South Devon and Torbay Clinical Commissioning Group PUBLIC - Governing Body

Transcription

1 South Devon and Torbay Clinical Commissioning Group PUBLIC - Governing Body Formal Governing Body meeting where members of the public are invited to attend South Devon and Torbay Clinical Commissioning Group, Pomona House, Oak View Close, Torquay, TQ2 7FF 25 May :45-25 May :45 Overall Page 1 of 282

2 AGENDA # Description Owner Time 1 Welcome and Apologies Formal opening of the public Governing Body meeting. 2 Declaration of Interests This item provides the Governing Body members with the opportunityto declare any conflicts of interest relevant to the items on today'sagenda. GB DoI May 2017.pdf 7 Dr Paul Johnson - Clinical Chair Dr Paul Johnson - Clinical Chair 11:45 11:50 3 Approve the minutes of the last meeting and review action log This item is for the Governing Body to approve the minutesand actionlog from the previous meeting and review matters arising andany actions outstanding GB Front Sheet Previous Meeting Minutes.docx 11 PJ Draft PUBLIC GB Minutes with PJ ch DRAFT PUBLIC Governing Body Minutes 26 Janua Non-Confidential_Action_Log.doc 41 Dr Paul Johnson - Clinical Chair 11:55 4 Questions from the public This allows the opportunity for any members of the public attendingthe Governing Body meeting to ask questions submitted in advanceof the meeting 5 Patient Story Verbal patient story to be provided by Governing Body GP Lead Clinician. 6 Clinical Chair's report This item describes the activities of the Chair since the last report, aswell as highlighting any national announcements that may have a localimpact. 1 GB Clinical Chair Public Report May 17.docx 45 Clinical Cabinet TOR revisedv3.pdf 49 Clinical Roles - Proposal (2).docx 53 GB NED Proposal (2).docx 57 Dr Paul Johnson - Clinical Chair Dr Mat Fox - Locality Clinical Director Dr Paul Johnson - Clinical Chair 12:00 12:05 12:15 Overall Page 2 of 282

3 # Description Owner Time 7 Assurance Framework This report provides assurance to the Governing Body that the CCGhas effective processes in place to identify, assess, manage andmitigate risk,and informs the Governing Body of any changes since thelast report was presented. 1 GB Risk and Assurance Report May 2017.docx 59 2 Weak Assurance pdf 71 3 Risk movement pdf 73 4 Risk register pdf 91 Mr Mark Procter - Joint Director of Primary Care, South Devon and Torbay and NEW Devon Clinical Commissioni ng Groups and Head of Primary Care, NHS England 12:25 8 Finance Update Mr John Dowell, Director of Finance 12:35 9 BREAK 12:45 10 Quality Report This report highlights quality and safety issues identified inconnection with commissioned services. Quality_GB report 25 May 2017_final.docx 133 Mrs Gill Gant, Director of Quality Assurance and Improvement 13:00 11 Community Services Update Mr Simon Tapley - Chief Operating Officer/ Deputy Chief Officer (Verbal) 13:10 12 Primary Care STP Framework 1 STP Coll Board Emerging Primary Care Strategy Draft Devon Wide Strategy for General Practice devonwide-strategy-for-general-practice draft Review of Committee Minutes Review of CCG Committee meetings held since the previousgoverning Body meeting Mr Mark Procter - Joint Director of Primary Care, South Devon and Torbay and NEW Devon Clinical Commissioni ng Groups and Head of Primary Care, NHS England South Mr Mark Procter - Joint Director of Primary Care, South Devon and Torbay and NEW Devon Clinical Commissioni ng Groups and Head of Primary Care, NHS England South 13:20 13:30 13:40 Overall Page 3 of 282

4 # Description Owner Time 13.1 Commissioning and Finance Committee This report highlights important information and decisions made bythe Commissioning and Finance Committee Mr Brian Mackness, Non-Executiv e Director 1 Ratified CFC Minutes 16th April 2017.pdf Ratified CFC Minutes 16th March 2017.pdf Committee GB report for CFC 18th May 2017.doc Primary Care Joint Committee This report highlights important information and decisions made bythe Primary Care Joint Commissioning Committee Mr Kevin Muckian, Non Executive Director PUBLIC PCJCC Approved minutes FC PUBLIC PCJCC Approved minutes.do PCJCC Public Committee Rpt May17.doc Engagement Committee This report highlights important information and decisions made bythe Engagement Committee Mr Chris Peach, Non-Executiv e Director EC FINAL minutes 07 March 17.docx 253 Committee GB report Template - Engagement Com Quality Committee This report highlights important information and decisions made bythe Quality Committee Dr Nick D'Arcy, Quality Lead GP Approved Minutes.pdf Approved Minutes.pdf Approved Minutes.pdf Audit Committee This report highlights important information and decisions made bythe Audit Committee Mr Nick Ball, Non-Executiv e Director NR Approved Mins Audit Committee docx Joint Localities Group There have been no meeting occurrences since March Governing Body to report upon. Dr Mat Fox - Locality Clinical Director 14 LUNCH 13:45 Overall Page 4 of 282

5 Title Firstname Surname Role or Position held with the CCG Committees attended Interests Date Interest from Nick Ball Vice Chair/Non Executive Director - Finance and Governance. Conflict of Interests Guardian Member of Governing Body;Member of Audit Committee;Member of Commissioning and Finance Committee;Member of Strategic Human Resources (HR) and Remuneration Committee;Member of Primary Care Joint Commissioning Committee Appointed Chair of Audit Committee for NEW Devon CCG (Dec 2016) Virgin Care (spouse/partner was a Portage Home Visitor to 2015 ) Date Interest to Date interest updated Type of Interest Is the interest direct or Action taken to mitigate risks indirect? 22/09/ /12/2016 Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Derek Blackford Deputy Chief Finance Officer Attendee of Governing Body;Member of Commissioning and Finance Committee;Attendee of Senior Leadership Team;A & E Delivery Board Governor - Torbay ans South Devon NHS Foundation Trust (April 2017) none declared 30/11/ /04/2017 ongoing 28/04/ /11/2016 Non-Financial Indirect Interest Professional Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr AC known as Felix Burden Non Executive Director - Secondary Care Member of Governing Body;Member of Audit Committee;Member of Quality Committee Director of Burdens of Diseases Ltd (2008) Declared on - diabetes and long term condition appointment education and Quality Assessment October IT clinical algorithms - specifically Blood glucose monitoring, commissioned by the Birmingham and Solihull CCGs but paid by Spirit health care, Abbott Diabetes Care and Glucomen (2013) Advice to Spirit Health care on clinical aspects of glucose monitoring (2013) External QA of Empower, a diabetes education programme ( Aug 2015) 13/10/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr AC Known as Felix Burden Non Executive Director - Secondary Care Member of Governing Body;Member of Audit Committee;Member of Quality Committee Royal College of Physicians - Fellow (1988) Declared on Diabetes UK previous vice chair, trustee, appointment Chair professional sections and member of October 2016 governance committee (1974) Labour party member (1974) Member of Heart International advisory board (dec 2015) Member of BMA (c1965) My son is due to rotate to work at the Royal Devon and Exeter Hospital [RDE] in general medicine with a respiratory interest (Aug 2017) My daughter in law works at the RDE as an Infection Prevention & Control Nurse Specialist (2015) 04/04/ /10/2016 Non-Financial Personal Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Ray Chalmers Head of Communications Attendee of Governing Body;Attendee of Senior Leadership Team;Member of Engagement Committee;A & E Delivery Board Dr Nick D'Arcy Clinical Lead Quality Member of Governing Body;Member of Quality Committee;Member of Primary Care Joint Commissioning Committee none declared 23/09/ /11/2016 Partner at Kingskerswell Medical Practice; Director (1986) Kingskerswell Medical Ltd (2013) Share holder Devon doctors on Call (2000) Kingskerswell and Ipplepen is a research practice and teaching practice for Peninsula Medical School Spouse is an associate specialist in paediatrics, SDHFT Dec 2015 declared an interest in the merger of the Newton Abbot GP practices. Member of the Board for Newton Abbot Federation 17/12/2015 ongoing 03/11/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Caroline Dimond Co-opted member of Governing Body Member of Governing Body;Member of Primary Care Joint Commissioning Committee Director Public Health, Torbay Council Contract CDT in Torbay 04/09/2015 Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. GB DoI May 2017.pdf Page 1 of 4 Overall Page 5 of 282

6 John Dowell Chief Finance Officer Member of Governing Body;Attendee of Audit Committee;Member of Commissioning and Finance Committee;Member of Senior Leadership Team;Staff Council SDTCCG Honorary contract with NEW Devon CCG (due to collaborative working) 14/08/ /05/ /12/2016 Non-Financial Direct Interest Professional Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Matthew Fox GP Co-lead, Coastal Locality Locality lead GP Member of Governing Body GP principle, Barton Surgery, Dawlish. Director, Dawlish Medical Group 22/09/2016 appointed Clinical Director of Localities with Torbay and Southern Devon Health and Care NHS Trust. Spouse is a co-owner of Barton Surgery Pharmacy Building 22/09/ /11/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Matthew Fox GP Co-lead Coastal Locality Locality Lead GP Member of Governing Body Parish Councillor, Holcombe-with-combe, parish council University of Exeter Medical School, Academic tutor and student teacher 29/11/ /12/2016 Non-Financial Direct Interest Professional Gill Gant Director of Quality Assurance and Improvement. Calidicott Guardian Member of Governing Body;Member of Quality Committee;Member of Senior Leadership Team;Member of Primary Care Joint Commissioning Committee Honorary contract with NEW Devon CCG (due to collaborative working) 05/08/ /05/ /11/2016 Non-Financial Direct Interest Professional Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Derek Greatorex Clinical Chair Member of Governing Body;Attendee of Primary Care Joint Commissioning Committee Derek retired as a GP partner from Kingsteignton Medical Practice on 30 September /09/2016 undertaking sessional GP work in local GP practices DDOC (Kingsteignton Medical Practice is a shareholder) Peninsula Medical School (Kingsteignton Medical Practice is a teaching practice) Torbay and Southern Devon Health and Care Trust (Kingsteignton Medical Practice is a member) Haytor Health (Kingsteignton Medical Practice is a member) 22/09/2016 Left the organisation 18/11/2016 Non-Financial 30 March 2017 Personal Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Derek Greatorex Clinical Chair Member of Governing Body;Member of Transforming Primary Care Group GP Appraiser - Receives funding from NHS England 1/10/2016 Left the organisation 18/11/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee 30 March 2017 agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Derek Greatorex Clinical Chair Member of Governing Body;Member of Transforming Primary Care Group Local Medical Committee (member) Bishopsteignton Museum Charitable Trust (member) Bishopsteignton Residents' Association (member) British Medical Association (member) Royal College of GPs (member) start of employment Left the organisation 18/11/2016 Non-Financial 30 March 2017 Personal Interest Indirect Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr David Greenwell Clinical Lead for Integration Member of Governing Body;Member of Commissioning and Finance Committee GP partner at Southover medical practice Member of an independant cooperative that provides out of hours medical cover to Devon Prisons Spouse is freehold owner of Southover Pharmacy Shareholder in Devon Doctors on Call Member of Upton Vale Baptist Church (personal interest) 20/08/ /11/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Paul Johnson Clinical Chair Member of Governing Body;Attendee of Audit Committee;Attendee of Primary Care Joint Commissioning Committee GP Partner, Cricketfield Surgery Locality Clinical Director at Torbay and South Devon NHS Foundation Trust (Nov 2016 to 28 March 2017) Clinical Chair SDTCCG 1 March /08/ /04/ /03/ /12/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. GB DoI May 2017.pdf Page 2 of 4 Overall Page 6 of 282

7 Brian Mackness Non Executive Director, Finance and Commerce Member of Governing Body;Member of Audit Committee;Member of Commissioning and Finance Committee;Member of Strategic Human Resources (HR) and Remuneration Committee Trustee and honorary secretary of ABBFEST, a community festival which makes grants to organisations which may include those providing health and social care. Member, County Organising Committee and County Publicity Officer, national gardens scheme which makes grants to inter alia, national charities working in the field of health and social care. Member, Parocial Church Council, St Mary' Abbotskerswell. The local Church may provide voluntary support and aid in the social care field. July /12/2016 Non-Financial Personal Interest Indirect Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Sonja Manton Director of Strategy (Joint post with NEW Devon CCG) Kevin Muckian Non Executive Director, non medical clinical member. Chair Primary Care Joint Commissioning Committee Christopher Peach Non Executive Director, Patient and Public Involvement Member of Governing Body;Member of Senior Leadership Team Honorary contract with NEW Devon CCG (due to collaborative working) Spouse is employed by TSDFT as Head of System Delivery, is currently working with SDTCCG. Member of Governing Body;Member of Quality Spouse is a GP principal and partner at Committee;Member of Strategic Human Resources Teignmouth Medical Practice and sits on (HR) and Remuneration Committee;Member of SDHFT's Serious Incident Review Panel Primary Care Joint Commissioning Committee;Strategic Medicines Optimisation Group Member of Governing Body;Member of Audit Committee;Member of Commissioning and Finance Committee;Member of Strategic Human Resources (HR) and Remuneration Committee;Member of Engagement Committee;Member of Primary Care Joint Commissioning Committee Elected as the chair for magistrate s bench for South West Devon and Torbay (added 28 Nov 2016) 03/04/ /05/ /04/2017 Indirect interest Indirect Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. 01/09/ /03/2017 Indirect interest Indirect Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. 14/08/2015 ongoing 28/11/2016 Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Virginia Pearson Co-opted member of Governing Body Member of Governing Body;Member of Primary Care Joint Commissioning Committee Director of Public Health, Devon County Council 10/08/ /02/2017 Financial Interest Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Virginia Pearson Director of Public Health, Devon County COuncil Member of Governing Body;Member of Primary Care Joint Commissioning Committee Member, Devon Health and Wellbeing Board Member, Exeter Health and Wellbeing Board Member, Devon Safeguarding Adults Board Member, Devon Safeguarding Children Board Attends Governing Body of NEW Devon CCG Council Member, Association of Director of Public Health Member, British Medical Association 02/02/ /02/2017 Non-Financial Interest Professional Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Mark Procter Joint Director of Primary Care, SDT and NEW Devon CCG, and NHSE South West. Senior Information Risk Owner (SIRO) SDTCCG Attendee of Governing Body;Attendee of Audit Honorary contract with NEW Devon CCG Committee;Member of Commissioning and (due to collaborative working) NHSE Joint Finance Committee;Attendee of Senior Leadership Director Primary Care May Team;Attendee of Strategic Human Resources (HR) South Devon Healthcare NHS Foundation and Remuneration Committee;Member of Primary Trust (Governor) (resigned April 2017) Care Joint Commissioning Committee;Member of Director of Hallbarton Ltd Transforming Primary Care Group;Strategic Director of Allerton Land Ltd Medicines Optimisation Group;Staff Council SDTCCG 01/09/ /05/ /04/ /11/2016 Financial Interest Indirect Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. GB DoI May 2017.pdf Page 3 of 4 Overall Page 7 of 282

8 Dr Jo Roberts Clinical Lead for Innovation and Medicines Optimisation Member of Governing Body;Member of Audit Committee;Member of Quality Committee;Strategic Medicines Optimisation Group Board Member and Director ASHN South West Board member Nice Implementation Collaborative Member of Pharmacy integration fund oversight Group. Spouse employed at SDHCFT as associate specialist in anaesthetics (indirect interest) 26/05/ /11/2016 Non-Financial Interest Professional Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Dr Nick Roberts Chief Clinical Officer Member of Governing Body;Attendee of Audit Committee;Member of Commissioning and Finance Committee;Member of Senior Leadership Team Dr Nick Roberts Chief Clinical Officer Member of Governing Body;Attendee of Audit Committee;Member of Commissioning and Finance Committee;Member of Senior Leadership Team Dr Eleanor Rowe Clinical Lead for Commissioning Member of Governing Body;Member of Audit Committee;Member of Commissioning and Finance Committee;Member of Engagement Committee Honorary contract with NEW Devon CCG (due to collaborative working) Part owner / executive partner of Kingskerswell and Ipplepen Company PLC (medical practice) Honorary contract with NEW Devon CCG (due to collaborative working) Spouse is GP partner at Kingskerswell and Ipplepen Medical Practice. British Medical Association (member) Royal College of GPS (member) Chair of Denbury Multicourt Group Royal College of GPs (member) Partner at croft hall medical practice. Practice receives rental income from Talking Therapies, Chime, John Gill (chiropractor), Care4u pharmacy. Practice receives income from peninsula medical school and deanery for medical student and GPST training. Shareholder of DDOC Shareholder of Haytor health Croft Hall -is federated with Chelston Hall and Barton ( Torquay) surgeries as Harbour Medical Group 13/08/ /05/ /11/ /8/ /05/ /11/2016 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Non-Financial Direct Interest Professional Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. 21/09/ /01/2017 Financial Interest Direct Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. Simon Tapley Chief Operating Officer / Deputy Chief Officer (SDTCCG) / Joint Commissioning Lead South Devon, DCC Member of Governing Body;Member of Quality Committee;Member of Commissioning and Finance Committee;Member of Senior Leadership Team;Member of Engagement Committee;Community Children's Health Service Re-commissioning Project Pre-procurement Group. Honorary contract with NEW Devon CCG (due to collaborative working) Spouse is employed by TSDFT (ICO) 31/03/2017 Brother in Law is employed as Clinical Procurement Manager - NHS South, Central and West Commissioning Support Unit 01/11/ /05/ /04/ /01/2017 Non-Financial Direct Interest Professional Where a piece of CCG work or an item on a CCG Committee agenda item concerns an area where this person has declared an interest, they would be allowed to input their knowledge and experience but not participate in the final decision/vote. GB DoI May 2017.pdf Page 4 of 4 Overall Page 8 of 282

9 GOVERNING BODY Report title: Governing Body Draft September 2016 Public Board Minutes Date of committee: 23 rd March 2017 Date report produced: 30 th March 2017 Author (s): Fiona Cartlidge Contact Details: Executive Lead: Dr Paul Johnson Contact Details: Summary of Purpose and scope of report: (Please also indicate if the report is for consultation, approval or information) Consultation Approval Information / discussion Executive Summary: The Governing Body is asked to approve minutes from the public meetings held on 26 th January 2017 and 23 rd March 2017, minutes appended. Strategic risk: (include risk number if on register) Mitigating Actions: The risk register is being regularly reviewed and updated in accordance with the Risk Policy. Management of Conflict of interests: Conflicts of interests are recorded on the register of interests, at each committee a list of recorded declarations is provided and confirmations of declarations are requested and noted. Any new declarations must be fully recorded and included in the minutes of the meeting and notified to corporate.sdtccg@nhs.net to update the central register. Committees that have previously discussed/agreed the report and outcomes: N/A Corporate Impact Assessment Quality & Safety/ Patient Engagement/ N/A Impact on patient services Finance, resources and QIPP What, if any, are the legal N/A implications? Communication plan and stakeholder N/A involvement Equality Impact Assessment: Are there any Quality or Equalities N/A (including inequalities) implications of this report? (Please specify) Have you carried out an initial Quality N/A and Equality Impact Assessment (Y/N) and is it attached? (Y/N) If not, why not? Key recommendations and actions requested: N/A Accompanying paper(s): N/A Reason for reports inclusion in the confidential section of the Governing Body meeting: N/A **Please add N/A if any of the sections are not relevant GB Front Sheet Previous Meeting Minutes.docx Page 1 of 1 Overall Page 9 of 282 1

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11 PUBLIC GOVERNING BODY MINUTES Thursday 23 rd March 2017 Pomona House, Oak View Close, Torquay TQ2 7FF Meeting Rooms 1A-C Attendees (attended* / apologies A ) Name Dr Paul Johnson* Dr Derek Greatorex* Mr Nick Ball* Dr Nick Roberts Dr Nick D Arcy* Mr John Dowell* Mr Kevin Muckian Mr Mark Procter* Mr Simon Tapley* Dr David Greenwell Dr Felix Burden* Mr Brian Mackness* Mr Chris Peach Dr Jo Roberts* Dr Ellie Rowe* Mrs Gill Gant* Dr Matt Fox* Co-opted Members: Dr Caroline Dimond* Dr Virginia Pearson In attendance: Fiona Cartlidge (Minute Taker) Sir Richard Ibbotson Title and organisation Clinical Chair Clinical Chair Non-Executive Director (Vice Chair) Chief Clinical Officer Clinical Lead for Patient Safety and Quality Chief Finance Officer Non-Executive Director Director of Primary Care and Corporate Services Director of Commissioning and Transformation Clinical Lead for Integration Non-Executive Director Non-Executive Director Non-Executive Director Clinical Lead for Innovation and Medicines Optimisation Clinical Lead for Commissioning Director of Quality Assurance and Improvement Chair of Localities Group Director of Public Health for Torbay Director of Public Health for Devon Personal Assistant Director of Primary Care & Corporate Services Chairman Torbay & South Devon Foundation Trust (TSDFT) Item 1 Welcome & Apologies In advance of the formal business of the Governing Body meeting, the Chair welcomed the members of the Governing Body, those in attendance and members of the public, the Governing Body meeting commenced at 10:10. Action 2 Declarartion of Interest The following additional/updated items were declared and the formal register of declared interests will be updated accordingly: Dr David Greenwell updated the Governing Body on his already declared interest related to out of hours cooperative that provides medical cover to Devon prisons, currently PJ Draft PUBLIC GB Minutes with PJ changes.docx 1 Page 1 of 15 Overall Page 11 of 282

12 involved with ongoing contract negotiations. Dr Paul Johnson although interest declared on overall register of interst for the CCG information need to be added to that of the Governing Body. ACTION: Fiona Cartlidge to ensure Dr Johnson interests are made available when publishing Governing Body papers. The Governing Body noted the amendments to the register of declared interests. 3 Minutes of November 2017 Governing Body and Action Log The minutes of the Governing Body meeting held on 24 th November 2016 were reviewed and approved as an accurate record of the meeting. The Chair asked if the minutes had been added from the public consultation held in January 2017, they had not been added. Update on Governing Body Actions The Chair asked for updates on the action log: Action 314 Complete request to close. Action 316 Dr Nick Roberts explained that this action has been ongoing and linked with the improvement of stakeholder returns and engagement by seeking best practice from other CCG s, contact has been made, awaiting details, hope to close by next formal meeting. Action 320 Dr Nick Roberts confirmed a visit to the SDTFT A&E department has taken place on Complete request to close. Action 322 Final figures for the cost of the public consultation have been calculated and published on the CCG website Complete request to close. Action 323 Confirmation received from Liz Davenport that plans have been incorporated into the new care model implementation plan to terminate the mobile clinic Complete request to close. Action 324 Confirmation received from Liz Davenport that as part of the implementation plan, they will continue to review the availability of specialist clinics at Paignton health and wellbeing hub Complete request to close. Action 325 Confirmation received from Liz Davenport that as part of the new care model implementation plan there will be the exploration into capacity for additional GP surgery led services for minor injuries in Paignton Complete request to close. Action Confirmation received from Liz Davenport that as part of the new care model implementation plan there will be swifter payments to care homes Complete request to close. Action 327 Mr Mark Procter confirmed that the local and countywide estates group is exploring what opportunities there may be to secure sill money Complete request to close. PJ Draft PUBLIC GB Minutes with PJ changes.docx 2 Page 2 of 15 Overall Page 12 of 282

