today was to update the CTC on progress against the initial actions agreed to support delivery of our strategy. There followed questions and comments from the CTC. CChi asked how clinical leadership could be ensured in the Vision and supporting strategy. DF replied that a Planning Lead had now been recruited and the CCG was looking for clinical engagement input regarding new QIPP ideas. Dr Andrew Murray (AM) said that there had been a workshop regarding the East Merton Model of Care and this had been very successful in sharing the Whole Merton vision of wellbeing. He added that it would be beneficial for the CTC to be involved in this area. AD stated that what the CTC was seeing today was only the beginning of the programme. What was still required was a clear and robust project structure and clarity over potential risks and their mitigations. Also important was establishing a clear timeline to monitor progress. He added that Out of Hospital services were key to achieving the CCG’s overall ambitions and the re-connection of community services and general practice was integral to this. The GP Federation would be a vital component of this but the Federation was not yet fully established. There would be a paper to the February meeting of the CTC regarding this particular issue and how any associated risks could be addressed. TH suggested that it may be more appropriate now to refer less to the “East Merton Model of Care” and more to “Whole Merton.” Although the general principle of this was acknowledged, Dr Karen Worthington and VG both stated the importance of recognising the health inequalities specific to East Merton. CC stressed the need for the CCG’s direction of travel to align with that of South West London as a whole.

CC/SH

4.2 Mobilisation of new provider of community services – Update

DF presented this item and informed the CTC that the Merton Community Services Mobilisation Steering Group has been established to oversee the delivery of a successful mobilisation following the community services re-procurement. At its first formal meeting, the Mobilisation Plan for CLCH (the new provider) was signed off. The Connect Mobilisation Plan has subsequently been signed off. In general, good progress was being made and only one area was currently “red rated”: IM&T. DF explained that the issue was the need for CLHC to be fully aware of the practical IM&T requirements to ensure that “going live” would be

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ACTION

efficient and seamless. There were site surveys currently underway and this should resolve any problems. The red rating was given to ensure that appropriate focus was given to the progress on this matter. AD suggested that if concerns remained it should be escalated to the CSU. Cynthia Cardozo (CC) stated that such an escalation had already been made and she was confident that work would be completed to schedule. In light of services being disaggregated between Merton and Sutton, AD raised the issue of every effort needing to be made to ensure that community services’ staff aligned with Merton did not feel the need to apply for posts in Sutton. DF commented that CLHC had already started work on this; at present, this had been of a general all-staff nature but they would now be interacting with relevant staff on an individual level. AD replied that that the CCG needed to be kept informed of progress on this work and its outcome and requested a further update to the February CTC meeting.

SH

5.

Any Other Business AD informed the Committee that DF was leaving the CCG for a new post and thanked him for his contribution during his time with Merton.

6. Date of Next Meeting

23rd February 2016 Time: 3.00pm – 5.00pm Venue: 120 The Broadway

7. Closure of Meeting

The Chair declared the meeting closed at 4.05pm.

Agreed as an accurate account of the meeting held on Thursday, 7th January 2016.

…………………………………………

Dr Carrie Chill - Chair

Date:

Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England

PAPER 02

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MINUTES (draft) Members in attendance

Name Organisation Designation

Carol Varlaam Wandsworth CCG Lay Member (Committee Chair)

Graham Mackenzie Wandsworth CCG Chief Officer

Dr Nicola Jones Wandsworth CCG Chair

Dr Chris Elliott

(arrived at 17:22pm)