13 Action 328 Dr Nick Roberts confirmed that work had been undertaken to explore opportunities to improve transport links, it was discussed at the Senior Leadership Team meeting, and improvement to transport links will be looked at by each implementation groups as per the locality. Complete request to close. Action 329 Mr Simon Tapley confirmed this action related to the parameters required pre-community hospital beds being removed is complete and Community Services paper on agenda. Complete Action 330 Fiona Cartlidge confirmed that a regular item will be added to Governing Body agendas for Community Services Transformation Implementation plan on a quarterly basis Complete request to close. The Governing Body noted the updates to the action log and approved the requested actions for closure to be closed and archived. 4 Question from the public There were no questions received from members of the public. 5 Patient Story The Chair Dr Greatorex explained that the inclusion of a patient story brought by a Governing Body lead GP is to set context in relation to the services provided and understand patient experiences within the local area, the care they have received and how that care affects them. Dr Nick D Arcy presented the experience of an 18 year old woman named Amy with anorexia nervosa, Nick explained the parameters of BMI measurements a level of normal, 19 underweight, 17 a cause for concern and 15 or below at serious risk of complications. Amy presented in January 2014 with a BMI of 17.3 and was referred to the Child and Adolescent Mental Health Service (CAMHS) where she received treatment with CBT. Amy lost a further more 5.5 kgs and in August 2014 there were serious concerns for her health. Amy water loaded to inflate weight so that she could go on a family holiday and on return it was noted that she has lost a significant amount of weight. In September 2014 Amy was admitted to a Tier 4 unit in Birmingham for treatment over a 3 month period during that time she had limited contact with family as the unit was out of area, during her stay she underwent intensive counselling and required naso-gastric feeding. On discharge with antidepressant medication Amy s BMI was and continued with outpatients appointments. In July 2015 Amy s BMI dropped by losing 5.5kgs to 17.9, which required a further admission to Holden Exeter unit, Amy continued to lose weight and in January 2016 was admitted to a Tier 4 unit in Stafford for 3 months. Amy took her own discharge due to increased stress from lack of contact with family but also lack of change to her condition. In July 2016 Amy transferred from child mental health services over to adult services, moving from an intensive CAMHS model and regular 2 weekly out-patients appointments with a consultant, to community based care with very little input. Amy continued to lose weight, the practice were asked to monitor Amy s BP, weight and bloods on a weekly basis and her BMI dropped below 15, this resulted in a further admission from September to November into the Holden unit and was discharged to have weekly monitoring by the practice. Amy s weight and condition continued to deteriorate to BMI14.15 in March 2017, the practice has recently had Amy admitted twice to the acute unit for very low BP (hypotension) and hypoglycaemia but was discharged after only a couple of hours, PJ Draft PUBLIC GB Minutes with PJ changes.docx 3 Page 3 of 15 Overall Page 13 of 282

14 returning to community as no admission were available within a unit. The practice undertook regular conversations with the gastroenterologist, but felt they were supporting an inappropriate case in the community. Discussion held with the gastroenterologist were difficult in terms of appropriate care plan provision, with the joint outcome decision to admit Amy to an elective unit that afternoon, with a further plan for Amy to be admitted to a residential unit thereafter. Learning points Deficit in provision of Tier 4 services within the area locally. Additional stress added to the patient and families based on the location of the unit. Poor control over the transition between child and adult services to a community based model of care. Lack of adult in patient service provision to be able to support the patient successfully, and meet their needs Dr Greenwell acknowledged that this is not an isolated issue, noting a 12yr old patient who has been admitted to a unit for the past 12 months in London and the family are experiencing similar separation, emotional and associated financial issues as the unit is located in London. The Governing Body highlighted that there is both a local and national shortage of long term Tier 4 services. It was also noted that there appears to be a trend towards communication via letter handover as opposed to that of a verbal, and that patients are not fully prepared on what to expect moving from potentially a high intervention service (CAMHS) to that which is community based and less interventional (Adult services), preparations should commence at 16 years moving towards 18 years to ensure clear care transition for all those involved, it was noted that there appears to be a lack of appropriate handover between all LTC. Dr Nick Roberts acknowledged that this is a known issue with our system, and will be explored further by the STP mental health review which Mr Tapley will be involved with, looking at the remit of mental health all age and specialist commissioning across the Devon wide STP foot print and beyond. Mr Tapley noted that currently mental health services are experiencing workforce issues particularly DPT, looking at managing the global workforce potentially from a national perspective to enable safe service provision. The Governing Body noted the Patient Story provided by Dr Nick D Arcy. 6 Clinical Chair Report Dr Derek Greatorex presented within his report his reflection and quotes regarding his period as clinical chair for the CCG, as part of the report the appended Boards in Common proposal was submitted for support and approval by the Governing Body. Dr Greatorex and Dr Paul Johnson met with Sir Richard Ibbotson on 14 th March 2017 to discuss developing a culture of undertaking regular boards in common to improve effective delivery of healthcare within the South Devon and Torbay area. Dr Johnson drafted the proposal after discussion held within the Governing Body Development day held in February 2017, the key priorities to develop relationships and collaborative framework ensuring accurate and timely sharing of information, presentation of a publically united voice in regards to service reconfiguration and develop a way of making quick and appropriate decisions. Dr Johnson explained that the proposed first steps towards working in this way will be to PJ Draft PUBLIC GB Minutes with PJ changes.docx 4 Page 4 of 15 Overall Page 14 of 282

15 arrange the first board meeting to take the form of a seminar meeting, using the challenge of a new contract as a focus in April or May 2017, with a secondary board taking the form a formal Governing Body meeting in June or July 2017 to agree future ways of working confirming the contract details. The Chair asked the Governing Body for their thoughts on the proposal; Ms Gill Gant pressed the importance of discussing and ensuring mutual agreement to the newly emerging architecture in relation to an Accountable Care system, and inclusion of other services such as adult social care. Dr Johnson explained that for the moment the agenda would concentrate of the unpinning of SDFTF contract, due to recent developments and issues and the need for relationship development between the CCG and SDTFT, but that these meetings have the potential to be broader and encompass other areas. Mr Nick Ball noted the huge potential benefit of having a singular agenda focused on SDTFT contract, which was supported by Mr Brian Mackness highlighting the need to focus on understanding proper business. Mr Simon Tapley highlighted the need for there to be organisational development, undertaking some pre-work ahead of these boards to develop relationships and air prejudices. Dr Nick Roberts explained that currently the executive teams meet on a two weekly basis, which builds on this softer operational development work. The Governing Body agree to the working principles of the proposal, noting that organisational development needs to be undertaken outside of the Boards in Common work. Action: Dr Johnson to discuss future organisational development with Sir Richard Ibbotson, and how this can be achieved. Dr Greatorex thanked the Governing Body for all their support, expressing what a tremendous privilege it has been to serve the CCG and the population of South Devon and Torbay over the last four years and it is with confidence that role will be served by Dr Paul Johnson. The Governing Body noted the contents of the Clinical Chair report, and wished The Chair all the best in his future endeavours. 7 Accountable Officers Report Dr Nick Roberts introduced his public report noting that the first items are Sustainability and Transformation Plan (STP) focused, Dr Roberts explained that the Governing Body are requested to endorse the Devon STP considering how the board can be better engaged moving forward with the STP, but also to approve the STP MoU as a mechanism of cooperation across the Devon Wide STP footprint. Dr Roberts explained that included within the appended documents is the main Wider Devon STP, a summary report written by Laura Nicholas Director of Strategy and the STP MoU. The Governing Body currently has representation at the Programme Delivery Executive Group by Dr Roberts, Dr Greenwell attends Clinical Cabinet meetings, current workings of the STP will have a significant impact on organsiations but also the population. Dr Roberts noted that this will be the first opportunity the Governing Body will have had to formally review and approve the MoU explaining that reassurance has been received from NHS England that it is not a legally binding document, but a set of set of principles for collaborative working. The Governing Body formally approved the STP MoU. Dr Roberts informed the Governing Body that as part of the STP collaborative approach to PJ Draft PUBLIC GB Minutes with PJ changes.docx 5 Page 5 of 15 Overall Page 15 of 282

16 working he is named primary care clinical STP lead whilst Mr Mark Procter will be lead primary care director for Devon. A team are currently developing a strategic framework. Two engagement meetings have been held with Devon GP s with a follow up being arranged for April 2017, the plan will then be to undertake wider engagement with the inclusion of stakeholder groups and patients. Dr Roberts made the Governing Body aware of the newly appointed members of staff, welcoming Dr Paul Johnson as our new Clinical Chair who has been shadowing Dr Greatorex, whose term of office ceases at the end of March Sonja Manton will be commencing her role as shared (with NEW Devon) Director of Strategy on Monday 3 rd April Lorraine Webber has recently commenced in her role as Deputy Director of Quality Assurance and Improvement. Non-Executive Director Nurse interviews were held on 22 nd March 2017, and the role has been appointed to. Dr N Roberts asked if the Governing Body had any queries in relation to the report; Dr Greenwell stressed the importance of the board understanding our relation with the STP and the need to be fully involved with ongoing processes. Mr Ball questioned whether Dr Roberts was fully satisfied that the Governing Body s formal rights and responsibilities are safe? Dr Roberts highlighted that the MoU has not been reviewed by our legal teams but that it has been by NHSE and it does not have any legal formality to override decision making of the organisation, but will form a firm part of the future architecture of the NHS. Dr Nick D Arcy highlighted that it was good to note that primary care had been commented on more, Dr N Roberts noted this and explained that primary care forms an important part in future STP s, and is integral within all 7 STP workstreams. Mr Simon Tapley highlighted with the commencement of the Director of Strategy, that part of that role will be to oversee the development of the STP workstreams, and therefore it would be pertinent to request ongoing developments form part of update reports to the Governing Body on the STP priorities, and ensure the voice of primary care is provided within each workstream. Dr Greatorex questioned Dr Caroline Dimond as to how involved Public Health and local authorities are within the STP discussion, are their services appropriately represented or is there still development required? Dr Dimond confirmed that they are involved with PDEG meetings and linked into prevention and early intervention work, highlighting the issue of their team being small limits their ability to be more involved.. The Governing Body noted the contents of the Accountable Officer s report. 8 Assurance Framework Mr Mark Procter presented the Assurance Framework and risk register providing the following updates against the high level risks, noting that there are 41 open risks within the overall register. Mr Procter highlighted the three risks within the table on section 1.8 which are scored as having weak assurance: 201 Mrs Gill Gant updated the committee on the status of the full planned CQC inspection report which has taken place subsequently to the unplanned inspection which took place last year. The unplanned report identified the hospital was failing to meet certain quality standards set by CQC. The Mount Stuart have received a draft report and completed any factual accuracies, and will await the full report, the CCG will have sight of PJ Draft PUBLIC GB Minutes with PJ changes.docx 6 Page 6 of 15 Overall Page 16 of 282

17 the report a week before it is published. The report will be embargoed formal publication Mrs Gant does not expect the inspection to reveal high levels of risk. Once the final report is published, the Quality team will monitor progress against improvement action plans. There are currently no routine indicators of risk being flagged. 208 Mr Mark Procter explained that this risk relates to the potential loss of mission critical primary care NHSE staff. Noting the resignation of Julia Cory, being the main primary care contracting link with no recognised deputy, Also that the head of finance Clive Colman will be retiring which may cause difficulties moving towards delegated commissioning within primary care. Mr Procter is currently working with both Mark Cooke and Amanda Fisk from NHSE to mitigate this risk. 212 Mrs Gant presented the newly added risk relating to the Designated Nurse for Looked After Children (LAC) being unable to give assurance that SDT CCG Governing Body have due regard to their statutory responsibilities for LAC for whom they are responsible health commissioners. This has been highlighted as a result of a safeguarding survey of GB members, the plan to mitigate and improve the adequacy of the score will be by way of training and development, therefore specialist training will be provided. Safeguarding team to work with a NED to understand the preferred method of delivery of the required training for GB members. Mr Procter highlighted the risks within section 1.9 of the report, where the CCG has 6 very high risks scoring 16 or more and requested updates on those scores to date; 20 Mr Tapley reiterated the risk to demand and capacity within Torbay Hospital in terms of exceeding the RTT a decision has been made collectively that SDTFT trust do not outsource this activity to catch up to the recommended treatment time of 18 weeks, risk remains unchanged. 91 Mr Tapley explained that an action plan is in place to deal with the risk that SDTFT A&E department will not meet the national 4 hour requirement set at 95%. Dr Roberts has undertaken a visit within the department, noting that January and February were very challenging periods for A&E department both locally and nationally, performance improvements have been seen subsequently in March. Performance information is sighted by the quality and commissioning teams and is reported through the A&E System Delivery Board, risk remains unchanged. 110 Mr Tapley explained there is an action plan in place to deal with potential delays when handing patients over to the Emergency Department (ED). Noting that Torbay has a particularly higher number of 999 calls and activations comparatively to other areas. Mr Tapley is working with Liz Davenport to understand this activity. Both Dr Roberts and Dr Johnson saw the rapid assessment team working within ED as part of their visit, positive feedback from on call consultant. Dr Roberts highlighted whether delay could be attributed to the mix of staff, Mr Tapley explained this was area was being assessed by Liz Davenport although data retrieval is difficult. Risk to remain unchanged at present. 178 Mr Tapley reiterated the well sighted risk of extended waiting times for patients referred to neurology, currently the trust have a locum and GP with specialised interest in place whom specialise in headaches this has made rapid improvements to waiting times which are now down to the 20 weeks, it is anticipated better performance over the coming months. Overall risk scoring to remain, review of adequacy scoring to show improvement. 166 Mr Dowell informed Governing Body the risk assessment reflects status currently with the development of the financial plan, financial plan contained within agenda. PJ Draft PUBLIC GB Minutes with PJ changes.docx 7 Page 7 of 15 Overall Page 17 of 282

18 Adequacy score green because financial reporting within SDT CCG committees. 167 Mrs Gant explained that there is a potential risk to patient experience when demand and activity is high within A&E, although the team have not received any information relating to compromised patient safety, if anything overall patient opinion is of having received a good experience, risk to remain unchanged. Previous discussions undertaken that the risk should be split to in two, for patient experience and patient safety. ACTION: Risk 167 to be split to reflect patient experience and safety. Mr Procter noted to the Governing Body that 5 new risks have been added to the register since the Governing Body last report on 16th November 2016 detailed in section There have also been 17 risk closures within this timeframe, detailed in section Mr Procter brought tabled papers to the Governing Body s attention, an open letter response from SystmOne, detailed BMA paper and a briefing notification from ICO. This was raised as an emerging risk the notification was brought to light last night, noting concerns raised by the Information Commissioners Office (ICO) that they have data protection compliance concerns with SystmOne s enhanced data sharing function. The ICO are working with TPP, NHS England, NHS Digital, BMA and the Department of Health to reach an agreed way forward for continued betterment of patient care, but the advice given is not to restrict or stop sharing SystmOne data as it would be detrimental to both patient care and the service that can be provided by patients. Mark informed the Governing Body that a teleconference meeting taking place with CCG staff currently to discuss how this issue will be dealt with locally and nationally, and the potential effect on community teams and the out of hour s system, noting that this issue is likely to become more publicised, practices will be made aware of situation and provided with advice, whereby they can make their informed decision. The Governing Body acknowledged that the risk of compromise to patient data is limited, compared to not having access and the potential impact. Data is only accessed by those who have been given appropriate permission the risk to inappropriate usage is limited, system can be audited. The Governing Body noted the contents of the assurance framework and risk register. 9 Finance, Operating and Performance Report Mr John Dowell presented the draft finance, performance and contracting report for 2016/17 for information and approval based on month 11, to 28 th February 2016/17. Mr Dowell explained the positive aspect of the report is that there has been a stable a position since the revised forecast outturn of 7.97m, first reported at month 9. Written confirmation from NHSE has been received that the 1% headroom of 3.9m will be released into SDT CCG accounts. With the application of this it will reduce CCG overspend 4.018m, but for performance purposes the CCG will be assessed at the higher figure of 7.970m which is some distance away from the target. The overall position also reflected stability in the forecast for TSDFT and our relationship with the Trust through the risk share agreement which has an influence on the CCG s overall financial position. The Trusts forecast outturn deficit being 11.4m after application risk share contribution that we make as a result of that is recorded as part of our year end position. The Trust will have delivered the 4m call to action plan. In terms of performance reflected within the dashboard of the report, the demand indicators monitored are those on GP referrals, general and acute referrals, cancer and two week wait (2WW) referrals and diagnostics. Some concerns raised over the level of 2WW referrals received which has increased by 20%. Work to be undertaken with TSDFT PJ Draft PUBLIC GB Minutes with PJ changes.docx 8 Page 8 of 15 Overall Page 18 of 282

19 to understand this flux in demand, which is explained by a change in recent NICE guidance. Non-elective performance has been previously discussed in terms of A&E performance and 4hr waiting time standards, also RTT is a generally deteriorating position. Dr Fox queried an increase within the high cost drugs? Dr Jo Roberts explained that there is ongoing work to manage these costs and an action plan has been approved, to encourage specialities to take a lead responsibility on this work linking in with Paul Foster from TSDFT to work collaboratively. Mr Tapley asked where SDT are in terms on performance compared with Plymouth, Mr Procter explained that this process of learning is still in transition but there is still further work to be progressed. The Governing Body noted the contents of the Finance, Operating and Performance Report. The Governing Body took a short recess and reconvened at 12:10. 9 Financial Plan 2017/19 Mr John Dowell provided an update on the operating plan for finance and performance , the report summarises the latest financial plan and performance trajectories for SDT CCG The drafted financial plan for highlights delivery of a forecast deficit of 15.7m in year 1 and a balanced plan in year 2. There is more detail within the report focused on 2017/18 plan, than that of 2018/19.Section 2 of the report sets out some of the performance in 2016/17 noting at the start of the year a high risk plan with 12m of unmitigated risks. Based on the previously discussed financial position and the CCG s performance against that there has been a recovery of about 5m unmitigated risk, therefore ending with 2016/17 a deficit of 7.97m before headroom. Mr Dowell noted the included table on page 4 of the report is a reminder of the QIPP challenge target for 2016/17 which was a gross target of 30.7m. The reason for noting this is that the top line figures within the table arevery influenced by the working and contractual arrangements that the CCG has with the TSDFT, so although there were good achievements made it was still short of the required target. That has influenced the potential move towards joint system working going into 2017/18, as this will be a more successful method of delivery. Section 3 is a contextual reminder that CCG allocated funds are judged to be above the CCG s fair share of the national total for health services and it shows that by 2021 we will be some 20m (5%) over our fair shares target. At present there is no indication that this will be removed from our allocated funding, but we should expect to receive lower than average growth. Section 4 provides information on how the CCG set the plan according to the required target. The first table included shows the level of QIPP delivery required in order to achieve the submitted plan. Within the plan there will be provisions made for 0.5% contingency and provision for 1% headroom. We are permitted to use half of that headroom and this has been accounted for within the plan. We are not achieving the 1% surplus which is stated within NHSE business rules for all CCGs, plans will be subject to further scrutiny and challenge from NHSE. Mr Dowell reminded the Governing Body that in terms of mental health services the CCG are planning to make a 1.6% uplift in aggregate investment within mental health services, in line with Parity of Esteem Commitment. Section 5 looks at the performance aspects supported by the plan in place, Based on the previous discussions held today the risk to achieving those assumptions is well PJ Draft PUBLIC GB Minutes with PJ changes.docx 9 Page 9 of 15 Overall Page 19 of 282

20 understood, in particular performance relating to RTT. Section 6 key risk and issues are related to the size of the savings programme required to deliver the plan which is being submitted.. The volumes of demand and activity performance within TSDFT are key determinants of financial performance for us because of the risk share agreement. The plan does rely on the achievement by TSDFT of the 5.8m sustainability and transformation funding, which is related to financial performance and A&E performance for 2017/18. Section 7 sets out the CCG is working as part of the wider STP and the arrangements which have been put into place within the SDT community and also to work with TSDFT as the CCG s main partner in the system Section 8 sets out the summary financial plan and the areas of expenditure, Mr Dowell noted the table detailing the 2017/18 plan which indicates a 15.7m deficit for the CCG. Previous discussions held within Governing Body and Commissioning Finance Committee have agreed the approach for our community being that of a 40.7msavings programme to be delivered across the CCG and TSDFT in 2017/18. The remaining deficit will be held on behalf of the community with the support of the STP. Section 9 identifies running costs, the overall running cost allowance for managerial costs for the CCG is approximately 6m which is about 1.5% of the CCG s overall expenditure. This compares favourably to other sectors. Work is ongoing to reduce these costs further through joint working arrangements Section 10 and 11 set out some of the operational approaches to system savings plans and through the scheme of delegation. Section 12 sets out the recommendation after suitable clarity and iterations from the Governing Body that the financial plan is approved for adoption. A further submission to NHSE is required on the 30 th March The recommendation is that this plan is agreed for submission. Mrs Gill Gant informed the Governing Body that executive team working together have agreed that each part of the savings plan will have a quality impact assessment completed, using the same agreed tool as used across the STP which is embedded within the PMO and that every program will have an initial QEIA and where required a full assessment. Mr Simon Tapley noted within section 5 where performance trajectory is mentioned, Mr Tapley drew to the attention of the Governing Body that discussions are taking place with agreement from TSDFT that RTT performance is moved to March 2018 which will require about 3m investment, therefore the likely hood is the trajectory will be changed to say it will only be achieved by March Mr Brian Mackness acknowledged that this is a very challenging plan, and although it doesn t meet all of the national regulatory requirements, it is an achievable plan, but certainly not comfortable. Mr Simon Tapley questioned how confident Mr Dowell is with the submitted financial plan and savings programme? Mr Dowell noted Appendix C which sets out system savings plan for the delivery of the programme; this is a combination of QIPP and a cost improvement programme for TSDFT and will be subject to regular reporting to both CCG Governing Body and TSDFT Board. Mr Nick Ball questioned the financial variances within the paper between 7.9m and 10.2m detailed in section 16? Mr Dowell explained that this is the difference between recurrent and non-recurrent positions. Mr Dowell explained that the 2017/18 plan makes no provision for repayment of 2016/17 deficit, but the plan starts from an overspent position, confirming that at the financial forecast at the end of 2017/18 will be a deficit of 15.7m. PJ Draft PUBLIC GB Minutes with PJ changes.docx 10 Page 10 of 15 Overall Page 20 of 282

21 The Governing Body noted the contents of the financial plan and the plan was approved for adoption. 10 Quality Report Dr Nick D Arcy presented the quality report explaining that the ratings provided are those given by the Quality team s assessment on quality riskof the providers. Currently using a Red/ Amber / Green rating which will change to a High/ Medium/ Low rating of the level of surveillance required. Devon Partnership Trust (DPT), TSDFT and South Western Ambulance Service NHS Foundation Trust have been risk assessed and require a heightened state of surveillance, noting that although DPT CQC report overall rating was good there are issues the team wish to maintain surveillance upon currently. Provider Quality Update TSDFT have a four hour national standard for time spent in A&E, and locally the STF agreed a trajectory of 92% which was not met in February 2017 (89.62%) although this is an improvement of January s position (86.9%), Current position for March 2017 meeting the 95% standard. Recommended Treatment Times (RTT) standard position for incomplete pathways was (87.3%) against a target of 92% this is reduced in comparison to December 2016 reported data (87.4%). TSDFT cancer standards currently are: - 14 day breast symptomatic standard Not met 89.3% target 93% - 31 day 1st treatment standard Not met 95.5% target 96% - 62 day from urgent referral Not met 83.9% target 85% 14 patients were reported at the end of January 2017 as waiting over 52 weeks for treatment. Dr Nick D Arcy reported on DPT that despite an overall good rating from CQC, some concerns remain in terms of quality of the service and safety to patients, this is being monitored across both NEWD and SDT CCG s. There is potential risk associated when investment into the central complaints and investigation team ceases in March. Risk surveillance rating to be increased to red based on these issues but also with the increase on reporting of patients whom are receiving or waiting for treatment who report as suicidal. This is a concern noted over Devon wide foot print therefore an investigation into this will commence by way of a deep dive, to be delivered on 8 th April Dr Nick D Arcy informed the Governing Body that the risk surveillance rating for SWASFT will increase to red status this based on the delayed ambulance response attendance, and two incidents where a delay was reported these are being investigated. Mr Tapley noted that there is a pressure on staffing levels currently which may be associated with the implementation of community based urgent care pilots e.g. Somerset. Also the commissioning of services takes place in Gloucester therefore a lack of understanding into the concerns and issues faced across the Devon and Cornwall may need to be addressed. Dr Nick D Arcy noted that the number of complaints acknowledged within 3 working days for Virgin Healthcare Services was 63% against the target of 85%. The Quality team will work with the service in terms of data improvement. Mount Stuart Hospital as previously discussed awaiting CQC report. PJ Draft PUBLIC GB Minutes with PJ changes.docx 11 Page 11 of 15 Overall Page 21 of 282