Sutton CCG Chief Officer

Tonia Michaelides Kingston CCG Chief Officer

Dr Naz Jivani Kingston CCG Chair

Kathryn Magson Richmond CCG Chief Officer

Dr Graham Lewis Richmond CCG Chair

Bob Armitage Richmond CCG Lay Member

Paula Swann Croydon CCG Chief Officer

Dr Tony Brzezicki Croydon CCG Chair

Adam Doyle Merton CCG Chief Officer

Peter Derrick Merton CCG Lay Member

David Sturgeon NHS England Head of Primary Care South London

Attendees

Name Organisation Designation

William Cunningham Davis NHS England Head of Primary Care South London

Nora Simon NHS England Assistant Head Primary Care Commissioning

Omid Gilanshah NHS England Assistant Head Primary Care Commissioning

Richard Jeffery NHS England Director of Financial Management, London Region

Dr Julius Parker Surrey and Sussex LMCs Representative

Dr Amer Salim Merton, Sutton & Wandsworth LMC

Representative

Julie Freeman London Wide LMC Representative

Cllr Ruth Dombey Sutton CCG Health and Wellbeing Board Representative

Cllr Christine Percival Richmond CCG Health & Wellbeing Board Representative

Cllr Julie Pickering Kingston CCG Health and Wellbeing Board Representative

Jamie Gillespie Wandsworth CCG Healthwatch Representative

Dave Curtis Merton CCG Healthwatch Representative

South West London Primary Care Joint Committee Meeting in public

Thursday 12th November 2015 17:00pm – 19:00pm,

Big Hall, Drake House, 44 St Georges Road, Wimbledon,

London SW19 4ED

Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England

PAPER 02

Page 2 of 8

SWL Collaborative Programme Team

Name Organisation Designation

Joanne Devlin SWL Collaborative Interim AD Out of Hospital and

Primary Care

Gurvinder Chana SWL Collaborative Governance Lead

Kasia Gaj SWL Collaborative Strategic Manager Primary Care

Clare Wilson SWL Collaborative Senior Strategy Manager

Members of the public

Name Organisation Designation

Kalsoom Bibi Qureshi

Greta Ruffino

Paul

Apologies

Name Organisation Designation

Dr Andrew Murray Merton CCG Chair

Dr Brendan Hudson Sutton CCG Chair

Sally Brearley Sutton CCG Lay Member

Helen Pernelet Croydon CCG Lay Member

David Knowles Kingston CCG Lay Member

Mike Sexton Croydon CCG Chief Finance Officer

Hardev Virdee Wandsworth CCG Chief Finance Officer

Matthew Trainer NHS England Area Director South London

Dr Jane Fryer NHS England Medical Director South London

Pete Flavell Sutton CCG Healthwatch Representative

Steve Hardisty Kingston CCG Healthwatch Representative

Charlie Ladyman Croydon CCG Healthwatch Representative

Paul Pegden-Smith Richmond CCG Healthwatch Representative

Cllr Maggie Mansell Croydon CCG Health & Wellbeing Board Representative

Cllr Jim Maddan Wandsworth CCG Health & Wellbeing Board Representative

Cllr Caroline Cooper-Marbiah Merton CCG Health and Wellbeing Board Representative

Dr Marek Jarzembowski London wide LMCs Representative

Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England

PAPER 02

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Item Title Action

1 Declarations of Interest – Carol Varlaam

No new declarations of interest were declared.

2 Welcome, Introductions and Apologies – Carol Varlaam

The chair welcomed the attendees and noted the apologies.

3 Minutes of the Joint Committee meeting held on 09.07.2015 – Carol Varlaam

The minutes of the last meeting were APPROVED as an accurate record of the meeting.

4 Action log from meeting held on 03.09.2015 – Carol Varlaam

The action log was reviewed and the outstanding action is on the agenda.

5 Matters arising not on the agenda – Carol Varlaam

None

ITEMS for DECISION

6 Terms of Reference and Memorandum of Understanding (for APPROVAL) – Graham Mackenzie

The SWL Primary Care Joint Committee ToR and MoU were updated following the agreement on the establishment of the working groups supporting the Joint Committee and approval of the working group membership at the last Joint Committee 03.09.2015. The three working groups supporting the Joint Committee are:

Quality, Prevention and Innovation Working Group

Capital and Estates Working Group

Finance and Contracting Working Group The Terms of Reference for the Joint Committee have incorporated the approved ToR’s for each working group into the annex, in accordance with section 23 of the Terms of Reference. The Memorandum of Understand has incorporated the agreed membership for these working groups into the annex. It was noted that Healthwatch representation and LMC representation is included on to the MoU and not the individual working group memberships. The Joint Committee APPROVED the ToR and MoU subject to the addition of Healthwatch and LMC representation being included onto the membership for each working group.

Gurvinder Chana

7 Contractual Changes: Tudor Drive (Kingston) Surgery (for APPROVAL) – David Sturgeon / William Cunningham Davis

David Sturgeon explained that the providers of the contract a Tudor Drive surgery have handed back their contract to NHS England with a termination date of 31st December 2015. NHS England have engaged with the local population, stakeholders and providers and together with Kingston CCG, they recommend that the 2,547 patients registered should be dispersed and patients be advised to register at an alternative local practice.

Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England

PAPER 02

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The patient consultation ran from the 24 September 2015 to the 25 October 2015. NHS England received 428 (17%) responses from the 2,547 patients registered at the practice.

234 (9%) supporting re-procurement of the service

174 (7%) supporting dispersal

20 (1%) reporting no preference

2119 (83%) of patients did not respond, with those who did respond presenting a mixed view. The overwhelming majority of patients are unmoved by the service re-provision.

NHS England and Kingston Clinical Commissioning Group are seeking approval from the Joint Committee to proceed with the recommendation outlined in the paper to disperse the registered list at Tudor Drive Surgery upon contract termination.

Dr Julius Parker said that on behalf of Surrey and Sussex LMC, no negative comments have been reported from patients or public

NHS England and Kingston CCG APPROVED the decision to disperse the registered list at Tudor Drive Surgery.

8 Contractual Changes: Wandle Valley (Sutton) Health (for APPROVAL) – David Sturgeon / William Cunningham Davis

David Sturgeon provided a brief summary on the position with The Wandle Valley Health Centre. He explained that the contractors, AT Medics, notified NHS England Primary Care team in writing on 23 July 2015 of their intent to end their contract to provide primary medical services from that practice. It was noted that NHS England and NHS Sutton CCG have worked together on this issue, engaged with the registered patients, stakeholders including Healthwatch, the Local Medical Committee and the local MP and councillors, to ensure continuity of care for the patients registered at the Health Centre. As part of this engagement, there was a month-long patient consultation; this included writing to all registered patients, holding two drop-in patient events at the practice, and seeking opinions by post, phone, email and web-survey. NHS England carried out a patient consultation exercise which ran from the 21s September 2015 to the 16 October 2015. They received responses from 24% (450) of the 1,914 patients registered at the practice:

361 (19%) supported re-procurement of the service

74 (4%) supported dispersal, and

15 (1%) reported no preference

1,464 (76%) of patients did not respond, so although those who did respond were opposed to dispersal, the majority of patients did not express any preference.

NHS England and Sutton CCG APPROVED the decision to disperse the registered list at Wandle Valley Health.

9 Operating Model (for APPROVAL) – David Sturgeon

David Sturgeon presented the Operating Model to the Joint Committee. He explained that the Operating Model has been developed by NHS England (London), with extensive consultation with CCGs and SPGs through the Co-Commissioning Next Steps Working Group, chaired by David Sturgeon. There were a number of comments and feedback which was received and incorporated into this document.

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Members of the Joint Committee asked if it is possible to see a tracked change version of the Operating Model to see what changes and where these have been made.

NHS England will submit a tracked change version and the committee agreed to send around any comments to Graham Mackenzie (SPG Lead for SWL) within two weeks from the date the model is circulated. It was also agreed that if no comments are received within two weeks, then it will be assumed that the Joint Committee for SWL approve the Operating Model.

Gurvinder Chana

ITEMS for DISCUSSION

10 Personal Medical Services Update – David Sturgeon

David Sturgeon presented the latest slide deck setting out an analysis of the existing PMS contracts in SWL. He explained that a baseline and analysis of finances, current service premium and KPI that are contractualised as part of the current PMS contracts in included. The current position of the review is that engagement with each individual CCG is now beginning to take place. Carol Varlaam asked if these dates are already in the diaries and David said that confirmed dates are not in the CCG diaries as yet, but the sharing of information with the CCGs has begun. Graham Mackenzie confirmed that following the Chief Officers Group meeting, it was agreed in principle that although most of the work around PMS review will be carried out in local CCG groups, the Primary Care Quality, Prevention and Innovation Working Group will be oversee the whole process and provide feedback to this committee. Naz Jivani provided an update on Kingston position regarding PMS. He said that KCCG are still having discussions around the definitions of the investment elements of the PMS savings. He said that a lot of clarity and consistency is needed around these definitions across SWL. It was noted that the six CCG Chairs wrote a letter to NHS England asking for a substantial extension regarding the PMS review. Graham Mackenzie said that a written response has not been received; however there has been some dialogue around the potential of a three month extension. On behalf of the six CCGs, he explained that this is not enough time and therefore the CCGs will just continue with the work. The Joint Committee NOTED the paper.