22 Recommendations received from the Quality Committee is that the Governing Body receive updated safeguarding training in all key aspects as soon as possible, as previously highlighted within the newly register risk. Dr Nick D Arcy highlighted to the Governing Body the addition of the appended Quality Directorate annual report which is not a statutory requirement but good practice. Mrs Gill Gant informed the Governing Body that Lorraine Webber has now joined the Quality team as Deputy Director of Quality and Assurance, noting the positive work already commencing particularly being a NHSE key line of enquiry around supporting care homes and identifying need. The Governing Body noted the contents of the Quality report. 10 Acute Services Review Dr Nick Roberts presented a Devon STP review of Acute Services paper produced by Mairead McAlinden in September 2016, which was received by Chief Executive Office s on 30 th November The purpose of the paper is to notify provider and commissioner boards of the ASR and seek endorsement of the criteria and principles. To date the paper and process has been agreed by the STP Leadership Group of Chief Executives and the Devon wide Clinical Cabinet In terms of public engagement there have been two events held to date, with a further planned for Friday 24 th March in Paignton. Dr Nick Roberts asked the Governing Body for feedback and suggestions; feedback provided from Governing Body was that the paper generally contained the right criteria, the paper will be submitted to GP Executive Group (GPEG). It was highlighted by the Governing Body that the paper focused on the acute system and did not focus on the system as a whole this could be improved. Dr Jo Roberts noted that the review did not show or reflect cost effectiveness which would provide clarity and information. Mr Dowell commented on an attended event where it was raised that the review did not include information pertaining to affordability or consider patient choice. The Governing Body noted that changes made to service provision during the period of purder will not be undertaken, although the workshop events can take place. The Governing Body noted the contents of the review and approved the strategy. ACTION: Dr N Roberts to feedback discussions and suggestion in terms of the ASR criteria, to Mairead. 11 Children s Services Update Mr Simon Tapley provide an update on the status of children s services procurement, the process has been split in two; moving forward an interim contract will be held by Virgin Healthcare. Public Health Service following consultation will be included within the 2018/19 scope of services on an ongoing basis. A call is scheduled on Friday 24 th March to align the position with the provider Virgin Healthcare. Part two of the ongoing procurement preparations will be to secure a 5, 7 or 10 year contract which is expected to commence 1 st April 2019; the commissioning project team is working with partners to ensure all priorities are encompassed, currently moving into a better procurement position than neighbouring CCG s. PJ Draft PUBLIC GB Minutes with PJ changes.docx 12 Page 12 of 15 Overall Page 22 of 282

23 The Governing Body noted the contents of the Children s Services update. 12 Community Services Update Mr Simon Tapley presented a quarterly update on Community Services Consultation providing an update on the progress made by TSDFT in implementing the decisions made by our Governing Body in January Mr Tapley noted that Ray Chalmers, Rebecca Foweraker and Jenny Turner have been heavily involved with the production of this process and associated papers. Mr Tapley, Dr N Roberts and Liz Davenport have been in attendance for several scrutiny committees where the parameters for implementation have been set with appropriate reporting taking place via Commissioning Finance Committee. Contracts are in place for intermediate care placements in care homes locally for Ashburton/ Bovey Tracey/ Paignton & Brixham/ Newton Abbot and Torquay. Clinical Directors insitu for Moor to Sea, Torquay & Paignton and Brixham localities. Mr Tapley noted that the Clinical Director post for Newton Abbot has recently become vacant with plans to recruit in April 17. Medical contracts are in place to support Intermediate Care in each locality. Staff will be used flexibly across sites to ensure that safe staffing levels are met, a full review of staffing levels in community hospitals in April The parameter for intermediate care opening for six days a week in the locality was already operational, and became a seven day service from 1 st March Intermediate Care teams are in place within all localities, outstanding vacancies will either be recruited to, or filled by way of redeployment. Daily multi-disciplinary team meetings are taking place within localities, also referral systems are in place for intermediate care and well-being co-ordination. Rapid response team staffing levels have been increased based on the anticipated increase in intermediate care activity; Mr Tapley confirmed that parameters are being met for all inpatient services. The parameters in place for minor injury units has not been met, and although a radiographer rota was in place subsequently notice has been received for one of those radiographers. Dartmouth Hospital is now closed to new patients, with anticipated safe discharge of all patients expected by 31 st March Paignton Hospital will be closed to new patients from 1 st April 2017, Bovey Tracey currently closed to new admission with planned discharges. Implementation of changes will be overseen by the CCG s Community Services Transformation Group with the support of implementation groups which are being formed within each town with the inclusion of stakeholders. Invitations are currently being issued; groups will initially be established in Ashburton, Bovey Tracey, Dartmouth and Paignton. Mr Tapley noted feedback from scrutiny committee was to increase publication of the positive impact and messages received in particular those from Coastal locality. Mr Tapley noted that Liz Davenport has noted this action to complete. The Governing Body noted an uncertainty as to what medical cover arrangements have been secured for intermediate care provision in Torquay locality? Mr Tapley explained that SDTFT are working on this issue and will, if not secured, provide support through their GP s. ACTION Mr Tapley to clarify arrangements secured for medical cover for intermediate care provision in Torquay Locality. The Governing Body questioned how will they be assured that the agreed models of care PJ Draft PUBLIC GB Minutes with PJ changes.docx 13 Page 13 of 15 Overall Page 23 of 282

24 are being adhered to? And what monitoring will take place? Mr Tapley confirmed that extra surveillance will take place during the transitional implementation period which will move to a normal level of monitoring. Mr Tapley confirmed that where concerns have been raised contact has been made directly with the provider to confirm arrangements, signing of papers or sufficient provision of medical cover, implementation of provider spot checks if required. Liz Davenport has been requested to confirm that safer staffing model have been adhered to in the hospitals concerned. The progress of implementation will be overseen by determined governance groups with quarterly updates being made to Governing Body. The Governing Body were satisfied with the checks and monitoring that have been put into place, also that there will be a period of heightened surveillance through the transitional implementation period. The Governing Body noted the contents of the Community Services update. 13 Review of Committee Minutes Commissioning and Finance Committee Mr Brain Mackness explained that two sets of Commissioning Finance Committee minutes have been deferred to the private section of the Governing Body based on content. The Governing Body received the report, minutes. No comments Audit Committee The Governing Body received the report and minutes. Quality Committee The Governing Body received the report and minutes. Primary Care Joint Commissioning Committee Mr Procter highlighted the main areas of focus from the last Primary Care Joint Committee was the demonstration from Torbay Healthwatch of their rate and review system, which has not as yet been implemented by Devon. Also the shifting costs across budgets associated with Denosomab (Osteoporosis) have been raised as an issue, but that ongoing discussions are taking place. The Governing Body received the report and minutes. Engagement Committee The Governing Body received the report and minutes, and acknowledged the tight timelines for engagement for re-procurement of children s services. 11 Close Joint Localities Group The Governing Body received the report and minutes. PJ Draft PUBLIC GB Minutes with PJ changes.docx 14 Page 14 of 15 Overall Page 24 of 282

25 Close of meeting 13:24 PJ Draft PUBLIC GB Minutes with PJ changes.docx 15 Page 15 of 15 Overall Page 25 of 282

26 Overall Page 26 of 282

27 MINUTES Meeting South Devon & Torbay Clinical Commissioning Group (CCG) Governing Body Venue Teign room, Newton Abbot Racecourse, Newton Abbot, TQ12 3AF Date / time of meeting Thursday 26 January 2017, 10:00-12:32 Chaired by Dr Derek Greatorex Minutes taken by Viki Kirby Board members: Brian Mackness* - BM Chris Peach* - CP David Greenwell (Dr)* - DGr Derek Greatorex (Dr)* - DG Ellie Rowe (Dr)* - ER Felix Burden (Dr)* - FB Gill Gant* - GG Jo Roberts (Dr)* - JR John Dowell* - JD Kevin Muckian* - KM Mark Procter* - MP Mat Fox (Dr)* - MF Nick Ball* - NB Nick D Arcy (Dr) - ND Nick Roberts (Dr)* - NR Paul Johnson (Dr)* - PJ Simon Tapley* - ST Co-opted members: Caroline Dimond (Dr) - CD Virginia Pearson (Dr) - VP In attendance: Kevin Foster* - KF Liz Davenport* - LDp Paul Cooper* - PC Sarah Wollaston* (Dr) - SW Steve Brown* - SB Viki Kirby* - VK Other CCG staff Members of the public Non-Executive Director Non-Executive Director Clinical Lead for Integration Clinical Chair Clinical Lead for Commissioning Non-Executive Director Director of Quality Assurance and Improvement Clinical Lead for Innovation and Medicines Optimisation Chief Finance Officer Non-Executive Director Director of Primary Care and Corporate Services Chair of Localities Group Non-Executive Director (Vice Chair) Clinical Lead for Patient Safety and Quality Chief Clinical Officer Incoming Clinical Chair Director of Commissioning and Transformation Director of Public Health for Torbay Director of Public Health for Devon Member of Parliament - Torbay Chief Operating Officer, TSDFT Deputy CEO / Director of Finance, Performance & Info, TSDFT Member of Parliament - Totnes Assistant Director of Public Health for Devon (attending for VP) Executive Assistant to Chief Clinical Officer and Clinical Chair Approx. 10 individuals attended as part of the audience Approx.150 individuals attended as part of the audience * Denotes member present () Denotes present for part of meeting Item Welcome and introduction DG welcomed individuals and read the statutory statement detailing the arrangements for the session. DG thanked Healthwatch for supporting the community services transformation consultation work. DG asked the Governing Body (GB) members to introduce themselves. Declaration of interests DG explained that these were submitted in advance and asked GB member for any additional comments. No updates were shared. Action Public questions submitted in advance of the meeting DG read out the questions submitted from the public in advance, which were answered by Driving quality, delivering value, improving your services 1 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 1 of 11 Overall Page 27 of 282

28 members of the GB, as below Question from Karen Jemmett "The proposed closure of Paignton Hospital in the CCG plan assumes that extra services will be in place which enables more patients to be cared for safely at home. Exactly how many extra residents are expected in the plan to be cared for at home in this way, how much time per day will the extra staff be able to devote to each person per day at their home, and how many extra trained people will be in place before the hospital would be closed? If no figures have been identified for any of this, how can there possibly be any confidence in such a plan being deliverable or clinically safe? Furthermore, the attendance allowance system is already over-subscribed and greatly abused, so the more people qualifying for domiciliary care of some kind under the new arrangements will further inflate the local attendance allowance budget. Although attendance allowance is funded by central government via the DWP welfare component, the sheer scale of the costs involved in effectively paying growing numbers of pensioners an 84 weekly pension bonus should be of concern to us all. Particularly, when the current workforce are being asked to accept a reduced state pension and having their own retirement delayed by up to seven years. When you consider that the CCG are applying stringent fiscal arguments to convince us all of the need for changes in the way services are delivered, I do think this kind of broader analysis of health and social care spending really should be highlighted. As Sarah Wollaston herself said on prime time TV last week, we need to take a broader, holistic approach to spending rather than focusing exclusively on Primary Care delivery." Answered by ST The new services available as part of the new care model will support an additional 1,600 people outside a hospital setting across Torbay and South Devon. We are bringing together teams of nurses, social workers, physiotherapists, occupational therapists, pharmacists and support staff, some of whom will have been hospital based. Torbay and South Devon NHS Foundation Trust (TSDFT) has recruited for intermediate care an additional 22 whole time equivalent qualified staff and an additional 38 whole time equivalent unqualified staff. TSDFT has also recruited 5 new locality pharmacists and 16 wellbeing coordinators. These staff will visit and support people in their own homes helping to provide alternatives to going into a hospital bed, which for some patients has been the only option available to them in the past. The amount of time staff spend with people in their own homes will vary according to the amount of care and support needed during the course of the patient s treatment and rehabilitation Question from June Pierce, Chair of Torbay Older Citizens Forum If the decision is taken to close the 4 hospitals and the subsequent loss of beds for people to recover to a point where they are able to go home, is there a plan B for consideration? If it is found that the main district hospitals are overwhelmed by patients not able to leave because there is no social care package in place, what will happen? Many care homes have closed over the last years, others are not up to standard following CQC inspections, and others are unaffordable to the general public. It is accepted the first 6 weeks of care in such homes is free of charge, some patients need longer than that, where is the money coming from? Is it the intention to close all 4 hospitals together, or phase in such closures so that lessons can be learned as the procedures and plans come into effect? Answered by ST ST explained that he will share more detail within his imminent presentation. The GB is being asked to approve parameters that will need to be met before any beds are removed from any of the 4 hospitals recommended for closure. If these are agreed, then beds will be removed from hospitals when these parameters are met so it is unlikely that all 4 will close simultaneously. Beds could be removed before outpatient clinics are moved as part of the transition process. The evidence suggests that the additional community based support provided as a result of switching spend from hospital bed based care to community based care will be sufficient to support people at home and therefore avoid unnecessary admissions and reduce length of stays. Successive audits show that about a third of people in community hospital beds could be cared for elsewhere if the out of hospital support was available. Only a very small proportion of these patients are waiting for packages of care. Driving quality, delivering value, improving your services 2 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 2 of 11 Overall Page 28 of 282

29 This week, 3 patients in community hospitals experienced a package of care delay. Patients currently tend to spend on average days in a community hospital. For the whole health and social care system to work effectively, partner organisations need to ensure that where appropriate there are support services available such as domiciliary care and care homes for those that are assessed as needing longer term care. ST is confident that the proposals will meet need and improve care, and that a plan B is not needed. Question from Cllr Stephen Smith (Dartmouth Town Council / Townstal Ward & Chairman of the Townstal Community Partnership) Now that the consultation has been formalised what is the final cost of the consultation process? Answered by JD The final figures will be calculated following today s meeting. This figure will be published on the CCG website in the next couple of weeks. DG pointed out that consultation is statutory. Question from Val Lightfoot There are already problems with agencies providing care - not enough staff, issues about recruitment, training and the limited time allocated to clients. Also bearing in mind the existing situation with the Mears Agency and the intervention of the Care Quality Commission. Where will all the additional staff needed to provide this increased level of care in the community come from? This needs to be resolved otherwise the existing bed blocking will only become worse. Answered by ST Pressure on staff applies across health and social care and one of the factors underpinning the consultation proposals is the need to use limited staff resource in the most effective way. As set out in the consultation documentation, almost 5 times as many people are supported at home than in a community hospital, and it is believed that investing in the services that most people use will improve care. Experience suggests that the new roles in intermediate care and health and wellbeing teams are attractive to potential recruits and as indicated in the consultation documentation, the TSDFT has been able to fill such vacancies. Experience also suggests that it is increasingly difficult to recruit and retain staff to community hospitals. The average stay in a community hospital is about 15 days. Many people who are currently admitted to a community hospital will, in the future, be cared for by the intermediate care teams either in their own homes or in care homes. For those people that need care and support in the longer term, work with partner organisations will ensure support services, where appropriate. Question from Vic Ellery, Independent & Ward Cllr for Berry Head / Furzeham How does Devon CCG s consultation on the Sustainability Transformation Plan (STP) effect any decision being made today if any of Devon s recommendations impact on the South Devon s Health Community? Answered by NR North, East and West (NEW) Devon CCG are undergoing an independent consultation process which is unrelated to the local consultation work. No consultation is currently taking place in relation to the Devon-wide STP. Engagement will take place about the acute services review in the coming weeks, and should the review identify any significant service change, appropriate consultation will take place too. The recommendations being discussed today are in line with the STP objectives. JD Question from Paul Raybould, GMB Torbay and South Devon Branch Can the CCG show clear documented evidence that the new care model with the loss of 4 community hospitals and 60 plus in-patient beds, improve the health and wellbeing of the residents of South Devon? GMB and Torbay and South Devon TUC have great reservations that the CCG have underestimated the impact that balancing its books by rationing services now, before the impact of the STP changes have been consulted on, may leave the local NHS needing more drastic cuts to staffing levels and impact on patient care that have as yet not been taken into consideration. Thus running before you can walk. Answered by NR Driving quality, delivering value, improving your services 3 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 3 of 11 Overall Page 29 of 282

30 The clinical case for change published during the consultation, provides the basis for the changes from a clinical point of view. This case for change was also reviewed by the South West Clinical Senate (an independent group of clinicians). This and other support documents published during the consultation, detail results from successive audits of bed occupancy - roughly a third of patients could be cared for in another setting if out of hospital care was available. There is also well documented evidence that the health of some people deteriorates if they remain in hospital beyond the point where they are clinically fit to be discharged. Evidence from both the intermediate care service in Torbay and the health and wellbeing team in Teignmouth and Dawlish show the effectiveness of these services. Overall the aim of the new care model is to invest in wellbeing and health promotion, building more resilient multi-disciplinary teams and more effective Minor Injury Units (MIUs). It is important to remember that almost 5 times as many people are cared for at home than in community hospitals and that the average patient stay in a community hospital is only 15 days. So the proposed changes will impact positively on many more people, thus improving the care that most people use. As indicated previously, these proposals are in line with the STP and with the approach of using resources in the way that provides the best care to the people of South Devon and Torbay Question from Ann Harding Reading your attachment leads me to believe that consultation meetings and petitions were nothing more than false exercises fooling the public into thinking they could affect the result. Hundreds of people attended and were unanimous in keeping the community hospitals open. My question - how therefore can the CCG now decide to close the community hospitals instead of keeping the beds and expanding the services within? This is totally in opposition to the wishes of the community. Answered by ST There is recognition that many people wish to retain their local community hospital. Most people also wanted to see the services that most people use strengthened, and for people not to be admitted to hospital unnecessarily or stay there too long. As detailed throughout the consultation, the CCG has a responsibility to use resources effectively and to ensure services meet the needs of the population as a whole. There is neither the finance nor the staff to retain all current community hospital beds and to invest in community based services that will meet future demand. There is also insufficient money required to bring the hospitals recommended for closure up to modern standards. It is therefore not sustainable to continue to spend as much money on hospital-based care where the evidence shows that supporting people in or near their own homes delivers better outcomes for many patients. The CCG was very clear during the consultation that doing nothing was not an option and asked for people s views on the proposals as well as any alternative suggestions. The evaluation process to reach the recommendations being made today has been robust. The CCG is trying to meet the range of views expressed and is being recommended to adopt an approach that will provide beds for when people need them and sufficient support in the community to help keep people out of hospital unnecessarily Question from Cllr John Robinson, Stoke Gabriel Parish Council The hospitals have no money therefore less beds. The beds are taken up by those wishing to leave hospital and recover somewhere where they will be looked after and monitored prior to going home. Regarding Dartmouth Hospital, it is intended to move to a combined new site at Riverview but they have offered only 4 beds which is simply is not enough. Where will you go when you want looking after? I have heard that funding for post heart attack care is also being cut. I am a volunteer at cardiac rehab and know exactly what the patients are going through and how they now worry about their well-being. I have personal experience of all 4 of the hospitals recommended for closure, having had close friends, me and family there all recuperating after hospital experiences. Where do you intend to place patients who require after care and how do you intend to move those still in hospital who are taking up beds unnecessary? The weakness in you argument is that 2/3 of the beds are still needed. This plan does not deliver this? Answered by ST Under the recommended proposals, there will still be beds for people who need to be in a Driving quality, delivering value, improving your services 4 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 4 of 11 Overall Page 30 of 282

31 hospital. At present people do not necessarily go to their nearest community hospital. As you say, successive audits have shown that about a third of beds have patients in them that could be cared for elsewhere, but 2/3 of beds are still required and these will still be provided at the remaining community hospitals. On page 30 of the GB report, the needs assessment for Dartmouth indicates that 4 beds are required for intermediate care and this is what is currently being discussed for Riverview. By switching spend from hospital bed based care to community based services, the CCG believes more individuals will be looked after at home and so reduce the number of people who need to be admitted to hospital. Should the recommendations be approved, implementing the changes will be done in a way that minimises any impact on patients in line with the parameters set out on pages 31 / 32 of the report. In terms of cardiac rehab, neither TSDFT nor the CCG plans to reduce this and do not envisage the reconfiguration proposals being discussed today having an impact on this service Question from David Halpin What plans do you have to care for people at home if you have neither nurses nor doctors in adequate numbers in the absence of Community Hospitals and their professional staff? If your plans implode, which is likely, will you walk away - and with or without any pensions accrued from the CCG? Answered from DG One of the challenges which face the current system is the difficulty of recruiting staff to community hospitals. The evidence suggests that the health and wellbeing teams provide a more attractive career option and that recruiting to these teams will be less difficult. Ensuring that health services have adequate staffing cover can be a challenge in times of holiday and / or sickness but stronger, larger multi-disciplinary health and wellbeing teams will provide more resilient staffing arrangements and a more robust service that will look after more people than can be supported in community hospitals. The CCG does not believe plans will implode. The CCG has an obligation to commission services to meet the quality and budgetary requirements laid down by the government and NHS England. Proposals meet legal requirements and are designed to respond to future demand for services (one of the CCG s duties), improve wellbeing and health promotion, and to avoid people being admitted unnecessarily to hospital. They seek to make best use of resources, are in line with the NHS Five Year Forward View and have been independently supported by the South West Clinical Senate. All members of the CCG are committed to improving the care of the people we serve. Address from Members of Parliament (MP) Dr Sarah Wollaston MP SW shared concerns about community hospital closure impacting on end-of-life care, and asked if local beds could be commissioned especially for this. SW highlighted that the UK has the lowest number of end-of-life beds in Europe. SW requested a guarantee that the new car model would be implemented before community hospital closures. SW acknowledged the CCG s challenge to provide services within budget using available staffing, and felt that no-one would want to see community hospitals close in an ideal world. SW thanked community hospital staff. Kevin Foster MP KF acknowledged estate issues at Paignton Hospital, especially x-ray services. KF highlighted that the proposals do not indicate which clinics will close. KF felt a lack of clarity on land available for new facilities and buildings in Paignton, and confirmed that he and SW had seen some available alternative sites. KF highlighted a lack of residential and care home beds which will delay discharge further if the community hospitals close. KF asked how the new care model will address staff recruitment / retention difficulties. KF highlighted issues with the recommendations and answers to the questions above. Driving quality, delivering value, improving your services 5 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 5 of 11 Overall Page 31 of 282

32 4.3 DG thanked SW and KF, and explained that their comments would be addressed within ST s imminent presentation 'Into The Future Re-shaping Community-based Health Services' presentation ST delivered the presentation and confirmed that he attended all but 1 of the consultation meetings and is fully aware, as are GB members, of the emotive issues and difficult choices to be made. ST thanked individuals for the large turn-out today. ST invited MF to share details of his journey and experiences of implementing the new care model within the CCG s coastal locality. MF explained: That there were 2 community hospitals (3 miles apart) in Dawlish and Teignmouth, which transitioned to in-patient beds in Dawlish and a clinical hub in Teignmouth. Every day, clinical hub staff discuss / understand the status of local patients, and ensure that they are cared for in the most appropriate environment, including home care as an alternative to Torbay Hospital. Clinical hub staff are best placed to do this as they know local people better. Clinical hub staff include the clinical hub co-ordinator, therapy leads, district nurses, GPs, community pharmacists, community social services, mental health staff, care homes and the voluntary sector. The transition to this model has been challenging but extremely positive. ST explained that although the people of Dartmouth did not want to see the voluntary levy taken forward, they were not necessarily unsupportive of the alternative to co-locate with Riverview and community out-based clinical and surgical provisions. ST apologised that his wording was clumsy. 6 Questions for GB As detailed in his presentation, ST posed the following questions to the GB Question 1 - does the GB agree that the 25 alternative proposals listed on pages should be discarded? CP highlighted that end-of-life care at home is not practical for some, and asked if Ashburton Hospital could provide this. ST explained that the Community Services Transformation Group discussed this and the TSDFT Medical Director (Dr Rob Dyer) confirmed that very few people die in community hospitals. As an alternative, hospice at home is provided by Rowcroft and Marie Curie, the CCG will have a contract with care homes, and acute / hospital medical care beds will still be available if needed. BM asked if plans to terminate the mobile clinic could be incorporated into the new care model implementation plan. ST confirmed that LD would incorporate this. MF added that end-of-life patients in the CCG s coastal locality are discussed daily (by the clinical hub staff) and the majority of patients are supported by enhanced services at home. Clinical hub staff work closely with Rowcroft and the dedicated end-of-life team. ER suggested further discussion about the new potential hospital site on the ring road. ST explained that this site had been discarded due to affordability and insufficient timeliness of the build. CP visited the coastal locality clinical hub and was impressed by the health and wellbeing teams, but questioned why GPs would not want to run the clinical hubs themselves. PJ confirmed willingness from GPs, but a lack of resource and capacity. PJ is currently a Locality Clinical Director with TSDFT, and work is ongoing within this role to understand the resource needed to support GPs. KM asked how clinical hub performance, quality, consistency and sustainability are assessed. MF explained that Plymouth University start a formal 12 week evaluation period LD Driving quality, delivering value, improving your services 6 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 6 of 11 Overall Page 32 of 282