11 Due Diligence Work Update – Graham Mackenzie / Mike Sexton

It was noted that five of the six CCGs have submitted their applications for move to level 3 delegations. Graham Mackenzie explained that all five submissions are subject to the completion of successful due diligence piece of work. He explained that the due diligence work is aiming to ensure that the CCGs are sighted on any contractual or financial risks that may be present in terms of taking on delegation. Two organisations have been commissioned to do this work; Capsticks for the legal review and RSM (formally Baker Tilly) for the financial work. They are due to report in the middle of December, in time for CCG Governing Bodies. Adam Doyle confirmed that Merton CCG have submitted their application and are keen to progress with delegation. However he highlighted how important the outcome of the due diligence is for each CCG and everyone needs to be clear of the consequences of the outcome. Chris Elliott supported Adam’s comment and said that CCG allocations for next year are not available as yet, so CCGs need to be sure that they can afford to take

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over these budgets following delegation. David Sturgeon acknowledged that NHS England have received all five applications have been received and the process of approval has begun, subject to a series of conditions. Budget allocations are due to be discussed at the National Board on 17th December 2015. The Joint Committee NOTED the update on the due diligence work.

12 Planning for London Stocktake visit 18.11.2015 – Graham Mackenzie

Graham Mackenzie informed the Joint Committee that NHS England are conducting a stock take review of progress with the delivery of primary care transformation in each of the strategic planning group areas in London. The six CCGs have been working with the collaborative team to put together a slide pack. The Executive summary was tabled at the meeting. Graham explained that the key lines of enquiry that have been asked by NHS England involve four main areas:

SWL strategy and our overall progress against the strategy How ready we are on the commissioning side of primary care transformation Provider side development – in terms of local practices Finances and other enablers to resource this piece of work

Slide 5 is a snapshot of progress and intended aims and objectives year by year up to 2019 against the main London specifications for General Practice, around access, coordinated care and proactive care. Nicola Jones said that discussions around the content of these slides have taken place amongst the CCG Chairs and their feedback has been incorporated accordingly. Naz Jivani said that there has been a bit of a pushback from Kingston CCG Council of Members around the 17 standards. They felt that when they were developed, they were appropriate but at this time, because of workforce, developments in primary care etc, they need a bit of tweeking to be able to represent what the current situation is. In essence the 17 standards should be adhered to but there are certain aspects around the wording of these standards; e.g. everyone needs to see a GP etc. Graham highlighted that one of the things SWL will be challenged on is the degree of consistency versus the variation and what is more tolerable to us across SWL. Carol Varlaam asked what is the expected range of outcomes from this stock take review. Graham said that it is a developmental piece of work, so the outputs will essentially highlight areas of challenge, successes, lessons learnt etc. The Joint Committee ACCEPTED and NOTED the planning for the Stocktake visit.

13 Finance Report Month 6 – Richard Jeffrey

Richard Jeffrey presented the month 6 finance report. He explained that the overall financial position for South West London GP Primary Medical services is showing an overspend of £652k against issued budgets for the 6 months ending 30th September 2015. This position is after the release of £1,029k non-recurrent 2014/15 accruals write backs. The overspend is largely due to unachieved planned QIPP savings. The year to date position comprises net overspends after QIPP on PMS £268k, GMS £231k, APMS £61k with a slight overspend on other. The gap between the QIPP target (£2.7m) and the recurrent QIPP opportunity continues to be the single biggest risk facing primary care budgets. NHS England has received a joint response from all CCGs regarding CCGs and NHSE collaborating to deliver transformation QIPP through primary care.

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It was noted that although a due diligence engagement has been commissioned to review financial and legal risks of delegated commissioning, any CCG considering taking on full delegation from 2016/17 must do so in the full knowledge of the current recurrent funding gap of £2.7m in GP primary care budgets.

Peter Derrick made a comment about QIPP and said that the success of the route that NHS England is embarking does not make him confident. He expressed that SWL are not making the QIPP targets and NHS England are making up the balance even then with some one-off non continuing savings. He said that he fears if this expectation is carried forward into 16/17; then SWL will be in a serious position in the first year of delegated primary care.

Richard explained that there will always be a QIPP ask for all of primary care for16/17; however in terms of the amount carried forward for this year because of the non-recurrent measures made, there will be some recurrent impact to some of those schemes.

Naz Jivani commented that there is a lot of pressure on primary care; QIPP initially was introduced to try and look at quality, prevention and innovation and we are still focusing on productivity and savings.

Tony Brzezicki said that it will be interesting to see the outcome of the due diligence work as there may even be a possibility that CCGs cannot actually take on their ambition of delegated commissioning.

The Joint Committee NOTED the contents of report.

ITEMS FOR NOTING / INFORMATION

14 Report back from Joint Committee Working Groups

Finance and Contracting Working Group (Mike Sexton) NOTED

Capital and Estates Forum (Hardev Virdee) NOTED

Quality, Prevention and Innovation Working Group (Dr Nicola Jones) The summary from the first meeting was NOTED and Nicola Jones explained that the focus for this working group until April 2016 is PMS review and also looking at how quality is monitored in reporting across SWL.

15 Contractual Changes – action log (to NOTE) – NHS England

NOTED

16 Open Space / Questions from the public – Members of the public

None

17 Any Other Business - All

None

The meeting closed at 18:20pm

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Date and Venue of next meetings

14th January 2016 14:00pm – 17:00pm 120 The Broadway, Wimbledon, SW19 1RH

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MINUTES Members in attendance

Name Organisation Designation

Carol Varlaam Wandsworth CCG Lay Member (Committee Chair)

Graham Mackenzie Wandsworth CCG Chief Officer

Dr Nicola Jones Wandsworth CCG Chair

Adam Doyle Merton CCG Chief Officer

Dr Andrew Murray Merton CCG Chair

Peter Derrick Merton CCG Lay Member

Paula Swann Croydon CCG Chief Officer

Dr Tony Brzezicki Croydon CCG Chair

Tonia Michaelides Kingston CCG Chief Officer

Dr Naz Jivani Kingston CCG Chair

Dr Chris Elliott Sutton CCG Chief Officer

Dr Brendan Hudson Sutton CCG Chair

Kathryn Magson Richmond CCG Chief Officer

Dr Graham Lewis Richmond CCG Chair

Liz Wise NHS England Programme Director, Transforming Primary Care

Attendees

Name Organisation Designation

William Cunningham Davis NHS England Head of Primary Care South London

Nora Simon NHS England Assistant Head Primary Care Commissioning

Omid Gilanshah NHS England Assistant Head Primary Care Commissioning

Toyin Akinyemi NHS England Head of Finance, Primary Care Commissioning

Mike Sexton Croydon CCG Chief Finance Officer

Cllr Caroline Cooper-Marbiah Merton CCG Health and Wellbeing Board Representative

Jamie Gillespie Wandsworth CCG Healthwatch Representative

Adrian Attard (representing Pete Flavell)

Sutton CCG Healthwatch Representative

John Anderson (representing Paul Pegden-Smith)

Richmond CCG Healthwatch Representative

Dr Julius Parker Surrey and Sussex LMCs Representative

Steve Uttley RSM Associate Director

South West London Primary Care Joint Committee Meeting in public

Thursday 4th February 2016 18:00pm – 19:00pm,

Room 6.2/6.3, 120 The Broadway, Wimbledon, London, SW19 1RH

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Jessica Kohler Capsticks Partner

SWL Collaborative Programme Team

Name Organisation Designation

Joanne Devlin SWL Collaborative Interim AD Out of Hospital and

Primary Care

Gurvinder Chana SWL Collaborative Governance Lead

Claire Wilson SWL Collaborative Senior Strategy Manager

Timothy Bennett SWL Collaborative Senior Strategy Manager

Members of the public

Name Organisation Designation

Kalsoom Bibi Qureshi

Eileen Fairclough

Apologies

Name Organisation Designation

Sally Brearley Sutton CCG Lay Member

Helen Pernelet Croydon CCG Lay Member

David Knowles Kingston CCG Lay Member

Bob Armitage Richmond CCG Lay Member

Pete Flavell Sutton CCG Healthwatch Representative

Steve Hardisty Kingston CCG Healthwatch Representative

Paul Pegden-Smith Richmond CCG Healthwatch Representative

Dave Curtis Merton CCG Healthwatch Representative

Cllr Ruth Dombey Sutton CCG Health and Wellbeing Board Representative

Cllr Christine Percival Richmond CCG Health & Wellbeing Board Representative

Cllr Julie Pickering Kingston CCG Health and Wellbeing Board Representative

Cllr Maggie Mansell Croydon CCG Health & Wellbeing Board Representative

Cllr Jim Maddan Wandsworth CCG Health & Wellbeing Board Representative

Charlie Ladyman Croydon CCG Healthwatch Representative

Richard Jeffery NHS England Director of Financial Management, London Region

Matthew Trainer NHS England Area Director South London

Dr Jane Fryer NHS England Medical Director South London

Hardev Virdee Wandsworth CCG Chief Finance Officer

Julie Freeman London Wide LMC Representative

Dr Amer Salim Merton, Sutton & Wandsworth LMC

Representative

Dr Marek Jarzembowski London wide LMCs Representative

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Item Title Action

1 Declarations of Interest – Carol Varlaam

No new declarations of interest were declared.