33 in February NB asked if there was mileage in exploring how radiographer staff could be developed now, to work in the areas needed. ST highlighted the related detail within the accompanying paper, summarising that there are not enough individuals undertaking the relevant training. ST is happy to explore the location of services in Paignton again if radiographer staffing availability improved within the next 5 years. MP asked ST to explain the rationale to locate a health and wellbeing centre in Paignton, whilst closing its MIU. ST explained that MIUs need consistent staffing and this has been challenging in Paignton. The state of the building is also poor, and services have been located in places where travel times best match the population as a whole. FB asked if the voluntary sector can provide end-of-life and loneliness support. MF confirmed that the coastal locality clinical hub discuss patient isolation and already tap into voluntary services. PJ also challenged the assumption that being in hospital beats loneliness. CP asked if the NHS can provide domiciliary care directly if the care market implodes. ST said intermediate care provides 2-3 weeks of intensive care. If an individual has personal care needs during this time, they are supported by in-house / NHS funded rapid response teams. If longer term support is needed, social care provision is provided, which is means tested (an individual is assessed to determine whether they are eligible for funded support, based on the individual or family s means to do without that help). LD confirmed that if the recommendations are approved, TSDFT community hospital staff can move into community teams. ST confirmed that Torbay Council and Devon County Council are fully aware of the new care model plans and have taken this into account when budget setting. Answer to question 1: Yes (see caveat at re radiographers) 6.2 Question 2 - is the GB assured that the case for reducing community hospital beds has been robustly made? Answer to question 2: Yes Question 3 - is the GB assured that the evidence is clear for the location of clinical hubs, namely Totnes, Newton Abbot and Brixham? ST pointed out that clinical hubs have inpatient beds and specialist outpatient clinics. NR said the availability of specialist clinics at the Paignton health and wellbeing hub are still to be reviewed. Answer to question 3: Yes Question 4 - is the GB assured that the evidence and rationale for the placement of MIUs has been made and is sound, namely Newton Abbot and Totnes? ST confirmed finite nursing and radiographer resource, and therefore the need to concentrate this. MF asked if cross-boundary working with NEW Devon CCG could be explored to support the Kingsbridge population too, with a possible MIU in Brixham and Kingsbridge. ST explained that NEW Devon CCG has already discussed this with their providers. Because radiographer availability is an issue, this is not an option. LD Driving quality, delivering value, improving your services 7 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 7 of 11 Overall Page 33 of 282

34 6.4.3 CP asked for clarity about the enhanced primary care service in Paignton. ST explained that capacity for additional GP surgery lead services for minor injuries is being explored, although this would not include all services provided by an MIU. This work will be included in the implementation plan. LD Answer to question 4: Yes 6.5 Question 5 - is the GB assured that the case for reduction of x-ray services in Torbay has been made based on sound evidence? Answer to question 5: Yes Question 6 - is the GB assured that care at home, namely intermediate care and rapid response will be sufficiently available and able to provide safe services? (In regard to the intermediate care services / short term therapy lead support to replace community hospital beds rather than social care funded personal care). MF highlighted the unhelpful and often unmanageable delay that care homes face when invoicing the CCG for care, as they have to wait 4 weeks before invoicing and up to 4 weeks for the invoice to be paid. ST confirmed that payment could be sped up as part of the implementation plan. FB asked if the average community hospital stay of 2 weeks is evidence-based. DG referred to the clinical case for change, highlighting the extensive evidence nationally that this model does reduce the need and dependence on hospital beds and stays. MF added that the average stay at Dawlish Hospital is 9.5 days, and patients are encourage to live like they are at home as much as possible. KM felt that intensive care unit beds are needed in each town. ST confirmed that some contracted beds are currently in place, and TSDFT is currently agreeing outstanding contracts. LD confirmed that these are block contracts for intermediate beds care only. Further work is needed to attract sustainable workforce capacity. Answer to question 6: Yes Question 7 - is the GB assured that concerns raised in regard to end-of-life care have been adequately addressed in the proposal? NR said that end-of-life care goes beyond these plans, and confirmed that the System Delivery Board (made up of local health and care leaders including Rowcroft s Director of Patient Care) discuss end-of-life provision on a rolling basis. ST added that GG sits on the local End-of-Life Board. MF confirmed to DG that the CCG s clinical lead for end-of-life care (Dr Carlie Karakusevic) is also reviewing the work carried out in the CCG s coastal locality, to explore best practice / lessons learnt. CP highlighted the current end-of-life care consultation available on the CCG website until 1 April 2017: - to request a copy by post, please contact the Patient Experience Team on (Monday to Friday, 9am-5pm) or patientfeedback.sdtccg@nhs.net Answer to question 7: Yes Question 8 - is the GB assured that adequate attention has been given to future population modelling? JD / LD SB explained that the Joint Strategic Needs Assessment (JSNA) is produced in partnership Driving quality, delivering value, improving your services 8 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 8 of 11 Overall Page 34 of 282

35 with the NHS and local authorities. It looks at the current and future health and care needs of local populations to inform and guide the planning and commissioning (buying) of health, well-being and social care services. SB confirmed that local data shows that work is needed to address an aging population, retain young people and support deprived areas. The Devon JSNA is available at: Phone The South Devon and Torbay JSNA is available at: Phone BM raised the issue of services needed to match housing developments, and ST confirmed that local health and social care planning is done in partnership with the local authorities. Obviously it is not possible to predict who will move into available housing. MF asked if the system is receiving sill money which is provided when residential property is developed, to support related services like health. ST confirmed that the CCG has good links with local authorities and district councils but acknowledged that a collaborative approach to secure this funding could be explored further. NB asked if Torbay Council is mirroring Devon Council Council s approach to adult social care funding. ST said the JSNA spans the patch and takes account of local population growth. ST confirmed to CP that population swelling over the summer is incorporated with the JSNA. LD added that TSDFT complete modelling throughout the year on service demand including peaks in the summer and winter. TSDFT work with partners accordingly to flex capacity up and down as needed. Answer to question 8: Yes Question 9 - it is recommended that the implementation plan include consultation feedback relating to transport, services provided in health and wellbeing centres, and mental health integration. BM highlighted that improved road and public transport was not in the CCG s gift, so felt the CCG needed to get involved in relevant discussions. ST confirmed that the CCG currently meet regularly with local authorities, but agreed more robust discussions are needed. ST added that support from the voluntary sector is also already in place. ST agreed with GG s suggestion to increase the focus on young people and families when planning the implementation of the health and wellbeing centres. MF reported that community mental health integration has been and continues to be challenging. ST acknowledged this too and confirmed that collaborative discussions continue between relevant organisations. DG said service delivery modification will also support some transport limitations, including blood tests at GP practices and virtual clinics. Answer to question 9: Yes Question 10 - is the GB content that the parameters for implementation are adequate for community hospital beds, community outpatient clinics and MIUs? The GB discussed the parameters within the accompanying report / detailed below for clarity. NR NR Box 1: Parameters to be met before change implementation In order for beds to be removed from a community hospital: Contracts are in place for intermediate care placements in care homes within the locality. Driving quality, delivering value, improving your services 9 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 9 of 11 Overall Page 35 of 282

36 Medical leadership in place in the locality. Medical contracts in place to support medical input to intermediate care within the locality. Remaining community hospital inpatient services in the locality meet the requirement for safe staffing standards for sub-acute bed based care. Intermediate care operating at least 6 days a week in the locality. Intermediate care teams are operating with a sufficient workforce that can safely deliver the service specification to the locality Daily multi-disciplinary team (MDT) meeting in each health and wellbeing team in the locality. Referral systems in place for intermediate care and wellbeing co-ordinators. Suitable capacity within short term intervention services. In order for community clinics and specialist out-patient clinics to be removed from a community hospital: Community Clinics appropriate to need (physiotherapy, SALT, podiatry) are being delivered in alternative local venues temporarily, or until permanently provided in the local health and wellbeing centre. In order for MIU to be removed from a community hospital: Newton Abbot and Totnes MIUs to be open 8am-8pm 7 days a week. Newton Abbot and Totnes MIUs to have radiology at least 4 hours a day, 7 days a week NB asked for an urgent piece of work to quantify the measures of these parameters, i.e. what constitutes a sufficient workforce? The GB agreed that: This should be undertaken and signed off at the CCG s Commissioning and Finance Committee, and include input from GG as the CCG s quality lead. TSDFT would have to provide the evidence in writing for each parameter being met for sign off at the CCG s senior leadership team meeting, before change could take place. Progress would be reviewed monthly at the CCG s Commissioning and Finance Committee, with continued input from GG. CP asked what notice period community hospital staff will receive. LD confirmed that communications with staff are ongoing and each person will be supported and managed on a case by case basis. LD added that continuity of patient care is paramount and again each person will be managed individually. Answer to question 10: Yes (see caveat at re parameter definition and sign off) LD / ST / GG 7 Recommendations for GB 7.1 Recommendation 1 that the GB agree with the statement that the proposed model of care represents the best way of delivering quality of care in a manner that is sustainable and affordable. The GB agreed this recommendation Recommendation 2 that the GB approves the proposals which formed the basis of consultation subject to the following changes: 1. Rather than disposing of Ashburton and Buckfastleigh Hospital, it is recommended that the hospital be evaluated as a base for the area s local health and wellbeing centre, including co-location of primary care. 2. The demand for x-ray and for a minor injuries unit in the Bay is recognised and the CCG plans to meet this through the proposed establishment of an urgent care centre on the Torbay Hospital site. 3. To enable specialist outpatient clinics to continue to be provided in Paignton where the volume of patients makes this a more appropriate option to travelling to Brixham, Totnes or Torbay. JR asked if co-location with GPs is a prerequisite to the location of the health and wellbeing centre. ST felt the Ashburton and Buckfastleigh Hospital site would be best although it could work elsewhere. Driving quality, delivering value, improving your services 10 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 10 of 11 Overall Page 36 of 282

37 The GB agreed this recommendation. 7.3 Recommendation 3 that the GB: 1. Approves the parameters for the implementation of changes relating to the care model. 2. Suggestions relating to implementation of the care model put forward in the Healthwatch Consultation Report are reviewed as part of the implementation process. 3. Progress reports on implementation of these proposals are reported quarterly to Governing Body. VK The GB agreed this recommendation Summary / close DG confirmed that the next stage of the process will be implementation. DG added that difficult decisions have had to be made to best meet service demand using the money available to deliver quality services. DG thanked everyone, including Healthwatch, for their involvement and attendance at the meeting today. Driving quality, delivering value, improving your services 11 DRAFT PUBLIC Governing Body Minutes 26 January 2017.doc Page 11 of 11 Overall Page 37 of 282

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39 GOVERNING BODY REPORT Report title: Non Confidential Governing Body Meeting Actions Date of committee: 25 th May 2017 Date report produced: Ongoing Author(s): Fiona Cartlidge Executive Lead: Dr Paul Johnson Contact Details: Contact Details: Summary of Purpose and scope of report: (Please also indicate if the report is for consultation, approval or information) Consultation Approval Information To review outstanding actions and update log Executive Summary: Governing Body meeting action log Strategic risk: (include risk number if on register) N/A Mitigating Actions: N/A Management of Conflict of interests: Conflicts of interests are declared as a standard Governing Body meeting agenda item. Committees that have previously discussed/agreed the report and outcomes: N/A Corporate Impact Assessment Quality & Safety/ Patient Engagement/ Impact on patient services Finance, resources and QIPP What, if any, are the legal implications? Communication plan and stakeholder involvement Equality Impact Assessment: Are there any Quality or Equalities (including inequalities) implications of this report? (Please specify) Have you carried out an initial Quality and Equality Impact Assessment (Y/N) and is it attached? (Y/N) If not, why not? N/A N/A None None None None Key recommendations and actions requested: None Accompanying paper(s): Ongoing love action log Reason for reports inclusion in the confidential section of the Governing Body meeting: N/A **Please add N/A if any of the sections are not relevant Driving quality, delivering value, improving your services 1 Non-Confidential_Action_Log.doc Page 1 of 3 Overall Page 39 of 282

40 No. Issue Date Lead Deadline Status and progress since the last meeting 316 Seek best practice from other CCGs 23/06/16 Dr Nick 04/07/16 Ray Chalmers is taking this forward who performed well in their 360 Roberts 22/09/16 ongoing stakeholder survey 29/09/16 & 11/11/16 VK asked RC for an update - ongoing 24/11/16 ongoing 23/01/17 PENDING RC said NHSE has now identified 2 CCGs rated as outstanding in the 2015/16 year end assessment, and which have published their 360 survey, so will follow this up 20/02/17 and 08/03/17 VK ed them for details of best practice 23/03/2017 GB updated by NR contact6 has been made with other CCG s in terms of best practice, awaiting details plan to close within next formal GB meeting. 04/05/2017 COMPLETE - results received from this years survey /03/20 Dr Paul Dr Johnson to discuss future 17 Johnson organisational development with Sir Richard Ibbotson, and how this can be achieved. 332 Risk 167 to be split to reflect patient experience and safety 333 Dr N Roberts to feedback discussions and suggestion in terms of the ASR criteria, to Mairead McAliden 23/03/ /03/20 17 Ms Gill Gant 03/05/2017 COMPLETE Dr Nick Roberts 04/05/17 COMPLETE 334 Mr Tapley to clarify arrangements secured medical cover for intermediate care provision in Torquay Locality. 23/03/20 17 Mr Simon Tapley 335 Non-Confidential_Action_Log.doc Driving quality, delivering value, improving your services 2 Page 2 of 3 Overall Page 40 of 282

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43 GOVERNING BODY Report title: Clinical Chair Public Report Date of committee: 25 May 2017 Date report produced: 18 May 2017 Author (s): Dr. Paul Johnson Contact Details: Executive Lead: N/A Contact Details: N/A Summary of Purpose and scope of report: (Please also indicate if the report is for consultation, approval or information) Consultation Approval Information Executive Summary: Reflective account of Clinical Chair period with SDT CCG. Clinical Representation Proposal PCJCC Proposal (appended proposal included) Strategic risk: (include risk number if on register) N/A Mitigating Actions: N/A Management of Conflict of interests: Conflicts of interests are recorded on the register of interests, at each committee a list of recorded declarations is provided and confirmations of declarations are requested and noted. Any new declarations must be fully recorded and included in the minutes of the meeting and notified to corporate.sdtccg@nhs.net to update the central register. Committees that have previously discussed/agreed the report and outcomes: N/A Corporate Impact Assessment Quality & Safety/ Patient Engagement/ Impact on patient services Finance, resources and QIPP What, if any, are the legal implications? Communication plan and stakeholder involvement N/A N/A N/A N/A Equality Impact Assessment: Are there any Quality or Equalities (including inequalities) implications of this report? Have you carried out an initial Quality and Equality Impact Assessment (Y/N) and is it attached? (Y/N) None No 1 GB Clinical Chair Public Report May 17.docx 1 Page 1 of 4 Overall v3 Page 05/01/ of 282

44 If not, why not? Not required. Key recommendations and actions requested: None Accompanying paper(s): None Reason for reports inclusion in the confidential section of the Governing Body meeting: Public Section **Please add N/A if any of the sections are not relevant 1 GB Clinical Chair Public Report May 17.docx 2 Page 2 of 4 Overall v3 Page 05/01/ of 282

45 Clinical Chair Public Report 1. Introduction As will be clear from this report and the contents of this morning Governing Body meeting, the changes are continuing and the pressures are persisting. But what is also clear is all the hard work that is going on, both within the CCG and in conjunction with our stakeholders and key providers to ensure that through the pressures and changes we endeavour to maintain safe, high quality and effective care for our population. 2. Torbay and South Devon NHS Foundation Trust Review of Board to Board Meeting Torbay and South Devon NHS Foundation Trust (TSDFT) Board members joined our governing body to undertake a Boards in Common meeting on Thursday 28 th April The aim of the meeting was to promote and facilitate collaborative working and effective decision making across the organisations. The areas of discussion focused on delivery of effective and affordable care for the South Devon and Torbay population, with a chance to explore jointly potential financial saving opportunities for the system. This is joint work that both I and Richard Ibbotson (Chair of TSDFT) are keen to continue and so further proposals we will consider are: - To arrange a joint Non-Executive Director meeting in the early summer - To plan regular board in common from Autumn Potential Boards in common meeting to decide on the contract (June / July) 3. NEW Devon Joint Board Development Session Just as we recognise the need for joint working at board level with the TSDFT, this is equally important with NEW Devon CCG. Work has commenced to begin exploring that relationship and how we might work more closely as boards. A joint Governing Body board development day has been arranged for 28 June This joint Governing Body session will focus on our roles as commissioners and the identification of opportunities for collaborative working in order to meet the challenges that both organisations face across the Health & Social Care system in Devon. Engagement with Primary Care Provider Organisations Dr Nick Roberts is leading on work to support our local GPs within the STP process, and it is clear from discussions I have had with Dr Tim Burke (NEW Devon Chair) similar challenges are being experienced across the NEW Devon footprint as they work on how to improve and better establish engagement with primary care as a provider. Dr Tim Burke and I have had initial discussions around trying to establish a consistent approach with Haytor Health along with the other provider organisations in Devon (Sentinal, Exeter Primary Care and Devon Health). Some progress has been achieved, however we acknowledge there is still much work to be done. My thoughts along with others is that a standardised approach will lead to a more robust relationship between organisations, which will better equip primary care providers to be part of system change in Devon. I will continue to explore this with Dr Tim Burke in alignment and collaboration with the work that Dr Nick Roberts is undertaking at the STP level. 4. Primary Care I have recently attended the five locality meetings to discuss the 360 stakeholder survey and the proposed reconfiguration of clinical representation in the CCG (proposal appended This proposal went to a seminar 1 GB Clinical Chair Public Report May 17.docx 3 Page 3 of 4 Overall v3 Page 05/01/ of 282

46 GB so will need formal approval at this meeting). These visits weren t complete at the time of writing this report, so I will provide a verbal summary. 5. STP Clinical Cabinet I attended the Clinical Cabinet meeting held on Thursday 4th May It was a timely visit as the Clinical Cabinet was in the process of reviewing their Terms of Reference (paper appended). It struck me as a potentially very useful meeting, with several very experienced clinicians well placed to provide clinical context to STP plans. However for the Clinical Cabinet to be most effective it is clear that the ToR s needed to be reviewed in order for this to achieved. I plan to be in attendance for future meetings, at least during this review process we benefit from significant clinical input in our decision making as a CCG and it would be good to see the Clinical Cabinet develop to be able to do the same at STP level. 6. Governing Body As you are aware, Mr Kevin Muckian will be leaving the CCG from 1 July 2017, and we wish him all the best in his next venture. One of his key roles within the CCG is to chair the PCJCC. Attached for approval is a proposal for how we would like to manage his leaving. 1 GB Clinical Chair Public Report May 17.docx 4 Page 4 of 4 Overall v3 Page 05/01/ of 282

47 TERMS OF REFERENCE Clinical Cabinet Purpose To provide clinical leadership to the programme, ensure the programme develops robust clinical proposals and make clinical recommendations to the Programme Delivery Executive Group. Specifically, it will: Provide senior leadership of clinical elements of the Success Regime and Sustainability & Transformation Plan (STP) programme of work, making recommendations to the Programme Delivery Executive Group. Co-ordinate the work of the Clinical Working Groups to develop a service model and proposals for consultation. Provide clinical input and leadership to the development and implementation of service change in 2016/17. Ensure that clinical colleagues are kept informed about the work and are engaged in the work as appropriate. Be ambassadors for the programme and ensure there are clinical and professional care advocates for proposals. Lead the implementation of the plans following consultation. The Clinical Cabinet will also: Ensure there are clinical advocates for proposals in each relevant service area Establish Working Groups where required to take forward short, focussed work to finalise clinical service models The Clinical Cabinet is authorised to instigate any activity within its terms of reference and to seek information as necessary. The Clinical Cabinet is authorised by the Success Regime/STP programme to secure the attendance or advice of such persons, including outsiders with relevant experience and expertise, as it considers necessary Responsibilities In order to achieve its purpose, the Clinical Cabinet has responsibilities to: Engage with clinicians within the sector to identify the clinical evidence base underpinning the case for change in NEW Devon Set out standards for high quality care, particularly in the areas outlined above Agree the resulting vision and clinical service models Recommend the criteria to be used to assess service options and service models to the Programme Delivery Executive Group Identify a clinical benefits framework for the programme Support the development of clinically appropriate options for acute service configuration and the definition of decision making criteria to appraise these options Ensure proposals for out of hospital care will enable the service standards to be met Engage with external expert clinicians and clinical advisory bodies, to provide clinical assurance of the service models and proposed configuration options Engage with other local clinicians to test and refine clinical proposals Clinical Cabinet TOR v3 revised Clinical Cabinet TOR revisedv3.pdf Page 1 of 4 Overall Page 47 of 282

48 Constitution, Decision-making and Behaviours The Clinical Cabinet is established by Success Regime/STP programme to advise the Programme Delivery Executive Group, and has no powers other than those included in its terms of reference. The Clinical Cabinet will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the Programme Delivery Executive Group. Members are expected to act as ambassadors for the Programme and engage clinicians within their organisations in the development of the Programme. Where clinicians raise concerns, the Programme team shall support the member in engaging relevant clinicians in addressing the concerns. Members are expected to provide information to the Clinical Cabinet to support the undertaking of accurate analysis and well informed decision-making. The Clinical Cabinet decisions will be based on the Design Principles listed in Appendix 1. Membership: The membership of the Clinical Cabinet shall be: Clinical Chair and locality chairs, NEW Devon CCG Clinical Accountable Officer South Devon & Torbay CCG Medical Directors: Northern Devon Healthcare NHS Trust Plymouth Hospitals NHS Trust Devon Partnership Trust Royal Devon and Exeter NHS Foundation Trust Torbay and South Devon Hospitals NHS Foundation Trust South Western Ambulance Service Trust 2 acute sector Directors of Nursing (by consensus), CCG s Director of Nursing, SWAST Director of Nursing An acute Trust Chief Operating Officer (by nomination) An executive representative from Live Well A director of public health (by consensus) Primary care provider GPs for each locality Healthwatch (3) An executive from the local authority sector Devon County Council Plymouth City Council Torbay Council In attendance: Communications and Engagement Group link person, Workforce Group link person The STP Medical Director shall act as Chair of the Clinical Cabinet. Clinical Cabinet TOR v3 revised Clinical Cabinet TOR revisedv3.pdf Page 2 of 4 Overall Page 48 of 282

49 Accountability The Chair of the Clinical Cabinet Chair is accountable to the Programme Delivery Executive Group. Programme Board Support: Support and advice to the Clinical Cabinet will be provided by the Programme Manager and the Programme Management Team. Frequency The Clinical Cabinet will meet every two weeks and more frequently if required to consider matters in a timely manner. Quorum The Clinical Cabinet will be quorate when at least two weeks notice has been given of the meeting and the Chair (or a Proxy) and three other members (or their proxies) are present Every member commits to attend or send a nominated deputy to each meeting or send apologies if unable to attend. Review Date The Clinical Cabinet shall keep its membership and responsibilities under review in the light of the development of the programme, and make any recommendations to the Programme Delivery Executive Group on changes to membership or responsibilities. Clinical Cabinet TOR v3 revised Clinical Cabinet TOR revisedv3.pdf Page 3 of 4 Overall Page 49 of 282

50 Appendix 1: Clinical Cabinet TOR v3 revised Clinical Cabinet TOR revisedv3.pdf Page 4 of 4 Overall Page 50 of 282

51 GOVERNING BODY - SEMINAR CCG Clinical Representation Proposal 1. Introduction Following on from the Council of Members and discussions at Governing Body away day and locality meetings, it s important that we respond in a timely way. This paper describes a proposed response as to how we plan to engage with primary care as our members and providers, and how we ensure we have the right level of clinical input into the CCG. We feel this represents a balanced and appropriate way forward that maintains clinical influence within the CCG, builds on engagement of our membership and responds appropriately to changes such as the establishment of locality clinical directors within SDTFT and the formation of larger primary care provider groups. The proposal covers several roles within the CCG, and although they are distinct, a clinician can hold more than one role. 2. Governing Body Clinical Representation 2.1 Proposal: Appoint 5 clinical Non-Executives Directors, each representing one of our localities. 2.2 Appointment Process: Application open to all GPs currently practicing at a member practice of the CCG (not necessarily from within the locality they would represent) Applicants will undergo a selection process by the CCG The CCG will put forward suitable applicants for vote of approval by member practices within the locality. Successful applicants will be those who pass the selection process and receive a majority support from the locality member practices*. 2.3 Role: The GP clinical NED will be expected to: Attend and actively participate in GB Attend and actively participate in one other committee** Engage with the member practices of their representative locality*** Number of Sessions: The GP clinical NED would be employed for 6 sessions a month: Governing Body 2 sessions Committee Attendance 1 session Meeting preparation 1 session Membership engagement 2 sessions 2.4 Commencement Date: September 2017 Clinical Roles - Proposal (2).docx 1 Page 1 of 3 Overall Page 51 of 282

52 3. Operational Clinical Support, Engagement with Primary Care Provider Proposal A review of existing GP leads has been undertaken and the following lead roles are needed to support key work areas going forward: Locality Clinical Directors (LCDs) x 5 days a week (CCG funds half) 5 system savings plan work streams: Elective Care 1 day/ week - Alex Rowe until 31/7 then possibly Derek Greatorex From 1/9/17 Urgent Care 1 day/ week - John Whitehead Placed People - nurse input - to be determined STP work streams: Mental health - 1day/ week - Andy Haytread Dementia - 1/2 day/ week - Vacant Children's - 1 day/ week - Keira Goss Acute Services - Maternity - Keira Goss Stroke - Eileen Deakin Vulnerable Services - Mix Prevention - Directors of Public Health Integrated Care Models - LCDs x 5 - Dr Matt Fox providing advice as lead The Primary Care lead GP position is currently vacant; also Dr Jo Roberts is retiring in the autumn 2017, which will leave the Medicines Optimisation lead position vacant. The emerging GP provider groupings along with the GPFV and STP GP input that is needed; it is proposed to have a 1.5 day a week lead GP position for a combined Primary Care Commissioning and Medicines Optimisation role and a 0.5 day a week lead GP Provider representative role. It is anticipated that Jo Roberts after his retirement would be retained on a reduced commitment basis to support the clinical effectiveness role. To support the new GP Governing Body representatives in engaging with their localities and support delivery of the CCG requirements it is proposed to give each a share of 100k pa to deliver against agreed outcomes using a memorandum of understanding approach. Examples of outcomes could be: Upper quartile referral rates (in Devon) Upper quartile prescribing (National/Cluster CCG) Delivery of key GPFV (Extended Access) Until the new structure was in place it is proposed that the locality Clinical Directors hold this budget and outcomes. These proposals are within existing budgets and therefore do not create any cost pressures. 4. Provider Organisation Engagement and Council of Members 4.1 It is agreed that, with the ongoing development of Haytor Health and the need for a single primary care voice to be involved in wider Devon STP discussions, we need to consider how we best support and engage with that single primary care provider voice. We are also aware that the Council of Members in its current format does not effectively engage with our wider membership. No proposal for achieving this has been agreed yet, but this is to highlight that we identify this as an important element of our engagement with primary care and a commitment from the SLT to work with Haytor Health to develop an agreed proposal. Clinical Roles - Proposal (2).docx 2 Page 2 of 3 Overall Page 52 of 282

53 * In the case of more than one applicant being put forward for approval, the applicant with the greatest number of votes will then be put forward for a second vote of approval as the single candidate whereby they would need to obtain majority support. In the event of a tie, the CCG selection panel will determine which candidate goes through. ** The committee they attend will be determined by the chair and based on the skill set they bring and where the greatest need for clinical input is felt to be. *** Clinical NEDs will be expected to demonstrate effective engagement through, for example, diary evidence, appraisal process and improvement in stakeholder survey results Clinical Roles - Proposal (2).docx 3 Page 3 of 3 Overall Page 53 of 282

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55 GOVERNING BODY CCG GB Non-executive Representation Proposal 1. Introduction South Devon and Torbay CCG have received notice from its Non-executive Director for Non-Medical, current responsibilities included within the CCG are membership of Governing Body, Chairmanship for Primary Care Joint Committee and input into Strategic Medicines Optimisation meetings. Given current financial pressures across both South Devon and Torbay CCG and NEW Devon CCG, the proposal brought to Governing Body for consideration is not to recruit to this post externally. This paper describes a proposed response as to how we plan to explore a possible a joint Non-executive post with NEW Devon CCG. We feel this represents a balanced and appropriate way forward that maintains Non-executive input within the both CCGs, builds on collaborative and aligned working with NEW Devon CCG, whilst also reducing costs within the system. The proposed interim arrangements would see Mr Chris Peach Non-executive Director, Patient and Public Involvement the current Vice Chair for Primary Care Joint Committee provide Chairmanship for this Committee. The intended timeline would see the Joint Non-executive Director providing Chairmanship with effect from Autumn Both CCGs are exploring the potential appointment to this post to be provided by NEW Devon CCG Nonexecutive Director Secondary Care, who currently provides Chairmanship for NEW Devon CCG Primary Care Committee. GB NED Proposal (2).docx 1 Page 1 of 1 Overall Page 55 of 282

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57 GOVERNING BODY Report title: Risk and Assurance Report Date of committee: 25 May 2017 Date report produced: 16 May 2017 Author (s): Theresa Farris Contact Details: Executive Lead: Mark Procter Contact Details: Report Approved by: Name: Mark Procter Date: 16 May 2017 Summary of Purpose and scope of report: (Please also indicate if the report is for consultation, approval or information) Consultation Approval Information To inform the Governing Body of the current position regarding the South Devon and Torbay Clinical Commissioning Groups (the CCG) risks. This report provides assurance that the CCG has effective processes in place to identify, assess, manage and mitigate risk, and informs of any changes since 16 March 2017 The report provides the opportunity to consider the adequacy and effectiveness of the controls and assurances identified, including measures to address gaps in controls and assurances and to identify any further measures that should be taken to manage its risks. Executive Summary: The risk profile (section 1.6) shows that the CCG is recording risks at all levels across the organisation and that high scoring risks are managed down to a more acceptable level over time. For each of the risks and controls a source of assurance is profiled (section 1.7) giving details of the level of reliance that can be placed on the actions and controls being taken to mitigate the risk. There is one risk recorded as having weak assurance section 1.8 The Assurance Framework comprises the CCG s very high risks, scoring 16-25; this is summarised in section 1.9 and summarises the risks in this category. There are four risks within the assurance framework. There have been seven new risks (1.10) added and five risks (1.11) removed from the risk register. The risk movement table allows identification of risks that need further investigation, this shows that two risks (198 and 216) have had the score increased by management action, due to adverse trends in this area and seven risks (27, 78, 91, 178, 191, 193 and 215) have a reduced risk score in this reporting period. At 16 May 2017 the CCG has 46 open risks. Strategic risk: (include risk number if on register) Mitigating Actions: The risk register is being regularly reviewed and updated in accordance with the Risk Policy. 1 GB Risk and Assurance Report May 2017.docx Page 1 of 12 Overall Page 57 1 of 282

58 Management of Conflict of interests: Conflicts of interests are recorded on the register of interests, at each committee a list of recorded declarations is provided and confirmations of declarations are requested and noted. Any new declarations must be fully recorded and included in the minutes of the meeting and notified to corporate.sdtccg@nhs.net to update the central register. Committees that have previously discussed/agreed the report and outcomes: Risk and assurance reports have been considered by the following committees: Audit Committee Quality Committee Commissioning and Finance Committee Primary Care Joint Commissioning Committee Strategic Risk Committee Corporate Impact Assessment Quality & Safety/ Patient Engagement/ Impact on patient none services Finance, resources and QIPP none What, if any, are the legal implications? none Communication plan and stakeholder involvement none Equality Impact Assessment: Are there any Quality or Equalities (including inequalities) implications of this report? (Please specify) Have you carried out an initial Quality and Equality Impact Assessment (Y/N) and is it attached? (Y/N) If not, why not? No Not applicable Key recommendations and actions requested: The Governing Body are asked to: Support the risk coordinators in ensuring that all risks are recorded, updated and have all the assurances, controls and mitigating actions recorded with regular reviews undertaken by all the teams. Identify any risks that need to be added to the risk register, or amended. Consider the adequacy and effectiveness of the controls and assurances identified in the management of risk including measures to address gaps in controls and assurances. Identify any further action that should be taken to manage the key risks. Approval to the addition and removal of risks to the assurance framework Note the content of the report Accompanying paper(s): Weak Assurance report Risk movement report Risk register Reason for reports inclusion in the confidential section of the Governing Body meeting: Not applicable **Please add not applicable if any of the sections are not relevant 1 GB Risk and Assurance Report May 2017.docx Page 2 of 12 Overall Page 58 2 of 282

59 Risk Report to Governing Body 1. Review of the corporate risk register and Assurance Framework 1.1 The CCG has articulated its risk appetite and this is detailed in the Risk Policy approved by Audit Committee in April The CCG score risk using the recommended 5 x 5 impact and likelihood matrix (Appendix 1) 1.3 Each risk is reviewed to assess the adequacy of the controls and assurances linked to each risk. 1.4 By overlaying the risk scoring matrix with the four responses to managing risk, (reduce/transfer, contingency plan, manage and accept, the following risk management grid is created: Risk Response Grid Contingency Reduce/Transfer Impact 1 Manage and Contingency Accept Manage 1 5 Likelihood 1.5 After identifying which risk response category the individual risks should reside in, it is possible to identify the CCG Risk profile using the current risk score and the target risk score after the potential impact of actions, controls and assurances have been considered. 1.6 The CCG risk profile can be represented by the following graph: 1.7 The CCG Adequacy of Assurance profile can be represented by the following graph. Work continues to be targeted at raising assurance from Weak to Moderate, and then to Strong. Data and reports presented to one of the CCG s formal committees form good internal assurance; data and reports presented to the Health and Wellbeing Boards and to NHS England s Area Team form good external assurance; Internal and External Audit reports also form good external assurance. This external assurance means that 20% of the CCG s risks currently have Strong assurance. 1 GB Risk and Assurance Report May 2017.docx Page 3 of 12 Overall Page 59 3 of 282

60 1.8 There is one risk scored as having weak assurance Risk Number Risk Score Risk description There is a risk that the provision of community pharmacy could decline due to a significant or geographically specific reduction in the number of community pharmacies. The impact is patient access to community pharmacy would be adversely affected due to the reduction of pharmacies and the location of remaining pharmacies. Date risk reviewed 19/04/2017 Date risk score set 16/03/2017 Date risk opened 16/03/2017 Exec Lead Mark Procter Adequacy Score The Assurance Framework comprises the CCG s very high risks, scoring 16-25; the following table summarises the four risks in this category Risk Number Risk Score Risk description Date risk reviewed Date risk opened Exec Lead Adequacy Score There is a risk that, due to demand and capacity at Torbay Hospital, waiting times will exceed 18 weeks and failure to achieve key RTT performance standards at SDHFT. 27/04/ /10/2013 Simon Tapley There is a risk that crews may be delayed responding to 999 calls on days when there are delays in handing over patients to Emergency Department. 04/05/ /07/2014 Simon Tapley There is a risk that the medium term financial plan would be impacted should the 5 year financial plan be unsustainable. 11/04/ /01/2016 John Dowell There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance, may have a poor experience of care. 02/05/ /01/2016 Gill Gant 10 1 GB Risk and Assurance Report May 2017.docx Page 4 of 12 Overall Page 60 4 of 282

61 1.10 There have been seven new risks added to the risk register since 16 March 2017 ID Risk description 213 There is a risk that the provision of community pharmacy could decline due to a significant or geographically specific reduction in the number of community pharmacies. 214 There is a risk that the deteriorating financial position within the health community whole system will have an adverse effect on patient safety and quality of care provided. There may be particular issues in respect of staffing levels throughout the throughout the Trust, but in particular in A&E, where staffing levels were increased in response to CQC judgements. The Francis report in Mid Staffordshire highlighted the link between a system focus on finance and performance, and possible deteriorating quality of care. Date risk opened 16/03/ /03/2017 Likelihood Impact Risk Score Adequacy Score There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance may have compromised quality of care & safety. 216 There is a risk that the capacity of the CCG to respond to change is reduced following the introduction of the new recruitment process and joint working arrangements. 217 There is a risk that the Trust may not be able to fully implement the four clinical standards for seven day services in urgent and emergency care by There is a risk that the Trust are not able implement best practice for managing potential emergency admissions, including acute frailty and same day emergency ambulatory care. 219 There is a risk that the number of 52 week waiters will continue to increase due to lack of capacity within the upper GI service. 30/03/ /04/ /04/ /05/ /05/ GB Risk and Assurance Report May 2017.docx Page 5 of 12 Overall Page 61 5 of 282

62 1.11 There have been five risks closed since 16 March ID Risk description Date risk opened Date risk closed Risk Score Adequacy Score Reason for closing risk Closing Committee There is a risk that NHS contracts are not in place for Care Homes and Independent Hospitals and therefore no assurance of regulatory and contractual indicators are met in operating safely and effectively. There is a risk that the proposed new care & nursing home tender will not complete by April 1st /05/ /09/ /03/ /03/ Request for closure at CFC as no longer a risk as contracts now in place for care homes and Independent hospitals Request for closure at CFC as process has been reviewed and no longer deemed a risk Commissioning & Finance Commissioning & Finance There is a risk that following the publication of directions for the CCG there will be pressure on Running Costs that will cause us to breach the cap. There is a risk that the due diligence process for transition to fully delegated commissioning may be impeded by competing priorities and workload pressures. There is a risk of additional financial cost to the CCG following the decision to extend the re procurement of community children services by 12 months (2019). 21/09/ /11/ /01/ /03/ /04/ /03/ The revised running cost has been reviewed by SLT and set within the current budget. The CCGs application for delegated commissioning was declined and will not be proceeding to in line with original timeline. Risk to be closed. Request for Closure at CFC - Risk reduced due to level of budget reserve to offset any financial impacts therefore no longer considered a risk Commissioning & Finance Primary Care Joint Commissioning Committee Commissioning & Finance 1 The Audit Committee (13 March 2014) made the decision that a risk can only be closed by a CCG Committee, not solely by a Director. 1 GB Risk and Assurance Report May 2017.docx Page 6 of 12 Overall Page 62 6 of 282

63 1.12 The risk movement grid allows identification of risks that need further investigation, this shows that two risks (198 and 216) have had the score increased by management action, due to adverse trends in this area and seven risks (27, 78, 91, 178, 191, 193 and 215) have a reduced risk score in this reporting period. Risk Number Risk description 27 There is a risk that patients will not receive the appropriate care to prevent them from developing pressure ulcers. 78 There is a risk that, due to demand and capacity at Torbay Hospital, waiting times will exceed 18 weeks and failure to achieve key RTT performance standards at SDHFT 91 There is a risk that the 95% of people seen 4hour wait standard in A&E is not met at Torbay and South Devon NHS Trust which may impact on achievement of national standards and patient experience (and risk of handover delays from the ambulance to A&E department - Ambulance Handover issue see Risk 110). 178 There is a risk that patients referred to a Neurology consultant in Torbay will have to wait at least 7 months for an appointment and that patients waiting a follow-up will also have a significant delay. NHS England will not allow the list to close as it has not been possible to secure assurance from neighbouring Providers that they could manage the additional demand. Date risk opened 25/05/ /10/ /02/ /05/2016 Date risk reviewed 15/05/ /04/ /05/ /05/2017 Previous Risk Score Risk Score Risk Movement Reason for risk movement Following review of PUs prevelance over the last 6 months (JD) SRC and risk owner agreed that impact score could be lower from a 5 to a 4. Improved performance Current position relatively stable Previous Adequacy Score Adequacy Score Assurance Movement 191 Gaps in service identified following the re-procurement of the 111 and Out of Hours service (Out of Hours community hospital cover, referrals from MIUs and paramedic helpline). Decision to fund, at financial risk, for six months to understand impact and nature of service. Risk of not being able to reach agreement on mainstreaming of services going forward. 193 There is a risk that strategic development will be slowed down due to need to obtain NHSE approval for fit with directions 07/09/ /09/ /04/ /05/ Risk was that would not be able to reach agreement but agreement has been reached for another 6month Strategic development has progressed and not been hindered by directions There is a risk that the CCG will see direct intervention if directions not implemented. 21/09/ /05/ NHSE involvement in CEP (Capital Expenditure Process) There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance may have compromised quality of care & safety. 30/03/ /05/ No evidence of increase in patient safety incidents There is a risk that the capacity of the CCG to respond to change is reduced following the introduction of the new recruitment process and joint working arrangements. 06/04/ /05/ risk has increased as the CCG is carrying vacancies. The further shared working with NEWD will continue the vacancy freeze GB Risk and Assurance Report May 2017.docx Page 7 of 12 Overall Page 63 of 7282

64 1.13 There have been seven new risks (1.10) added and five risks (1.11) removed from the risk register A copy of the full risk register is included to provide a detailed overview At 16 May 2017 the CCG has 46 open risks. 2. Recommendations 2.1 It is recommended to: Support the risk co-ordinators in ensuring that all risks are recorded, updated and have all the assurances, controls and mitigating actions recorded, with regular reviews undertaken by the risk owner. Identify any risks that need to be added to the risk register, or amended. Consider the adequacy and effectiveness of the controls and assurances identified in the management of risk including measures to address gaps in controls and assurances. Identify any further action that should be taken to manage the key risks. Approval to the addition and deletion of risks to the assurance framework Responsible Director: Report prepared by: Mark Procter, Director of Primary Care and Corporate Services Theresa Farris, Risk and Governance Officer, Corporate Services. Date of report: 16 May GB Risk and Assurance Report May 2017.docx Page 8 of 12 Overall Page 64 8 of 282

65 Appendix 1 Risk Scoring Matrix South Devon and Torbay Clinical Commissioning Group Assessing the impact of risk Score Public staff and patient safety (physical or psychological harm) Quality/complaints/ audit Finance Staff Service delivery / business management Environment estate and IT Catastrophic Incident leading to avoidable death or serious permanent harm due to a failure of process, breach of policies or protocols/procedures or safe working practices. An event which adversely impacts on a large number of patients or multiple permanent injuries or irreversible health effects, or serious safeguarding issues Increased mortality rates or serious incidents/never events indicating failure of the services to deliver patient safety, requiring immediate intervention such as suspension of service or escalation. Totally unacceptable level or quality of treatment/services. Gross failure of patient safety if findings not acted upon. Inquest/Ombudsma n s enquiry with identification of gross failure to meet national standards of care or treatment. Totally unsatisfactory patient outcome or experience Catastrophic impact on financial position of CCG Non delivery of key objective / service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff Sustained failure to meet standards and / or national requirements. Serious impact on overall performance and possible intervention Serious long term impact (nationally and locally) on reputation, prolonged interest and DoH / Select Committee overview Serious breach with potential for ID theft or over 1000 people affected Permanent loss of service or facility Catastrophic impact on environment, multiple breach and prosecution Damage will spread beyond one item of equipment and take over 1 week to repair Major Major injury leading to long term incapacity or disability (not irreversible) Requiring time off work for >14 days Increased length of hospital stay by >14 days Mismanagement of patient care with long term effects, including safeguarding Increased mortality rates or serious incidents/never events indicating urgent interventions e.g risk summit, improvement plan or contractual action Non -compliance with national standards with significant risk to patients if unresolved Multiple complaints or an independent review Low performance rating Critical report (internal or external) Mismanagement of patient care long term effects Major impact on financial position of CCG Uncertain delivery of key objective / service due to lack of staff Unsafe staffing levels or competence (>5 Days) Loss of key staff Major impact on overall performance which puts achievement of standards and / or national requirements at risk. National and local interest and impact on reputation specific to an issue prolonged interest Serious breach with either particular sensitivity e.g. sexual health details, or up to 1000 people affected Loss / interruption of service or facility > 1 week Major impact on environment, multiple breach and prosecution notice issued Equipment will be out of action less than 1 week to repair 1 GB Risk and Assurance Report May 2017.docx Page 9 of 12 Overall Page 65 9 of 282

66 Moderate Moderate injury requiring professional intervention and leading to long term incapacity or disability Requiring time off work 4-14 days RIDDOR reportable incident An event which impacts on a small number of patients including safeguarding Increased length of hospital stay by 4-15 days Treatment or service has significantly reduced its effectiveness Formal complaint with potential to go to independent review Repeated failure to meet internal standards Major patient safety implications if findings are not acted upon Mismanagement of patient care short term effects Moderate impact on financial position of CCG Late delivery of key objective / service due to lack of staff Unsafe staffing levels or competence (>1 Day) Failure to meet internal standards with some impact on overall performance of the CCG. Local interest and impact on reputation specific to an issue Serious breach of confidentiality e.g. up to 100 people affected Loss / interruption of service or facility > 1 day Moderate impact on environment, improvement notice issued Equipment shut down immediately and restarted in less than half a day. An increasing mortality rate or serious incidents/never events trend requiring monitoring with action plan to mitigate risk Minor Insignificant Minor injury or illness requiring minor intervention Requiring time off work >3 days Increased length of hospital stay by 1-3 days Mortality rates within normal limits or individual serious incidents that require monitoring Minimal injury requiring no/minimal intervention or treatment No time off work Mortality rates or serious incidents require routine monitoring. Overall treatment or service suboptimal Formal complaint local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved Unsatisfactory patient experience easily resolvable Peripheral element of treatment or services suboptimal. Informal complaint / enquiry Unsatisfactory patient experience not directly related to patient care Minor impact on financial position of CCG Insignificant impact on financial position of CCG Low staffing levels that reduces the service quality Nil Failure to meet internal standards with some impact on overall performance Short term local interest and impact on reputation specific to an issue Serious potential breach & risk assessed high e.g. unencrypted clinical records lost. Up to 20 people affected Failure to meet individual employee objectives Minimal impact Rumours Potential for public concern Potentially serious breach. Less than 5 people affected or risk assessed as low, e.g. files were encrypted Loss / interruption of service or facility > 1 day Minor impact on environment, single breach of legal requirement Moderate damage to equipment easily repairable. Loss / interruption of service or facility > 1 hour Minimal or no impact on environment Little damage to equipment 1 GB Risk and Assurance Report May 2017.docx Page 10 of 12 Overall Page of 282

67 Assessing the likelihood of risk Score Description Definition 5 Almost Certain 4 Likely 3 Possible 2 Unlikely 1 Rare Very likely. The event is expected to occur in most circumstances as there is a history of regular occurrence at the CCG or within the NHS. There is a strong possibility the event will occur as there is a history of frequent occurrence at the CCG or within the NHS. The event may occur at some time as there is a history of ad-hoc occurrence at the CCG or within the NHS Not expected but there is a slight possibility it may occur at some time. Highly unlikely, but it may occur in exceptional circumstances. It could happen but probably never will. Risk scoring matrix (5x5 scores for impact & likelihood) Impact 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost Certain 1 Minimal Minor Moderate Severe Catastrophic Risk scoring categorisation 1-4 Low risk 5-9 Medium risk High risk Very high risk 1 GB Risk and Assurance Report May 2017.docx Page 11 of 12 Overall Page of 282