2 Welcome, Introductions and Apologies – Carol Varlaam

The chair welcomed the attendees and noted the apologies.

3 Minutes of the Joint Committee meeting held on 12.11.2015 – Carol Varlaam

The minutes of the last meeting were APPROVED as an accurate record of the meeting.

4 Action log from meeting held on 12.11.2015 – Carol Varlaam

The action log was reviewed and all the actions from the minutes of 12th November 2015 are now complete.

5 Matters arising not on the agenda – Carol Varlaam

None

6 SWL Collaborative, Transforming Primary Care Delivery Plan Review – Graham Mackenzie

Graham Mackenzie introduced the paper and explained that the focus of the paper is around the strategic work around transforming primary care across South West London. He explained that following the Joint Committee meeting in November, the SWL Primary SPG met with Simon Weldon and colleagues from NHS England following a stocktake exercise to review SWL’s progress in strategic planning and development for transforming primary care. In the course of this stocktake, there was strong recognition of the range of work underway in each of SWL’s CCGs against the London specifications for General Practice. However at that stage, it was felt that SWL were not able to demonstrate or describe in sufficient detail an overall collaborative strategic approach for on-going progress for this programme of work across SWL. SWL SPG therefore agreed to undertake some further work, which has been done at local CCG level in the last 2-3 months with some support from colleagues in the Healthy London Partnership team. Graham explained that the paper represents the detail of the work and illustrates the quality around the work that is already in progress or is planned in SWL in the next 2-3 years; all of which is aimed to get SWL CCGs to a point in 2018/19 where we are fundamentally and consistently meeting the London Specifications in common across SWL. Nicola Jones provided some examples of some of the key areas of focus across SWL:

Access – choice of access options, including rapid access and patient online

Coordinate Care – development of MDT and MCP models

Proactive Care – co designing services and expert patient programmes Nicola highlighted that this piece of work has enabled shared learning and there is still some reflecting to do on the on going progress and monitoring of this plan. There are opportunities for CCGs to share best practice. It is important to understand what the baseline is to enable monitoring progress of this going forward.

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She summarised that the next steps following the development of this plan is to look at the SWL Collaborative shared ambition for transformation and work together in finalising the CCG plans and agreeing a SWL Collaborative approach to track progress going forward. The Joint Committee NOTED the plan and AGREED the next steps.

7 Delegated Commissioning – Graham Mackenzie / Mike Sexton

Feedback on delegated commissioning

It was noted that 5/6 CCGs have formally submitted their applications to take on delegation from 1st April 2016. Graham Mackenzie explained that there has been a significant amount of progress made since the submission of the applications. Each application has been through a process of moderation at regional level by the London team and also nationally by NHS England. Each of the of the five CCGs has received individual feedback on that moderation process, that has identified some areas of work to do to strengthen the arrangements prior to taking on the additional responsibilities. This feedback is summarised in paper 05. Some of the actions apply to all of the CCGs and some of them are more specific to individual CCGs based on the details in the applications submitted.

Graham summarised that this paper is here for information to assure the Joint Committee that we are tracking the progress against the work required in the action plans across SWL ahead of 1st April 2016.

The Joint Committee NOTED the paper.

Financial and legal due diligence

Mike introduced the legal and financial due diligence reports. He explained that this piece of work was commissioned in September 2015 and RSM and Capsticks were appointed to carry out the due diligence. Both RSM and Capsticks have worked very closely with NHS England and a comprehensive report has been produced of their findings and recommendations. He informed the Joint Committee that a draft action plan is being put together following the recommendations to follow up any actions and this will be brought to the next Joint Committee meeting in March 2016.

Action: Draft action plan to be finalised and brought to next Joint Committee meeting

Steve Uttley from RSM provided an brief overview of the Financial due diligence report:

Carried out this piece of work at a CCG level

Look at key financial risks around budgets, QIPP and accruals

Budgets – majority of the budgets were overspending, budgets had not been shared with GP practices and have been managed centrally

QIPP – large shortfall in delivering the 2015/16 target

Carried out GP surveys around contract monitoring

Put together some mitigations which will feed into the overall action plan

A number of recommendations have been proposed following this piece of work; financial reporting, accruals, contract management

Naz Jivani expressed concerns and apprehension around the outcome of this work and the lack of clarity around the outstanding financial issues still not resolved with the practices. He said that it feels like there is still a lot of work that needs to be done and

Mike Sexton / Graham

Mackenzie

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questioned whether the next steps are actually carried out by RSM or individual CCGs have to work to a granular level to assess each of the financial risks highlighted in the reports.

Mike Sexton said that some of these risks will be picked up as part of the draft action plan which is being put together by CCGs and NHS England. There will be some issues that will need to be progressed collectively across the six CCGs but there will also be some actions that are CCG specific which will need to be incorporated as part of the action plan.

Naz Jivani acknowledged Mike’s comments, however explained that this needs to be signed off before the end of March by CCG Governing Bodies to be able to take on delegated commissioning on 1st April 2016.

Mike Sexton provided some assurance around one of the biggest risks identified across all six CCG’s – budget setting. He explained that this piece of work is already underway by NHS England and the five SPG leads. He assured the Joint Committee that in terms of any significant legal challenges hidden or liabilities that SWL CCG’s wouldn’t be aware of; there is nothing that has come out of the due diligence piece of work that suggests there is a massive contractual issue. The types of issues that have been surfaced contractually are around DES’s which in themselves carry a fine line risk.

Liz Wise explained that NHS England is working through the approach to the budget setting for next year. She explained that the allocation she has seen is a capitation allocation to each CCG for primary care.

Brendan Hudson, on behalf of Sutton CCG also expressed his concerns around the outcome of the financial due diligence work. He said that Sutton CCG has identified premises costs as one of the biggest risk and in particular the fact that the district valuer has not valued Sutton practices for five years. Sutton CCG is writing to NHS England asking to be indemnified against the risk of that amount being significant.

Jessica Kohler from Capsticks provided a brief summary of the work that was carried out supporting the legal due diligence piece of work:

Capsticks did not review all contracts; in specifics Capsticks did not review any GMS contracts

Looked mainly at generic PMS and APMS contracts for each area

Looked at a legacy list provided by NHS England

Looked at breach and CQC notices

Provided a list of recommendations for CCGs and NHS England to consider individually or to work jointly around

This joint committee will cease to exist once the delegation agreement has been signed

Managing of conflicts of interests – delegated CCGs will need to have a robust process for managing conflicts

The Joint Committee NOTED and ACCEPTED the financial and legal due diligence executive summaries from RSM and Capsticks and NOTED NHS England’s response regarding these reports.

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Delegation agreement

It was noted that all CCGs have received the delegation agreement and the submission date for this agreement is 26th February 2016.

Proposed operating model

Graham Mackenzie presented a future working arrangements paper and highlighted three key areas of proposed operational arrangements under delegation:

- Governance

- Commissioning Support

- Strategy and Transformation

He explained that there is still some potential to continue to work together across SWL. The platform for governance for delegated commissioning is the local committee within each CCG. In this context, this joint committee will cease effect from 31st March 2016 on the assumption that all the CCGs except Croydon will proceed with delegation. Croydon CCG will continue in shadow form at level 2 delegation. There is still some scope for shared governance continuing across SWL – a proposal to set up an advisory panel. This panel will be a panel that meets adhoc to discuss common issues / themes across SWL, such as managing conflicts of interest. There is some potential for bringing together local experts; clinically and managerially to provide some local support to one another.

Brendan Hudson supported the creation of an adhoc advisory panel and highlighted that this is a time of transition, so it will be a great vehicle for CCGs to come together and discuss common problems and particularly legacy issues.

Naz Jivani and Adam Doyle also highly supported the created of an advisory panel and asked how this panel would be made up.

Graham Mackenzie agreed for a draft Terms of Reference to be brought to the next Joint Committee to proceed this work forward.

Action: Draft ToR for Advisory Panel to be brought to the next Joint Committee meeting.

In terms of commissioning support, as part of taking on the full responsibilities for level 3 delegated commissioning, each CCG will need to ensure that they have sufficient capacity and capability in their workforce to manage the range of contract, financial and performance management issues related to the commissioning of primary medical services.