68 Appendix 2 Adequacy of Assurance scoring This score is used to inform the CCG of the degree of reliance they can place on an item of assurance. 1 Does this assurance provide evidence that the controls are achieving the desired outcome? Yes - proceed to Section 2 No - Do not proceed with this assessment and the score will automatically be 0. If the item highlights areas where controls are not in place or are not achieving the desired outcome, please add this information to the "gaps in Controls" section of the Risk. 2 Timeliness Score 2a If the information is older than 6 months then the adequacy score automatically becomes 0, otherwise proceed to question 2b 2b How old is the most recent information on which the Assurance is based? Within the last month between 1 and 3 months between 4 and 6months Scope of Positive Assurance Score 3a Does it provide positive assurance on all aspects of the issue? 3 For example, CCG is fully compliant / achieving the target. 3b Does it provide partially positive assurances? For example, compliance in some areas. 1 4 Sufficiency Score 4a Is this a key/definitive source of assurance for this area? 3 For example, CQC, formal reports, data. 4b Is this one of a number of sources of assurances contributing to an overall 2 picture? 4c Is this an indicator of likely achievement of the outcome rather than evidence of actual achievement? 1 5 Basis for Assurance Score 5a What is the Assurance based on? Evidence - Audited externally Evidence - audited internally Self-assessment - externally validated Self-assessment - without audit or validation Score 0 Score 1-7 Score 8-10 Score No assurance Weak assurance. Very limited reliance can be placed on this as an indicator. Moderate assurance. Limited reliance can be placed on this as evidence. Strong assurance. This evidence can be strongly relied upon. 1 GB Risk and Assurance Report May 2017.docx Page 12 of 12 Overall Page of 282

69 Risks with an adequacy of assurance score between 0 and 7 between dates ID Risk description Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Date risk opened Committee reported to Risk Owner Risk Coordinator Plan On a Page Links 213 There is a risk that the provision of community pharmacy could decline due to a significant or geographically specific reduction in the number of community pharmacies. The impact is patients access to community pharmacy would be adversely affected due to the reduction of pharmacies and the location of remaining pharmacies. 19/04/ /03/2017 Joint Primary Care Mark Procter Paul Baker Fiona Cartlidge Mitigation being agreed at CCG's LPC liaison that LPC will share in private session their assessment of vulnerability to inform understanding. No gaps identified CCG has suggested NHSE reviews their risk register in this regard. No gaps identified no actions recorded 22/03/2017 Date risk score set Risk Score Likelihood Impact Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score 16/03/ /03/ Weak 16 May Assurance pdf Page 1 of of 1 1 Overall Page 69 of 282

70 Overall Page 70 of 282

71 Risk Movement between defined dates 16 May 2017 ID Risk description Date risk opened Date risk reviewe Risk Scores 27 There is a risk that patients will not receive the appropriate care to prevent them from developing pressure ulcers. Risk elements: Increase in cost Patient Safety - increase harm Increase length of stay Nursing resources 25/05/ /05/2017 Date risk score set Risk Score Likelihood Impact 09:27:07 15/05/ /04/ /04/ /05/ Actions Update as of 29/06/2015: Collaborative pack of information designed by team, this will be rolled out firstly to areas of high pressure damage, (TQ, PGN, BXM) & will go to all nursing, IC & Allied Health Professionals. Community teams are using the safety Summary of work undertaken by providers to reduce pressure ulcers since (previous updates in relation to this risk have not been carried forward with transfer to a new database). - Pressure ulcer relief mattresses are now standard on A 04/01/ /05/2012 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /04/ /11/ /10/ /06/ /04/ /03/ /12/ /10/ Risk movement pdf Page 1 of 17 Page 1 of 17

72 /06/ /04/ /04/ /02/ /12/ /05/ Risk movement pdf Page 2 of 17 Page Overall 2 of 17 Page 72 of 282

73 ID Risk description Date risk opened Date risk reviewe Risk Scores 78 There is a risk that, due to demand and capacity at Torbay Hospital, waiting times will exceed 18 weeks and failure to achieve key RTT performance standards at SDHFT. Also refer to Risk Entry 10 (Closed - risk logged by Finance team) 22/10/ /04/2017 Date risk score set Risk Score Likelihood Impact 27/04/ /10/ /06/ /02/ /10/ /02/ /10/ Actions Apr 17 - neurology plan not implemented - decision between CCG and Trust that could not be implemented (NHSE informed). Opthalmology - activity undertaken as planned. Returns submitted to NHSE. Month end position still to be established. 26/04/17 - November NHS England assurance meeting on 30/11. Providing full briefing, not anticipated to recover in 16/17- Planned achievement for March Jan 17 - Trust has applied for some NHSE funding for support with RTT achievement for Opthalmology June Trust predicted to fail target. Action plan completed, mitigation works in progress, reports being shared with the CCG. July RTT achieved to June 2016, Trust are forecasting missing target in July. Forecast trajectories combined with ne Vanguard unit is on site and cataract operations have commenced. Outsourcing to plastics is going well and the backlog has been cleared. NHS England Intensive Support Team have visited. Some recommendations but overall are complimentary of the way SDH Vanguard unit is on site and cataract operations will start soon. Outsourcing to plastics is going well and the backlog should be cleared by end July. The NHS England Intensive Support Team have been in and have made some recommendations but overall Mar 15 - Ophthalmology Referral to Treatment Times still a problem due to sharp increase in the number of cataracts referrals. Cataracts C&B at Mount Stuart has been reinstated but SDHFT do not have any plans at present to commission them for list transf 27/04/ /04/ /11/ /05/ /06/ /04/ Risk movement pdf Page 3 of 17 Page Overall 3 of 17 Page 73 of 282

74 Work plan in progress, identified and prioritised patients waiting over 52 weeks. Patient Access Policy in draft. 52 week waiters are being monitored via Joint Technical working group. 3/6/14 - Good progress with orthopaedics in line with backlog red 09/09/2014 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /02/ /10/ /02/ /01/ /07/ /06/ /06/ /04/ /02/ /12/ /10/ Risk movement pdf Page 4 of 17 Page Overall 4 of 17 Page 74 of 282

75 ID Risk description Date risk opened Date risk reviewe Risk Scores 91 There is a risk that the 95% of people seen 4hour wait standard in A&E is not met at Torbay and South Devon NHS Trust which may impact on achievement of national standards and patient experience (and risk of handover delays from the ambulance to A&E department - Ambulance Handover issue see Risk 110). (Cross reference with Risk 109 / 110 and 113) 11/02/ /05/2017 Date risk score set Risk Score Likelihood Impact 25/04/ /03/ /01/ /12/ /11/ /10/ /08/ /10/ /07/ /04/ /09/ /02/ Actions Feb actions continue in addition agreed that revised A&E improvement will be available for February A&E delivery board. March improvement plan delayed; expected March. Performance has however improved second half of Febraury and into Mar 04/05/2017 Dec Unfortuately now below trajectory, loss of assessment unit space and issues with flow perceived to be main issues. Anticipation that completion of estates work and targetted work on ED re-direction and flow/discharge will start to improve the Oct Fortnightly review of A&E action Plan continues alongside daily, weekly and monthly analysis of treatment against trajectory. A&E action plan to bring together trust plan, wider system actions and to incorporate 5 high impact changes due end o 4 Jun 15 - Whole system action plan to recover 4hr wait achievement agreed. Fortnightly review meetings have commenced. Revised trajectory agreed, with 95% achievement due from July 15 onwards. Review and monitoring meetings taking place revised tra 07/02/ /11/ /04/ Risk movement pdf Page 5 of 17 Page Overall 5 of 17 Page 75 of 282

76 Whole system action plan to recover 4 hr wait achievement discussed at Feb 15 and March 15 Urgent Care Board. Fortnightly review meetings of the same to commence mid Mar 15. Revised trajectory to be agreed April 15. NHS England requested additional EC Revised Urgent Care Board commences meetings commenced 17th Nov. At this meeting it was agreed that SDHFT will present consolidated action plan for review, incorporating progress against ECIST recommendations at the next meeting on 17th Dec 14. Oct perfor 09/04/ /01/2015 1/07/14-1) Daily community wide escalation calls continue as required. 2) All actions from Winter debrief meeting agreed by all parties 3) Consultant expert in Emergency dept operations visiting Torbay hospital on 3rd july 14 4) Visit to Plymouth Hos 01/07/2014 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /02/ /10/ /12/ /10/ /08/ /06/ /12/ /02/ Risk movement pdf Page 6 of 17 Page Overall 6 of 17 Page 76 of 282

77 ID Risk description Date risk opened Date risk reviewe Risk Scores 178 There is a risk that patients referred to a Neurology consultant in Torbay will have to wait at least 7 months for an appointment and that patients waiting a follow-up will also have a significant delay. NHS England will not allow the list to close as it has not been possible to secure assurance from neighbouring Providers that they could manage the additional demand. The impact of this is that some patients will have a delayed diagnosis and the health of some patients may be adversely effected and their condition deteriorate whilst waiting for an appointment. Some patients may be unable to access services elsewhere. 19/05/ /05/2017 Date risk score set Risk Score Likelihood Impact 04/05/ /05/ Actions May 17 - Current position relatively stable, however RD&E continue to see increased referrals from South Devon and Torbay and current locum registrar contract is due to expire in August 2017 and no firm plans yet in place for how to replace that capacity. Jan Latest trajectory from the Trust describes a plan to bring waits down to 10 weeks by August 2017 by utilising existing resource. Also pursuing NHSE RTT funding to support this work. Feb NHSE RTT funding awarded with criteria (activity 09/05/ /04/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /11/ /05/ Risk movement pdf Page 7 of 17 Page Overall 7 of 17 Page 77 of 282

78 ID Risk description Date risk opened Date risk reviewe Risk Scores 191 Gaps in service identified following the reprocurement of the 111 and Out of Hours service (Out of Hours community hospital cover, referrals from MIUs and paramedic helpline). Decision to fund, at financial risk, for six months to understand impact and nature of service. Risk of not being able to reach agreement on mainstreaming of services going forward. 07/09/ /04/2017 Date risk score set Risk Score Likelihood Impact 25/04/ /09/ Actions March costs available from DDocs; working with NEW Devon to arrive at value for money set of costs for services going forward as need for services remains into 17/18. Apr 17 - agreed to fund. Continue to monitor activity. March costs available from DDocs; working with NEW Devon to arrive at VFM set of costs for services going forward as need for services remains into 17/18. DDoc SOPs for services reviewed by provider leads. Risk impact assessment being undertaken by TSD based on DDoc activity figures. Dec 16 - position statement thus far produced, and two months activity data now available and being reviewed by HoUC. DDoc SOPs for services reviewed by provider leads. Risk impact assessment being undertaken by TSD based on DDoc activity figures. Dec 16 - position statement thus far produced, and two months activity data now available and being reviewed by HoUC. Jan 25/04/ /03/ /02/ /02/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /09/ Risk movement pdf Page 8 of 17 Page Overall 8 of 17 Page 78 of 282

79 ID Risk description Date risk opened Date risk reviewe Risk Scores 193 There is a risk that strategic development will be slowed down due to need to obtain NHSE approval for fit with directions 21/09/ /05/2017 Date risk score set Risk Score Likelihood Impact 06/04/ /11/ Actions 04/05/2017 no change 16/11/2016 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /02/ /01/ /11/ Risk movement pdf Page 9 of 17 Page Overall 9 of 17 Page 79 of 282

80 ID Risk description Date risk opened Date risk reviewe Risk Scores 198 There is a risk that the CCG will see direct intervention if directions not implemented. 21/09/ /05/2017 Date risk score set Risk Score Likelihood Impact 04/05/ /11/ Actions 04/05/2017 the CEP process and re-submission of 17/18 plan. NHSE review meeting May /04/2017 reviewed NR no change 16/11/2016 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /02/ /01/ /11/ Risk movement pdf Page 10 of 17 Page 10 Overall of 17 Page 80 of 282

81 ID Risk description Date risk opened Date risk reviewe Risk Scores 213 There is a risk that the provision of community pharmacy could decline due to a significant or geographically specific reduction in the number of community pharmacies. The impact is patients access to community pharmacy would be adversely affected due to the reduction of pharmacies and the location of remaining pharmacies. 16/03/ /04/2017 Date risk score set Risk Score Likelihood Impact 16/03/ Actions no actions recorded 22/03/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /03/ Risk movement pdf Page 11 of 17 Page Overall 11 of 17 Page 81 of 282

82 ID Risk description Date risk opened Date risk reviewe Risk Scores 214 There is a risk that the deteriorating financial position within the health community whole system will have an adverse effect on patient safety and quality of care provided. There may be particular issues in respect of staffing levels throughout the Trust, but in particular in A&E, where staffing levels were increased in response to CQC judgements. The Francis report in Mid Staffordshire highlighted the link between a system focus on finance and performance, and possible deteriorating quality of care. The impact of this is that the cost improvement (savings) plans may result in changes to staffing or ways of working that may have a detrimental effect on care. 27/03/ /05/2017 Date risk score set Risk Score Likelihood Impact 27/03/ Actions none recorded 27/03/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /04/ Risk movement pdf Page 12 of 17 Page Overall 12 of 17 Page 82 of 282

83 ID Risk description Date risk opened Date risk reviewe Risk Scores 215 There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance may have compromised quality of care & safety. The impact of this is that patient safety might be compromised potentially resulting in harm or care error occurring (clinical incident). 30/03/ /05/2017 Date risk score set Risk Score Likelihood Impact 15/05/ /03/ Actions March No actions identified at this time 30/03/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /05/ Risk movement pdf Page 13 of 17 Page Overall 13 of 17 Page 83 of 282

84 ID Risk description Date risk opened Date risk reviewe Risk Scores 216 There is a risk that the capacity of the CCG to respond to change is reduced following the introduction of the new recruitment process and joint working arrangements. The impact of this is the capacity to meet deadlines and attend appropriate meetings 06/04/ /05/2017 Date risk score set Risk Score Likelihood Impact 04/05/ /04/ Actions 04/05/ risk has increased as the CCG is carrying vacancies and the on going. Further shared working with NEWD will continue the vacancy freeze. NR 06/04/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /04/ Risk movement pdf Page 14 of 17 Page 14 Overall of 17 Page 84 of 282

85 ID Risk description Date risk opened Date risk reviewe Risk Scores 217 There is a risk that the Trust may not be able to fully implement the four clinical standards for seven day services in urgent and emergency care by The impact of this is that the Trust would not be complying with national guidance to enable it to continue to provide a safe and sustainable urgent and emergency care pathway. 27/04/ /04/2017 Date risk score set Risk Score Likelihood Impact 27/04/ Actions Review of the last set of audit results from February to identify areas of strength (access to diagnostics and consultant led interventions) and issues (consultant review within 14 hours of arrival). 27/04/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /04/ Risk movement pdf Page 15 of 17 Page Overall 15 of 17 Page 85 of 282

86 ID Risk description Date risk opened Date risk reviewe Risk Scores 218 There is a risk that the Trust are not able implement best practice for managing potential emergency admissions, including acute frailty and same day emergency ambulatory care. The impact of this is that the number and rate of emergency admissions will continue to rise beyond that which is sustainable. 02/05/ /05/2017 Date risk score set Risk Score Likelihood Impact 02/05/ Actions Further modelling of potential for ambulatory care is underway with the Trust. 02/05/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /05/ Risk movement pdf Page 16 of 17 Page 16 Overall of 17 Page 86 of 282

87 ID Risk description Date risk opened Date risk reviewe Risk Scores 219 There is a risk that the number of 52 week waiters will continue to increase due to lack of capacity within the upper GI service. The impact of this is an increased risk to patient clinical safety from increasing number of 52 week waiters at TSDFT, position forecasting no improvement due to capacity issues in Upper GI and may attract scrutiny from NHS England. 11/05/ /05/2017 Date risk score set Risk Score Likelihood Impact 11/05/ Actions May 17 - Receipt of action plans and regular review through the contract monitoring process and RTT assurance meeting. 11/05/2017 Adequacy of assurance score Score Evidence Timeliness Scope Sufficiency Basis Date scoring done Lastest Score /05/ Risk movement pdf Page 17 of 17 Page Overall 17 of 17 Page 87 of 282

88 Overall Page 88 of 282

89 Risk Register ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 13 There is a risk that the C diff targets will be exceeded in the health community, which includes both secondary and community care. The target is 77 community, 18 acute with a total of /05/ /01/ /11/2016 r- Community services C Diff Gill Gant Lorraine Webber Sue Drew April CCG have liaised with Selina Hoque, DIPC for TSD & she has provided the information on the rationale for the trust using a different test for CDiff compared to other organisations. This does appear to be in line with DH updated guidance on the diagnosis & reporting of Clostridium Difficile (March 2012) which recommends a two-step testing/screening process. CCG have confirmed with Selina that the trust do undertake the two-step testing. They screen with molecular testing PCR and confirm with serology. Labs in SW use either PCR or serology for CDiff scrreening serology for confirming (LW) March Dep Dir of Quality attending IPC (LW) November All C- Diff RCAs have been reviewed by the CCG to provide assurance that appropriate actions have been taken to prevent further infections (KG) Ongoing monitoring and reporting at Quality Committee. Action plan with SDHFT. June RCA's on all acute cases continue & these are recorded on a data base enabling discussion around themes from RCA & antibiotic prescribing. TSDHFT are reviewing the testing for c.difficile samples. The present test is very sensitive. Not all areas are using this more sensitive test. An action plan has been written following the peer review of cdifficile within the hospital. This is reviewed at the IP&C meetings held at the hospital (LC) None identified May This risk was originally registered in It has been requested that this be closed and a new risk be added to cover all HCAI targets (LW) April This risk details targets for a previous year and needs to be updated to 16/17. The year end 16/17 number of CDiff cases reported for TSDFT are 94 - quarters 3 (16 cases) & quarter 4 (12 cases) had significantly reduced numnbers reported from Q1 (37 cases) and Q2 (29 cases) (LW) April CCG have liaised with Selina Hoque, DIPC for TSD & she has provided the information on the rationale for the trust using a different test for CDiff compared to other organisations. This does appear to be in line with DH updated guidance on the diagnosis & reporting of Clostridium Difficile (March 2012) which recommends a two-step testing/screening process. CCG have confirmed with Selina that the trust do undertake the two-step testing. They screen with molecular testing PCR and confirm with serology. Labs in SW use either PCR or serology for CDiff scrreening serology for confirming (LW) November Faecal implant started with recurrent infections (2 patients). C-Diff action plan reviewed & updated with PH England and the ICO (KG) October Risk reviewed - no change (GG) September KG has met with the DIPC at the ICO & discussed the C.Diff Reduction plan which is robust & provides close None identified July An action plan has been written by IPC following the review of cdiff. the CCG will monitor progress and compliance o plan through regular meetings with IPC team (KG) Update The acute trust has exceeded its number of c with 23 cases reported April- December Of these 6 were re as lapses in care and only 1 avoidable. All cases continue to be re by LC and IP&C team. A meeting was held C.Difficile steering group continues to meet, review cases look at national initiatives for reducing cases. Each recurrent inf is counted as a case, therefore each one count towards the targe Infection Control are reviewing how recu Quality 11 04/04/ Risk 16 May register pdf Page 1 of of Overall Page 89 of 282

90 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name monitoring of clinical practice associated with C.Diff risks. All C.Diff cases are subject to RCA investigation which is reviewed by the CCG to identify any lapses in care. Although the numbers of C.Diff are reducing, it is still likely that there will more than the ceiling target and we remain higher prevalence than other areas therefore I think the score remains the same as it is difficult to recommend reducing the likelihood of exceeding our ceiling (KG) August The regional HCAI monitoring data for July shows a reduction in Total C.Diff cases reported to 6, which is encouraging. With all C.Diff actions in place and evidence of infections beginning to fall, the likelihood of this risk has been reduced to 4; if rates maintain at this level or decrease further, we can review likelihood again (KG) June The number of cases from April 2016 date are 8 for the Acute trust against a target of 18 cases. 9 for the rest of the CCG footprint against a target of 97. RCA's on all acute cases continue & these are recorded on a data base enabling discussion around themes from RCA & antibiotic prescribing. TSDHFT are reviewing the testing for c.difficile samples. The present test is very sensitive. Not all areas are using this more sensitive test. An action plan has been written following the peer review of cdifficile within the hospital. This is reviewed at the IP&C meetings held at the hospital (LC) Bi-monthly report to Quality Committee. Bi-monthly 4 Risk 16 May register pdf Page 2 of of Overall Page 90 of 282

91 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name report to Governing Body. Cdiff data is now included in the Quality Dashboard. CCG Presentation to NHS England Area Team: 13/08/2013, 4/12/2013, 28/01/2014, 25/02/2014. NHS England Quality Surveillance Group 16/12/2013, 03/02/ Risk 16 May register pdf Page 3 of of Overall Page 91 of 282

92 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 27 There is a risk that patients will not receive the appropriate care to prevent them from developing pressure ulcers. Risk elements: Increase in cost Patient Safety - increase harm Increase length of stay Nursing resources /05/ /05/ /05/2017 r- Community services Pressure ulcers Gill Gant Jennie Dodge Sue Drew May The newly integrated tissue viability service will be leading the Collaborative PU Prevention workstream across all acute settings. Each ward/area will be allocated to a tissue viability lead to ensure continued support. This will be monitored via the PU Prevention Group and will report into the Quality Improvement Group (JD) April The PUP group meet monthly to review training levels, monitor PUs (incl targeting areas of low level PUs) & continuing with the champion programme. The CCG receives a monthly update on the PUP via the Quality Improvement Group (JD) Developmental work has been agreed and includes working with Care Homes to implement a Quality and Effectiveness Safety Trigger tool. None identified May the trust achieved a 50% reduction in avoidable Grade 3 & 4 PUs - this means 9 patients have not developed significant pressure damage which was deemed avoidable (JD) April The risk score has been reduced following a review of PUs prevalence over the last 6 months. There has only been 1 PU reported over the last 6 months & the PUP group meet monthly to review training levels monitor PUs (incl targeting areas of low level PUs) & continuing witht he champion programme. The CCG receives a monthly update on the PUP via the Quality Improvement Group (JD) November there have been 7 PUs reported on STEIS since update in April 2016, 3 of which took place in ED. Assurance was gained that contributory factors to these were not linked to previous PUs reported in ED during March Outcome of whole system meeting following March ED PUs has taken place and an overall action plan has been agreed and is being monitored via SGing route (JD) May As a result of pressures in ED a targeted piece of work is being conducted by Assistant Director of Nursing to reduce development of Pressure Ulcers for long waiters. The community Pressure Ulcer Lead, (Tracey McKenzie) is now covering the whole ICO and will be looking to align processes & programmes of Education across the organisation. Risk to remain same rating until an improvement / None identified Update as of 29/06/2015: Collaborative pack of information desig team, this will be rolled out firstly to areas of high pressure dam (TQ, PGN, BXM) & will go to all nursing, IC & Allied Health Profes Community teams are using the safety Summary of work undertaken by providers to reduce pres ulcers since (previous updates in relation to this risk have been carried forward with transfer to a new database). - Pressu relief mattresses are now standard on A Quality 10 04/04/ Risk 16 May register pdf Page 4 of of Overall Page 92 of 282

93 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name reduction is seen. (JM) : From April 2014 the TSDHCT target has been a 10% reduction in avoidable Grade three and four pressure ulcers across all community hospitals and Zones. 24/07/2013: Quality Committee: Additional assurance has been received from TSDHCT - additional resource recruited. The overall trend is improving, along with improved data analysis. The reasons for the relatively high numbers of pressure ulcers in the Community is not better understood - patients often have this existing condition when first seen by Health Visitors, which is the first recording of the condition. NHS England Quality Surveillance Group 03/02/ : TSDHCT have appointed a project manager to implement their Action Plan within their services and in Care homes. As part of the requirements for the Trust Development Authority, TSDHCT are providing monthly updates to their Board which they will share with us. All providers report all grade 3 and 4 pressure ulcers that are reviewed as part of the SIRI process. Information has been provided relating to the provenance of the pressure ulcers. An indepth review of reporting patterns. An annual report on pressure ulcer related activity. Pressure Ulcers continue to be reported as SIRIs - work is underway across the Care homes and the community teams but implementation and embedding of the learning is still required. 4 Risk 16 May register pdf Page 5 of of Overall Page 93 of 282