Tonia Michaelides supported the approach to develop a shared commissioning support service and highlighted that it is important to keep the legacy continuing.

Graham summarised that overall delegation is an important enabler of strategy and transformation, therefore when ceasing the joint committee, it is important to ensure that some of the working groups supporting the joint committee currently (Capital and Estates Forum and Quality, Prevention and Innovation Working Group) are continued under different workstreams enabling and supporting the wider transformation strategy over time.

The Joint Committee CONSIDERED and CONFIRMED that subject to the formal

Graham Mackenzie

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commencement of level 3 delegated commissioning by CCGs in SWL in 2016/17 (and for iii and iv subject to local CCG Governing Body discussions/decisions):

i) the SWL Joint Committee for Primary Care will cease with effect from 31st March 2016;

ii) an Advisory Panel will be established to support local delegated commissioning;

iii) a primary care commissioning support team will be identified/established for SWL under the direction of the SWL CCGs. This is subject to further work on the location and operation of this team and the outcomes of the current workforce review across London;

iv) the Primary Care Delivery Group will continue to lead collaborative work for the strategic transformation of primary care across SWL.

8 Personal Medical Services – Liz Wise / William Cunningham Davis

Liz Wise updated the Joint Committee on the current progress to date on the PMS Review:

- Slide deck sets out the background to the PMS review and agreements - It is a national requirement to do this, but it is also an enabler in transforming

primary care, particularly delivering elements of the strategic commissioning framework

- Significant piece of work - NHS England noted the challenging timescales and offered a three month

extension - Have until the end of June 2016 to agree with practices the new PMS contracts - CCGs have been briefed on the London offer - The information in this slide deck is slightly out of date – progress has now been

made on the agreement of the key performance indicators and the premium specification and the core

- There is still some work to do on some of the detail and how individual contracts will work

- Agreement has been sought from London wide and Surrey and Sussex LMCs - Next steps – NHS England to start working with CCGs to start drawing out

CCGs commissioning intentions for PMS The Joint Committee NOTED and ACCEPTED the progress on the PMS Review and NOTED the requirement to review PMS contracts by March 2016 and to offer and to consult by June 2016.

9 Finance Report Month 9 – Toyin Akinyemi

Toyin Akinyemi presented the month 9 financial position for SWL:

- The financial position for SWL Primary Medical Services showing an overspend of £1,286k against issued budgets

- The overspend is largely due to under achieved planned QIPP

- Medical services are showing an overspend of £1,286k (0.8%) of which £1,988k is attributable to QIPP under-delivery offset by a non-recurrent release of 2014/15 accruals (£968k) across South West London.

- Annual budgets are allocated net of £2.7m QIPP savings across South West London, but including the contingency allowance (£899k) which has been allocated to budgets.

- There has been a year on year growth of 0.5% in South West London’s weighted population from April 2014 to April 2015. The capitation report shows a growth of 0.8% year to 1st October 2015

- The total planned QIPP for Primary Care across London Region is £12.7m of

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which £2.7m relates to SW London. There is likely to be significant under-delivery on the savings required on Medical services as a considerable proportion of the savings remains unsupported by schemes.

- The total planned QIPP for Primary Care across London Region is £12.7m of which £2.7m relates to SW London. There is likely to be significant under-delivery on the savings required on Medical services as a considerable proportion of the savings remains unsupported by schemes.

- Based on month 9 results the Medical services budget is forecast to be £1.5m (0.8%) overspent due to the QIPP position.

The Joint Committee NOTED the contents of the finance month 9 report and NOTED the current position of QIPP.

ITEMS FOR NOTING / INFORMATION

10 Report back from Joint Committee Working Groups

Finance and Contracting Working Group (Mike Sexton) NOTED

Capital and Estates Forum (Hardev Virdee) NOTED

Quality, Prevention and Innovation Working Group (Dr Nicola Jones) NOTED

11 Contractual Changes – action log (to NOTE) – NHS England

NOTED

12 Open Space / Questions from the public – Members of the public

None

13 Any Other Business - All

None

The meeting closed at 19:00pm

Date and Venue of next meetings

10th March 2016 17:00pm – 19:00pm Room 6.2/6.3, 120 The Broadway, Wimbledon, SW19 1RH

APPROVED 10.03.2016