94 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 30 There is a risk of widespread disruption across the healthcare community due to norovirus. Risk elements: Ward closure, Poor patient experience, Disrupted flow in the Hospital. Impact- Increase pressure on the whole system /05/ /05/ /09/2016 r- Community services Norovirus Gill Gant Lorraine Webber Sue Drew May There is now considerable service monitoring in place both operationally (daily as part of control meeting) and also monthly through quality surveillance. There is also a clear process followed by the Trust in response to outbreaks of norovirus. Any ward closures due to outbreak are subject to a full RCA and any learning/actions identified. Overall during 16/17 the KPI of individual ward closure for no more than 12 days was maintained (LW) March Dep Dir of Quality will now attend the IPC meetings (LW) July Any ward outbreak resulting in closure of ward is subject to an RCA investigation to ensure all infection control measures are taken appropriately (KG) July Policy and Procedures for outbreak management apply across all wards acute and community hospitals (KG) July outbreak status is included in daily operational management meetings (KG) Monitoring by the Infection control lead, Quality Committee, HCAI committee (Devon/SD&Torbay/ Plymouth) : HPA community Tools e.g (vomitometer) may not be routinely used. May There is now considerable service monitoring in place both operationally (daily as part of control meeting) and also monthly through quality surveillance. There is also a clear process followed by the Trust in response to outbreaks of norovirus. Any ward closures due to outbreak are subject to a full RCA and any learning/actions identified. Overall during 16/17 the KPI of individual ward closure for no more than 12 days was maintained (LW) November No outbreaks in the last couple of months. Hospital cleaning plan has been reviewed at ICO IPCC and is on track. Outbreak prevention and management training and awareness is in place across the ICO. PH have sent out awareness re: Norivus prevention to care homes (KG) September We have had a couple of outbreaks of norovirus in Community hospitals, leading to closure of hospitals outbreaks managed well with full support from IPC, so that the impact of outbreaks was reduced although closure of community hospital increases the impact I think the likelihood needs to increase to 3 and the impact to 3 giving this a revised score of 9. I have reviewed both the RCAs and also outbreak management plans in the ICO all relevant measures are taken to reduce spread and impact of norovirus (KG) May All non acute cases are now notified by microbiology dept directly to GP. GP's to make contact with patient including further written information : Action taken to manage on-going outbreaks that are linked to fulfilling the category of a SIRI May SD&T CCG remains an outlier in the SW due to excessive cases (LC) May The ICO are reviewing less sensitive methods of testin Quality Other hospitals are using less sensitive but NHSE approved testin Current testing contract runs until later in the year (LC)Updated 11 02/03/ Linda Churm No Change Updated 31/12/20 04/04/2017 Update 24/06/2015 Reviewed by Linda Churm - no change. Updat Linda Churm The amount of circulating Norovirus rem low in the acute trust and community. The norovirus tool kit has updated and initial letters have been sent out to Press releases have been issued and letters regarding h deal with Norovirus have been sent to schools, nurseries, GP s a homes : Further action is required i.e. review/changes community deep clean processes. 24/07/201 4 Risk 16 May register pdf Page 6 of of Overall Page 94 of 282

95 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name Plans in place to audit system. Green cards will be sent out out to individuals by IP&C team. ICO will pay postage. (LC) Reporting to Quality Committee; SIRI reports identifying learning following reporting of Norovirus ward closures 32 There is a risk of long waits for children's neurological 4 04/04/2017 assessments and lack of clarity for future provider of assessments 2 15/06/ /04/2015 m- Children's services childrens neurological assess Simon Tapley Jo Hooper Gail Searle Joint working with Devon on community based pathways and service specification supported by clinical leads and health care professional. Close scrutiny by BPP. Raised through JTWG. Dec Service review meeting scheduled for end of January 2016 to consider pathway and trajectories. Finalisation of service specification to take place end January 2016 (JH) Jan Finalisation of service specification to now take place end March 2016 (JH) Autism assessment services are included in the reprocurement proposals for childrens services. none identified Discussion with community provider who are keen to lead pathway. New pathway compliant with NICE guidelines Dec Wait times are decreasing from 2 years to 18 months and actions are planned to reduced this further (JH) Jan End of year review of ASD assessment services for South Devon will also be proposed at IPAM (JH) Feb TSDFT have produced a position statement YTD Jan There is a projected trajectory to clear 18+ wk waiting lists by Sept From Jan 2016 all assessments are being completed within 6 wks (JH) April End of year statement produced detailed trajectories to reduced waiting times by Torbay. Lead has been nominated in Virgin to support review of South Devon position on ASD (JH) VCL have been asked to provide a 15/16 review of service by 10th June. The ICO will also be asked to update their 15/16 review. VCL have confirmed they will not meet the 18 week target. They have agreed to lead county wide workshops to look at a new condensed pathway which should reduce waiting times in April Torbay needs to appoint new service lead following resignation of the current post holder which could delay trajectories (JH) VCL have not reached agreed target - 18 week waits by August VCL have not been able to confirm a date when they will achieve the 18 week wait target. Mar Waiting times continue to reduce for TAAS (Torbay Au Assessment Service) (5-18 years). Virgin have run a series of wor which has been quarter 4 of 2016/17 and into Quarter (17/18) to r their pathway condensing clinic appointmen Oct 14 - Some costs agreed and some being discussed by senior managers at hospital and CCG. Jan 15 - Most costs agreed by sen managers at hospital and CCG. Advert out for 2 key posts - antic will start to see impact on waiting list during 2015/1 Discussions are in progress with Torbay's Children's Services aro use of CAF and the long-term development of the pathway. Plan developed by provider to manage the waiting list. Awaiting assu regarding progress of the action plan. 11/3/14 - Commissioning & Finance 10 08/03/ Risk 16 May register pdf Page 7 of of Overall Page 95 of 282

96 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 73 There is a risk that the Torbay CAMHS service is not meeting the needs of the service users in a timely way. Concern that service users needing care will experience delays in accessing care /05/ /10/ /02/2017 m- Children's services CAMHS Simon Tapley Louise Arrow Gail Searle Monthly CAMHS Governance Group established (chaired by Dr Rowe) with providers and commissioners. Service improvement plan reported on. IPAM contract monthly meetings with Virgin provider. Dec CAMHS Commissioner appointed 17/12/2017 will take up post by 01/04/16 (JH) Jan New CAMHS Commissioner starts 22/02/16 (JH) National waiting time funding recieved by CCG Monitoring via JTWG and Contract Review None identified Jan CAMHS Redesign Board has not had strong support from partners in Q3, need to re-engage education & social care colleagues, also Chairs role will need to be reassigned as current role has changed (JH) Monitored through the local CAMHs Governance group. Reviewed by Quality Committee Discussed / presented at CCG : TSDHCT Exec to Exec meeting 17/03/2014 NHS England Quality Surveillance Group 16/12/2013, 03/02/2014 Notification to providers of finance (through s256) available to secure solution. Virgin contract varied in year to provide consultant in put to pathway for South Devon. Nov CAMHS transformation monies to be released in 2015/16, plans have the support of Paediatric CPG, CAMHS Redesign Board, parents, young people, Governing Body, Devon and Torbay HWBs. NHSE have confirmed partial assurance, a further submission for eating disorder plans is due at the end of November Dec CAMHS Transformation Plans have received full assurance from NHSE (JH) Jan Virgin is reporting RTT as 100% in Nov for South Devon however Torbay??. Consideration is being given as part of CAMHS Transformation & Eating Disorders to non recurrent allocation of funds to target wait list & accessibility (SG) Feb NEW CAMHS Commissioner now in post (JH). SDTCCG staff received education session on data produced by VCL (JH) April CCG is receiving weekly and monthly data to monitor waiting times. Weekly phone ins are to be reinstated around some areas of service delivery e.g. Out of hours psychiatry. Virgin CAMHS are achieving 100% RTT in 18weeks No assurances identified May 17: reduction against internal waits has reduced wait times. Challenges from the organsiations decision of a vacancy freeze h affected the impact of these reductions. Data from orgaisation s that Feb 17: 95% and March 100% of CYPS accepted into Nov % of Torbay service users seen within 18 weeks RTT that by March 2017 no one will wait more than 7 weeks for furthe treatment after first assessment. Waiting list monies added to T CAMHS to further address waits. Apr 17 - a 21/07/2016- A meeting took place between representatives of CC (Deputy Director of Commissioning, Head of Mental health and C Commissioner) with representatives of the ICO (Chief Operating Deputy Director of Public Health and CAMHS service m August 15 - The Children s PoS in Plymouth, continues to be fully operational but has not received any CCG footprint children. No CAMHS transformation funds to be released upon final submissi ED plans to NHSE on Post for CAMHS Following external review, action plan has been written and serv development group set up to oversee with representation from team and senior commissioner (chaired by Dr Adam Morris). Key finding from the review was that existing resourcing in th External review of Torbay service completed. Awaiting results an recommendations to inform any structural change; intervention investment. Virgin have commenced the assertive outreach serv further recruitment to substantive posts. Review an 5 Jun 14 - On going vacancies remain an issue with agency staff c where possible. Agreement reached with SCG who will fund 250 towards Assertive Outreach Service with CCGs picking up the remainder. Virgin Healthcare have begun recruitment with s Commissioning & Finance 11 06/04/ Risk 16 May register pdf Page 8 of of Overall Page 96 of 282

97 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name however, there are some outliers which we have requested a deep dive around. Workforce plan and trajectories requested from ICO who deliver CAMHS for Torbay. The challenge is the cost of agency staff. Meeting booked with Director of Commissioning and Transformation to discuss next steps around challenges facing CAMHS delivered by ICO (LA) May A letter has been sent from the CCG to the ICO outlining concerns held around their CAMHS service and a detailed response has been requested by the 24th May A meeting has been arranged with Director and Deputy Director of Commissioning, CAMHS Commissioning Manager and Head of Joint Commissioning to discuss their response on 31st May Quality Committee and CFC are aware of concerns. Monitoring via JTWG and Contract Review meetings 4 Risk 16 May register pdf Page 9 of of Overall Page 97 of 282

98 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 78 There is a risk that, due to demand and capacity at Torbay Hospital, waiting times will exceed 18 weeks and failure to achieve key RTT performance standards at SDHFT. Also refer to Risk Entry 10 (Closed - risk logged by Finance team) /04/ /10/ /04/2017 Simon Tapley Beverley Parker Gail Searle b- Sustainable financial balance, d- Excellent customer experience 18 weeks RTT Action learning set model described to tackle RTT underperformance in Ophthalmology, Dermatology, Upper GI and Colorectal NHS England Intensive Support Team have visited. some recommendations but overall are complimentary of the way SDHFT run their RTT processes None NHS England Intensive Support Team have been in to SDHCT. Performance report to Governing Body, Planned Care Strategic Network work plan 52 week waiters are being monitored via Joint Technical working group Trust has asked for support from the CCG - CCG are working with them to try to understand reasons behind this growth. CCG Presentation to NHS England Area Team: 13/08/2013, 28/01/2014, 25/02/2014 Apr 15 - Progress monitored through Bi monthly Action learning set meetings, Weekly performance phone calls with SDHFT, Weekly Operational Response Group meeting, monthly performance report. Fortnightly RTT meetings. None Apr 17 - neurology plan not implemented - decision between CCG Commissioning & Finance Trust that could not be implemented (NHSE informed). Opthalm activity undertaken as planned. Returns submitted to NHSE. Mo 13 end position still to be established. 26/04/17-08/02/2017 November NHS England assurance meeting on 30/11. Provid full briefing, not anticipated to recover in 16/17- Planned achievem for March Jan 17 - Trust has applied for some NHSE fundin support with RTT achievement for Opthalmology June Trust predicted to fail target. Action plan completed, mitigation works in progress, reports being shared with the CCG RTT achieved to June 2016, Trust are forecasting missing t July. Forecast trajectories combined with ne Vanguard unit is on site and cataract operations have commence Outsourcing to plastics is going well and the backlog has been cl NHS England Intensive Support Team have visited. Some recommendations but overall are complimentary of the way SDH Vanguard unit is on site and cataract operations will start soon. Outsourcing to plastics is going well and the backlog should be c by end July. The NHS England Intensive Support Team have bee and have made some recommendations but overall Mar 15 - Ophthalmology Referral to Treatment Times still a probl to sharp increase in the number of cataracts referrals. Cataracts Mount Stuart has been reinstated but SDHFT do not have any pla present to commission them for list transf Work plan in progress, identified and prioritised patients waiting 52 weeks. Patient Access Policy in draft. 52 week waiters are be monitored via Joint Technical working group. 3/6/14 - Good prog with orthopaedics in line with backlog red 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 98 of 282

99 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 86 There is a risk that drugs which are excluded from 12 04/04/2017 payment by results (Pass through drugs) are the highest Mark Procter financial challenge for SDTCCG. The growth in spend in growth area of prescribing and represent significant 3 23/12/2013 SDHFT is around 20% and this cost is passed directly to commissioners. Clarity and robust plans for the future 4 Larissa Sullivan management of this area of prescribing is required to 05/07/2016 mitigate the clinical and financial risks associated with Fiona Cartlidge pass through drugs. b- Sustainable financial balance, q- Medicines optimisation Pass through drugs Pharmacist resource in Medicines Optimisation team and TSDFT to work on mitigating the risk. A QIPP plan is being implemented for Blueteq and biosimilars in 16/17. Risk share arrangement within overall contract with TSDFT. Lack of ownership of the budget by TSDFT Little resource within the current CCG structure to manage this risk Lack of clarity about relationships between NHS England Specialised Commissioning and the High cost drugs group reporting to Strategic Medicines Optimisation Group (SMOG) in place to manage this agenda. Embedded pharmacist and TSDFT accountants provide regular narrative and financial reporting to SMOG. Deputy Medical Director at TSDFT supporting medicines optimisation within the trust. No gaps identified Continue to work with TSDFT to manage risk and identify opport Commissioning & Finance for financial savings as part of QIPP. Resources to implement wo plan are under review by TSDFT/High Cost Drugs Pharmacist 9 Continue to work with TSDFT to manage risk and identify opport for financial savings as part of QIPP Reviewed 25 May - no chang 23/10/15 - Blueteq is being implemented to provide assurances th are being used within commissioning policy. Ensure a robust horizon scanning process for budget forecast ne for 2016/17. Introduce incentives through contracting for SDHFT manage expenditure on pass through drugs. Provisional approval for embedded pharmacist granted, await fin off by NHS England Specialised Commissioning lead prior to recruitment. 31 July 2015 Pharmacist appointed and takes up po September /02/2017 Business case to be developed for embedded pharmacist jointly by CCG/NHS England and taken to BPP for approval. Facilitate robust horizon scanning process for budget forecast n for 2015/16. Secure funding for recruitment of embedded pharmacist. To be complete by February Engagement with acute trust at senior level via Clinical Manag Group. and peninsula chief pharmacists network developed to encourage peer review and shared learning. Paper describing t issues and highlighting focus areas written following meetin Paper about the management of PbR excluded drugs produced raise awareness at board level of the risk and seek support to de management plan for these drugs Collective engagement of ac trust chief pharmacists 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 99 of 282

100 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 87 There is a risk of ever growing demand on services 9 06/04/2017 supporting patients with Long Term conditions. Need to ensure that patients have access to self care and preventative services to support alongside Healthcare Professionals /01/ /06/2014 Simon Tapley Paul Hurrell Gail Searle a- Reducing inequalities, d- Excellent customer experience, j- Self-care prevention & personal responsibility, l- Joined-up community hubs closer to home, t- Long term conditions Long term conditions May Prevention, Wellbeing and Self-Care Board; Vanguard Project Board. Prevention, Wellbeing and Self-care implementation plan (draft). Stakeholders in partnership organisations (PH) Self Care Procurement. Stakeholders in partnership organisations. No gaps identified Sept stakeholder engagement taking place across the system, via multiple forums. Response to model very positive. Successful bids to Arts Council; Torbay Medical Research Fund. Early adoption areas identified &implementation now commencing. Social segmentation being applied to workstreams across Vanguard & also projects outside of this agenda. Resourcing of the programme for wider rollout remains an issue discussions taking place within ICO to identify how we might release some additional facilitation resource to support the work (PH) August Rightcare & locality team events planned to identify target communities / cohorts. Torbay Medical Research Fund bid successful to support Arts & Culture research project (singing groups for COPD). Self-care navigation tool go-live planned for (PH) May Prevention, wellbeing and self-care board monitoring of implementation of joined-up plan Vanguard project board monitoring of performance and delivery of self-care plan (PH) Marh rollout of self-care model via three delivery workstreams (Learning and Development Programme; Community Asset Development; and Information Asset Development). Information asset and community asset workstreams focussed on delivering requirements of Health and Wellbeing teams + focus in primary care for emerging health May Mainstreaming of prevention, wellbeing and self-care into BAU commissioning functions & governance (PH) Dec Project management reosurce remains an issue within enabling workstreams. Primary care engagement limited to date. March further detail required from L&D workstream in relation focus and pace of L&D programme. March Information assets and Community asset s workstre being merged into one workstream to take advantage of overlap Tender process under way for Information Assets partner. Plann rollout of MiDOS (national direectory of service) to HWB tea March 16 - As part of the the Vanguard Self-care workstream, the to look at appointing a clinical lead for Self-care (to extend into prevention work). Also looking to appoint to a Project Manager care to work across the system. Colleagues fr Caroline Diamond confirmed that she had taken Integrated Prev Strategy to the Health and Wellbeing Board where it was endors way forward. Delivery is a partnership responsibility. Next steps embed in performance framework. 3 Jun 14 - new self-care service provider secured. Service live to n referrals from 1st July 14.Prevention strategy in development and engage with redesign group to capture other prevention initiativ 14/08/14 - Self care service now live wi Quality 10 14/03/ Risk 16 May register pdf Page of 42 of 42 Overall Page 100 of 282

101 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name navigators roles. Further detail & assurances required from L&D workstream. 91 There is a risk that the 95% of people seen 4hour wait standard in A&E is not met at Torbay and South Devon NHS Trust which may impact on achievement of national standards and patient experience (and risk of handover delays from the ambulance to A&E department - Ambulance Handover issue see Risk 110). (Cross reference with Risk 109 / 110 and 113) /04/ /05/ /02/2014 Simon Tapley Christine Branson Gail Searle c- Achieving national requirements, d- Excellent customer experience, g- Patient Experience, h- Clinical effectiveness, i- Safety, k- Sustainable health & care system, u- Urgent care 4 hour A&E performance Revised trajectory agreed. Following CQC letter, revised action plan in place. Monitored through fortnightly urgent care improvement and assurance meetings - CCG attends. Weekly performance metrics produced by trust to show progress against time to initial assessment, time to treatment and frequency of observation. SRG agreed trajectory for improvement on 4 hour wait with trust (combined ED and MIU). No gaps identified Monthly reporting to Commissioning and Finance Committee, Senior Leadership Team and Governing Body in place. Daily reporting to CCG On Call Director and others as part of daily escalation processes. Weekly SIT reps to NHS England Board to board meetings. CQC visit February and initial findings March shared with CCG; action plan produced as a result. CQC report published shows A&E inadequate due to long waits, will re-inspect in July (to be confirmed). The full suite of key performance metrics are reviewed weekly by the CCG UC team & trajectory compliance with the 4hr wait standard daily. The UCB & VPB will be merged from August to become the A&E improvement board, following the recent NHSE letter - this will bring together execs from all UEC organisations to focus on A&E improvement. The CCG are also in the final stages of agreeing a stretch plan to move to 95% compliance, from the current improvement trajectory (CB) August 2016 onwards urgent care board becomes A&E delivery board, chaired by Liz Davenport System Lead for UEC. Patient flow Board meeting monthly to discuss issues. No gaps identified Feb actions continue in addition agreed that revised A&E improvement will be available for February A&E delivery board improvement plan delayed; expected March. Performance however improved second half of Febraury and into Mar Dec Unfortuately now below trajectory, loss of assessmen space and issues with flow perceived to be main issues. Anticipa that completion of estates work and targetted work on ED re-dir and flow/discharge will start to improve the Oct Fortnightly review of A&E action Plan continues alongs daily, weekly and monthly analysis of treatment against trajector action plan to bring together trust plan, wider system actions an incorporate 5 high impact changes due end o 4 Jun 15 - Whole system action plan to recover 4hr wait achievem agreed. Fortnightly review meetings have commenced. Revised trajectory agreed, with 95% achievement due from July 15 onwar Review and monitoring meetings taking place revised tra Whole system action plan to recover 4 hr wait achievement discu at Feb 15 and March 15 Urgent Care Board. Fortnightly review me of the same to commence mid Mar 15. Revised trajectory to be a April 15. NHS England requested additional EC Revised Urgent Care Board commences meetings commenced 17 Nov. At this meeting it was agreed that SDHFT will present consolidated action plan for review, incorporating progress agai ECIST recommendations at the next meeting on 17th Dec 14. Oct 1/07/14-1) Daily community wide escalation calls continue as req 2) All actions from Winter debrief meeting agreed by all parties 3 Consultant expert in Emergency dept operations visiting Torbay hospital on 3rd july 14 4) Visit to Plymouth Hos Commissioning & Finance 11 08/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 101 of 282

102 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 109 There is a risk that the number / rate of cancelled elective operations is not decreasing, which could impact on patient safety. (Cross reference with Risk 91 re SDHCT 4 hour performance) /05/ /07/ /11/2014 Simon Tapley Beverley Parker Gail Searle g- Patient Experience, i- Safety, k- Sustainable health & care system, p- Planned services Cancelled operations Monitored on Trusts performance report. Review by Quality committee. Monitoring tool set up by performance team to identify number and reason for cancelled operations. No gaps identified Reported to JTWG. Reported to Governing Body. No gaps identified 24 Sept 15 - Continue to monitoring referral to treatment times v monthly performance reports. Action learning sets in place with specialities with particular RTT issues. June Still being mon Oct Monitoring tool set up by per 10 Jun 15 - Monitoring referral to treatment times via monthly performance reports. Action learning sets in place with specialit with particular RTT issues. Appropriate monitoring in place and n longer considered a risk. Request for discussion a July % of elective operations are cancelled on the day of th admission. 9/9/14 - Actions implemented following the ECIST (Emergency Care Intensive Support team) have had a positive ef the 4hr performance although there have been days whe Quality 9 04/04/ There is a risk that crews may be delayed responding to 999 calls on days when there are delays in handing over 16 04/05/2017 patients to Emergency Department. This also means 4 16/07/2014 that the ambulance handover performance standard may not be met and the immediate handover SOP may 4 be implemented. (Cross reference with Risk 91) 08/03/2017 Simon Tapley Christine Branson Gail Searle c- Achieving national requirements, i- Safety, u- Urgent care Ambulance handovers Daily reporting regarding ambulance handover and ED performance activity. Monthly dashboard discussed ata&e Delivery Board monthly meeting. On call provider to provider discussion as required. Performance agaist trajectory reviewed monthly. Handover trajectory recieved from Trust and RAP. Sept Ambulance handover concordat agreed at September A&E delivery Board. Nov Acute handover plan formally requested from Trust to reduce delays. Handover process agreed between TSDfT and SWAST. No gaps identified Ambulance handover position regularly discussed at A&E Delivery Board. Handover delays discussed at monthly SWASFT IPMQ meeting including review of performance against trajectory. August 2016 onwards - CCG & Trust staff attended the recent ECIP reducing handover delays event; a draft concordat to reduce delays has been shared from the meeting which will be taken to the A&E improvement board for debate & agreement. The Trust have also reinstated their regular operational meetings with SWASFT on handover delays to validate information & improve processess. CCG now regular attender SWAST / ED fortnightly handover meetings. Tactical advice on ambulance handover to hospital and ambulance service (national document) to go to Apr 17 A&E delivery Board. No gaps identified 4 May 17 - The Western Division has shown a worsening position the SWASfT footprint. Overall hours lost to handover in March 1 4th worst in SWAST footprint (out of 18). 174 hours lost to handovers >15 mins in March 17. Tactical advice on amb March significant improvement in handover delays (correla with A&E performance). Apr 17 - handover delays continue to im Fortnightly meetings take place between SWAST and ICO with C representation to improve cross organisational work Jan 17 - Handover plan and divert process in draft for agreement and SWAST. Regular CCG attendance at fortnightly provider han meetings. Daily review of hours lost of handover and category o performance. Dial into daily control to raise i August A draft concordat to reduce delays has been share the ECIP meeting which will be taken to the A&E improvement b for debate & agreement. The Trust have also reinstated their reg operational meetings with SWASFT on handover del 30/06/2016- A&E improvement plan is leading to a reduction in h lost. 08/07/15 - Ambulance handover protocol being reviewed by esca planning group as part of overall revision of resilience systems an processes. 11/08/15 - Continue to review and discuss ambulance handover protocol at fortnightly escalation meetings/t SWAST whole system action plan meetings taking place. Improve in waiting times in A&E have led to a reduction in lost ambulance handover times. Daily monitoring continues. Lost hours informat continues to be reviewed at fortnightly escalation m Fortnightly handover review meetings take place between SWAS SDHC and CCG. Increases in waiting times in A&E have led to inc hours of lost ambulance time. Ambulance handover position reg discussed at Urgent Care Board. Ambulance servic Fortnightly handover review meetings take place between SWAS SDHC and CCG. Improvements in waiting times in A&E have led reduced hours of lost ambulance time. Ambulance handover po regularly discussed at Urgent Care Board. Commissioning & Finance 11 06/01/ /07/14 - Investigation of a specific incident reporting underway 30/09/14 - In Sept the fortnightly provider to provider operationa meetings restarted. SWASfT sought approval for revised handov SOP. Some concerns expressed locally. Ongoing discu 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 102 of 282

103 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 113 There is a risk regarding the availability of increased workforce in community and secondary care during 12 25/04/2017 periods of escalation. (Cross Reference with Risk 91) 4 12/08/ /01/2017 Simon Tapley Christine Branson Gail Searle c- Achieving national requirements, d- Excellent customer experience, i- Safety, k- Sustainable health & care system Community workforce Regular updates to Commissioning and Finance Committee, Senior Leadership Team and Governing Body. Staffing issues reviewed daily as part of escalation processes. No gaps identified Discussed at monthly A&E Delivery Board. Workforce plan includes reducing reliance on agency staffing and increasingly prioritising community staff resources where need is greatest. No gaps identified Oct Included as part of escalation and winter planning proc Logged as an issue by A&E Delivery Board, subject to monthly re Dec Staff needs against demand part of winter planning processes. Jan CCG oversight of daily staffi South Devon Healthcare has recently advertised a number of rol this proceeds to recruitment, risk level will reduce. 14/05/15 - Som still out of advert. Some posts successfully filled. 8 Jul 15 - risk mitigated by joint working to get best 12 Aug 14 - System Resilience Group to be convened. GP resource utilised to treat patients in A&E during busy periods Developmen ICO approach will allow current workforce to be deployed more efficiently / effectively to meet demands. Mar 15 Commissioning & Finance 11 08/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 103 of 282

104 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 130 There is a risk that cases of MRSA bacteraemia will 15 15/05/2017 exceed target for 2015/16. Target remains at zero. 5 27/03/ /09/2016 Gill Gant Lorraine Webber Sue Drew c- Achieving national requirements, d- Excellent customer experience, h- Clinical effectiveness, i- Safety, r- Community services, j- Self-care prevention & personal responsibility MRSA exceeding target March Dep Dir of Quality will be attending IPC (LW) July Screening for MRSA is undertaken on all new admissions to hospital to identify any patients who may be carrying this; eradication therapy is then given to any patients screened as positive (KG) May PIR completed for all cases. No cases so far 2016/17 (LC) CCG represented at TSDFT IP+C meetings and oversees all MRSA RCA's for shred learning and assurance. TSDFT follows DH guidelines on screening and assessment of individuals prior to admission to hospitals. Those found to be positive are given suppression therapy and cases are reviewed as necessary. All is documented in the hospital and GP notes. MRSA positive cases may not be followed up by GP unless GP is notified post discharge post discharge unless GP is notified. If community nurses are involved with individuals care they also need to be notified May Zero target was breached 2015/16 May this risk was originally registered in May 2016 and it has been requested that a new risk be added to cover all HCAI (Cdiff, MRSA, MSSA, EColi) (LW) April This risk details risk of breach of target for 15/16 and needs to be updated for 16/17 and for 17/18. 2 cases of MRSA reported by TSDFT in last quarter of 16/17 (one in Feb and one in March) - PIRs underway (LW) November MRSA action plan reviewed by CCG and is reported to the IPCC. All actions on track. The RCA on the one case reported has been reviewed at the SIRI panel, all actions completed. Incident arose due to noncompliance of screening (KG) September To date we have had one MRSA bacteraemia reported this year, which is currently being investigated; therefore this risk is a certainty as our ceiling target is zero; I have looked at the IPC Saving Lives action plan of the ICO and there is a good screening programme in all clinical areas with regular monitoring of Saving Lives IPC standards of all wards by the IPC team. Will continue to monitor (KG) July Screening for MRSA is undertaken on all new admissions to hospital to identify any patients who may be carrying this; eradication therapy is then given to any patients screened as positive (KG) May PIR completed for all cases. No cases so far 2016/17 (LC) MRSA screening is on discharge letters and positives entered in patients records as appropriate. Certain March Additional MRSA case reported, CCG awaiting investigation (LW) Good communication between agencies is required. This applies between hospitals as some cases are known to have contact with more than one hosptial July Exec Nurse capacity to attend all IPC meetings (KG) March Linda Churm There has been 2 further cases of MRS a male with Alcoholic Liver Disease and a 6 month old baby. It is thought that the baby specimen may be a contaminate as she w colonised with MRSA in throat and nose. December 2015 Quality 9 04/04/ Risk 16 May register pdf Page of 42 of 42 Overall Page 104 of 282

105 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name individuals are at more risk for example those attending more than one hospital for care, those who are immunocompromised or undergoing chemotherapy. Those with indwelling catheters or intravenous lines. 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 105 of 282

106 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 131 There is a risk to patient clinical harm with patients not 12 02/05/2017 being seen within defined RTT timescales and therefore may suffer further deterioration of their condition. 4 31/03/ /03/2015 Gill Gant Joanne Panitzke- Jones Sue Drew d- Excellent customer experience, g- Patient Experience, h- Clinical effectiveness, i- Safety Impact of RTT delays Feb 2017 Ongoing monitoring and discussions with the TSDFT around triage of patients and RTT times. JPJ June 2016 (GG) Reported and discussed at CRM re RTT delays and at QC and SLC. TSDFT have been asked to provide assurance that patients on waiting list are safe and that processes are in place to ensure no harm caused by extended waiting times. to Rob Dyer (Medical Director) asking for assurance of Clinical Harm review. No gaps identified March Dir of Quality attended Clinical Management Grp at ICO. Agenda item on group was in respect of this issue and the Med Dir spoke of the work going on to ensure robust clinical review of 52week waiters & others affected by the RTT issue. Reasuring to note the focus within the trust on ensuring patient safety. (GG) November Medical Dir is taking a report to the Trust board in Dec outlining the risks and actions being taken to mitigate those risks in respect of patients who are waiting over time re: RTT. The Trust will share with the CCG that report during Dec. The issue is due to be raised at the CRM on 23/11/16 to ensure it remains a live issue. We have been told by the MD & the DoN that there are various mechanisms in place within directorates but not much in the way of standardisation (GG) Sept The CCG continue to work with the Trust to ensure that patients are risk assessed. The process was due to be discussed at the CRM on the 28/09/16 but the meeting was cancelled. Will definitely be discussed at the next CRM if not virtually beforehand (JPJ) June meeting arranged with Medical Director later this month (JPJ) Reported and discussed at CRM re RTT delays and at QC and SLC. No gaps identified Commissioners are working with the trust to support an improve trajectory. The Quality Team has the Yellow Card System (YCS) i which allows GPs to report any issues of poor patient experience long waits for treatment. We have to date re Quality 9 28/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 106 of 282

107 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 141 There is a risk that inability to recruit staff means safe staffing levels in community hospitals and MIUs may not be maintained. This may have an effect for patients of Dartmouth, Ashburton and Bovey Tracey due to having to travel further to access an MIU /05/ /06/ /10/2015 Simon Tapley Rebecca Foweraker Gail Searle d- Excellent customer experience, f- Proud, motivated & skilled workforce, g- Patient Experience, i- Safety, k- Sustainable health & care system, r- Community services Escalated to System Resilience Group and Community Services Transformation Group. The CCGs CFC and SLT meetings are overseeing the governance of the achievement of the Care No gaps identified The CCGs CFC and SLT meetings are overseeing the governance of the achievement of the Care model parameters. Comms team producing regular consultation No gaps identified Jan The CCG Governing Body will consider the outcome of consultation including the evaluation of alternative proposals at Governing Body meeting on 26th January 2017 which will enable to be formed around MIU provision for these comm 4 Jun 15 - MIUs at Ashburton and Dartmouth are closed tempora whilst recruitment drive continues. Use of agency staff to ensure staffing levels, although this leads to cost pressures. Briefing giv Sarah Wollaston MP for local assurance and Commissioning & Finance 8 09/11/2016 MIU Staff Shortages 142 There is a risk that people requiring the allocation of a 15 04/05/2017 recovery coordinator in secondary mental health Simon Tapley of this is that people may experience deterioration in services are being subjected to long waits. The impact 3 08/06/2015 their mental state while waiting for services which increases the risk to the individual and the public. Long 5 Derek O'Toole waits for recovery coordination have been listed as 08/06/2015 contributory factors in two recent serious incident Gail Searle investigations one involving risk to the individual and one involving risk to the public. g- Patient Experience, h- Clinical effectiveness, i- Safety, s- Mental health services DPT Recovery Coordination Waiting lists for recovery coordination introduced as a standard agenda item on Mental Health and Learning Disability Redesign Board and CRM Performance data being developed No gaps identified Assurance monitored through monthly Mental Health and Learning Disability Redesign Board, monthly Acute Care Pathway Steering Group and Contract Review Meetings. Nov 15 - David Somerfield presented figures at the August DPT CRM detailing the current waiting lists and updated on current work taking place to reduce waiting lists. It was noted there was a large improvement in waiting times which continue to reduce (AR) January Assurance monitored through the monthly CRM process (AR) February Discussed at CRM Director of Operations (DPT) to present action plan to next meeting (AR) April Will now move to weekly monitoring of performance with DPT as agreed at the EXec to Exec meeting 12/4/16 (DO) August Still ongoing monitoring of weekly performance with DPT (LP) Regular contract review meetings continue and performance data being developed No gaps identified Mar 17 - DPT to provide monthly data to CCG reporting how man Quality people are waiting for allocation of a care co-ordinator. Ongoing discussions at JTWG and CRMS looking at performance in more d 9 May discussions continue with DPT. 23/02/2017 Feb 17 - Commissioners assured at contract review meeting in Fe 17 that everyone has an allocated worker and if any delays in allo are experienced then patients are rated in terms of risk. Further workshops planned with DPT and Dartington to August 15 - An action plan to bring all waits under 18 weeks has b received from DPT at CRM last Tuesday. Will be monitored throu design Board. May Performance team to monitor weekly a reports submitted to CRM quarterly. Oct 16 - DPT as 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 107 of 282

108 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 143 There is a risk that people cannot access multidisciplinary community eating disorder services in line 15 04/05/2017 Simon Tapley with NICE guidance. The impact of this is that there is 5 08/06/2015 increased likelihood of deterioration in physical and mental state in the patient group and use of inpatient medical beds or tier 4 eating disorder service. The lack of a specialist community eating disorder service was noted as a contributory factor in a serious incident 3 01/04/2016 Derek O'Toole Gail Searle investigation. c- Achieving national requirements, g- Patient Experience, h- Clinical effectiveness, i- Safety, k- Sustainable health & care system, p- Planned services, r- Community services, s- Mental health services Community ED Pathway Business case being developed for NICE compliant multidisciplinary approach & initial summary presented to Mental Health &Learning Disability Redesign Board in April Quarterly Devon Eating Disorder Pathway Group led by NEW Devon. Monthly South Devon &Torbay Eating Disorder network group. To be discussed through Contract Negotiation for 2016/17 (AR) Consultant Psychiatrist for Mental Health and Recovery Team in Torbay has specialist knowledge of Eating Disorder however there is no consistency in specialist knowledge across South Devon with the exception of the Eating Disorder Coordinator post which provides a consultation role only. Community dietetics is a recommended part of multi-disciplinary NICE pathway for Eating Disorder. A community dietetics service previously provided by Torbay Hospital has recently closed to referrals for eating disorder as it is seen as specialist service provision for which no formal commissioning process has taken place. Funding required/no current resource allocated to the development of eating disorder community clinical pathway. Should enhanced multidisciplinary community eating disorder service be introduced potential quality innovation productivity and prevention (qipp) cost savings related to reductions in use of medical inpatient beds and tier 4 eating disorder service. Tier 4 Eating disorder service is commissioned by NHS England not CCG. Quarterly Devon Eating Disorder Pathway Group led by NEW Devon. Monthly South Devon &Torbay Eating Disorder network group. Reporting to monthly Mental Health &Learning Disability Redesign Board Sept The Transformation plan is going to the Governing Body Seminar in Sept for agreement in principle (DO) Jan To be discussed through Contract Negotiation for 2016/17 (AR) Feb Ongoing discussions through Contract Negotiations (AR) August Discussions still underway with providers to commission an Eating Disorder Service (LP) Need consistent attendance from DPT Specialist Services Directorate, the Directorate within which Eating Disorders sits at Mental Health and Learning Redesign Board. Mar 17 - DPT to provide a business case to both CCGs following th evaulation of the current eating disorder pilot. Once this is prese the CCGs will refiew alongside demand for the pilot to make a de regarding commissioning intentions. A joint May Discussions with alternative provider underway. Pape presented to OSG/ CFC in June. Nov Ongoing discussions w providers. Communtiy Eating disorder review to be presented to Nov or Dec to understand the current need/deman August 15 - Risk remains for Adults however Eating Disorder for u 18yrs will be substantially improved the the CAMHs transformati Longer term plans will consider a service up to 25 yrs. Sept 15 - Transformation bids submitted to NHS England in S Commissioning & Finance 8 11/04/ Risk 16 May register pdf Page of 42 of 42 Overall Page 108 of 282

109 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 151 There is a risk of sustaining robust general practice due to recruitment and associated workforce challenges. The impact would be reduced scope and quality of services to patients, as capacity in primary care will not increase sufficiently to allow practices to cope with increasing rates of consultation and provide prompt patient access to reduce reliance on other services /01/ /04/ /08/2015 Mark Procter Paul Baker Fiona Cartlidge g- Patient Experience, k- Sustainable health & care system, o- Primary care GP Sustainability Primary Care Joint Commissioning Committee Transforming Primary Care Group No gaps identified Encouraging collaborative working on a locality basis to establish increased resilience. Work with the ICO to establish broader based models of care. NHSE led practice resilience toolkit Successful Primary Care Development Fund bids to enable development of sustainable models Heatmap devised to identify vulnerable GP practices Merge request received involving one of the practices we identify as being under particular pressure in this regard. No gaps identified 30/03/2016 all localities now confirm actions and progression tow working at scale to mitigate. 27/10/15 LM This risk has been amm following discussion at the Primary Care Joint Commissioning Committee on the 13th October The committee agr Joint Primary Care 9 25/01/ There is a risk that currently no intermediate care placements can be placed out of area whilst we await new funding agreement from TSDFT. Risk that this will increase admissions to hospital and/ or delay discharge from hospital if places aren't available /05/ /12/ /12/2015 Simon Tapley Rebecca Foweraker Gail Searle g- Patient Experience, d- Excellent customer experience, a- Reducing inequalities, k- Sustainable health & care system, o- Primary care, r- Community services Provision of IC medical input ICO and localities are co-designing a proposal for medical cover which will form a key component of the new model of care. Following legal advice taken by the ICO contracts for new services cannot be enacted ahead of the community consulatation which will launch in September. The CCGs CFC and SLT meetings are overseeing the governance of the achievement of the Care No gaps identified ICO and localities are codesigning a proposal for medical cover which will form a key component of the new model of care. No gaps identified Mar 17 - Care model parameters have been met for the establishmcommissioning & Finance medical contracts in place to support medical input to intermedi care in Moor to Sea locality, Coastal, Paignton and Brixham, New 8 Abbot and Torquay. April 17- Interim medical c 03/11/ /12/16 - Practices have expressed interest to provide medical co The timeline for the procurement of these services is to be clarifi with Commissioners. Interim medical cover arrangements are in and funded via the slippage in the MLTC work s 01/07/2016- ico engaging with practices to develop a proposal fo medical cover which will form part of the new model of care. Engagement events planned with practices to take place in July. 25/07/2016- The ICO will be issuing guidance to practices as to - Seeking resolution with LMC and contractors. - Contract for me cover has been drawn up by TSDFT and is currently being offered practices. 24/05/2016- Medical cover model under consideration localities as part of the new model of care. 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 109 of 282

110 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 162 There is a risk that non housebound tier 2 patients under 9 11/05/2017 the care of the Lower Limb Therapy Service (i.e. non Simon Tapley healing following 4 weeks of treatment with housebound patients who have shown no significance of 3 10/12/2015 compression therapy) will not receive on-going wound care. Neither Primary Care nor the LLTS are 3 Rebecca Foweraker commissioned to provide on-going wound care to 03/11/2016 patients who fall within this category. Treatment of Gail Searle these patients is therefore reliant on goodwill from primary care (albeit with support and review from LLTS). g- Patient Experience, h- Clinical effectiveness, t- Long Should primary care refuse, these patients will not term conditions, r- Community services, o- Primary care receive any on-going wound care, the wound/s will deteriorate and they will need to be admitted to Leg Ulcer Commissioning Gap secondary care. (linked to risk 94) Short term tier 2 specification for primary care initiated with several practices signing up. Discussions due to commence on long term solution including possible service redesign Performance data from the service is now being received via icare and is monitored regularly. This now includes waiting numbers and times. Patients of practices that have not signed up up to tier 2 specification or those who have not undertaken the required compression training. Some practices to continue to treat patients despite this being unfunded. LLTS is offering training to practice nurses for the treatment of tier 2 patients which, if taken up, will increase the number of practice nurses skilled to do the work. All tier 2 patients are being treated either by LLTS or general practice. Practices have only signed up to the tier 2 specification as a short term measure and may serve notice (3 months) if they do not believe it is financially viable. The service continues to experience blockages due to the treatement of Tier 2 patients that under the terms of the spec they are not required to treat. May 2017: Three options for the provision of tier two care long te have been defined: 1. Commission the whole pathway from the L Work on a different solution with primary care 3. Participate in a Devon-led locality based procurement for the w December Tier two working group to meet again on 10 Jan 17. Feb 17 - working group met 6 Feb 17 and will be updating pra managers meeting at end Feb 17. Hope to have plan in place by A Implementation to follow. April 17- Wor August LMC have raised concern regarding the requireme leg ulcer treatment covered within the Patient Pathway Optimisa spec which threatens sign up to the Tier2 spec. Paul Baker & Joh Whitehead are due to meet with LMC at the end of A 23/06/16 - Payment strategy finalised and tier 2 draft spec provid LMC for consulation. Accredition of PN's is slower than expected LLTS capacity. Some reduction in tier 2 patient numbers but wait increasing due to LLTS capacity in pro Paper discussed at OSG 23/03/16 seeking decision to recommend options 3 and 4. Decision agreed but time period limited to 1-mth more detail is worked up, particularly around future of LLTS and interface with LMAT s. Updated paper to be taken Commissioning & Finance 9 11/04/ Risk 16 May register pdf Page of 42 of 42 Overall Page 110 of 282

111 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 164 There is a risk that due to the increase in spam being received that a member of staff clicks on a link or opens an attachment that contains malware. This could include the ability to steal banking details, or personal financial details or corporate financial details. The impact of this is that the network could be compromised or individual personal financial details could be stolen /03/ /04/ /12/2015 k- Sustainable health & care system, i- Safety Cyber Security Mark Procter Gary Kennington Fiona Cartlidge 08/03/ NHS Mail has implemented additional controls that further mitigate/reduce the amount of Spam being received by organisations, and whilst not reducing the risk of staff clicking on a link or opening an attachment that could contain malware, it reduces the likelihood of receipt of this type of . The CCG are also introducing enhanced controls within its Antivirus software to quarantine and restrict the effects of any malware that is accessed via an that contains it. New NHS mail elements to be implemented which will further reduce risk. Staff awareness training should be on-going and regular. Training is being reviewed nationally and cyber security e learning will be introduced in 16/17 to increase user awareness. The HSCIC has implemented carecert which will include e-learning on cyber security which will be introduced in No gaps identified 01/02/ Ongoing user education is the best form of defense against Phishing s. There is now an IT Security Tab on Iknow, which provides low level advice on how to deal with this threat, and via our Social Media training, and the use of awareness posters, we aim to continue to reduce the possibility that an attack is successful03/11/2016 additional controls have been put in place by NHS mail team which will help to reduce the amount of spam received. Staff education is key to helping reduce the likelihood of infection by spam. New courses will be available by end of The IT Operations Manager has attended the HCISPP (Healthcare Information Security and Privacy Professional) course and is also a member of the Cyber Security Information Sharing Platform (CISP) which publishes detailed updates on the increasing risk cyber security poses. Cyber security is reported to the IG Forum and to the Quality committee quarterly. No gaps identified NHSmail has produced a Cyber Security Guide to assist with edu Quality and National e-learning is shortly to incorporate advice/guidance mitigating the threat through education. 26/04/ no change 9 01/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 111 of 282

112 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 166 There is a risk that the medium term financial plan would 16 11/04/2017 be impacted should the 5 year financial plan be unsustainable. 4 15/01/ /01/2016 b- Sustainable financial balance Medium term financial plan John Dowell Derek Blackford Emma Cane Detailed financial plans developed following allocation announcements. Agreed through Commissioning & Finance Committee and approved via Governing Body. This will highlight risks and mitigations and resultant impact upon providers and services for the local health economy. Plan submission and ongoing monitoring and progress reported monthly to DCIOS Area Team. No gaps identified In depth review through Commissioning & Finance Committee and through planning process and submission to NHS England. No gaps identified Further savings opportunities to be reviewed within the CCG and monitored via OSG/CFC. Current 2016/17 plan identifies 16.5m of QIPP delivery required, 25/01/2017 shortfall in plans to deliver this. Medium term plan being develop part of STP process, due for submission in June Commissioning & Finance 11 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 112 of 282

113 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 167 There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance, may have a poor experience of care. The impact of this having to wait overlong for assessment and treatment may result in patients and families/carers having poor experience during their time in ED /05/ /01/ /08/2016 g- Patient Experience, i- Safety A&E Pt Experience & Safety Gill Gant Gill Gant Sue Drew April Demand still high on A&E, all monitoring continuing (GG) March Complaints, Yellow Card, feedback PALs, F&FT monitored through CCG & Trust (LW) Feb 2017 Daily escalation reports received from TSDFT to allow close minitoring of situation. The mitigations are that there is a new action plan in place which seeks to address the issues identified by CQC in recent inspection. There is a new goverance system in place - Feb 2016 Tuesday TSDFTholds urgent care Assurance and Improvement meeting (attended by CCG Quality team member and commissioner) follwed by Exec oversight meeting?(in Trust) on Wednesday; follwed by Exec to exec meeting ro discuss progress / challenges and provide assurance. Additionally, performance team now links with TSDFT daily to monitor'live' data from ED in respect to time to triage/ time to obs/ time to clinical review. Sepsis audit / EWSYS audit also shared with CCG regularly. Staffing in ED monitored closely with the Trust expected to submit this information daily. There is a weekly call with CQC +NHSE to report progress against action plan. Also monitoring tests of change such as moving AMU and new triage process. June ongoing fortnightly meeting with the medical director & COO to discuss progress against the improvement action plan. Ongoing attendance at the ICO internal improvement meeting. Weekly April None identified (GG) March None identified (LW) November None identified (GG) May none identified (GG) June none indentified (GG) March Complaints, Yellow Card, feedback PALs, F&FT monitored through CCG & Trust (LW) Oct Ongoing monitoring of data and weekly briefings. No new serious incidents reported however demand on A&E remains high & therefore the risk to patient safety has not yet diminished. Data indicates an improvement in those measures, monitored regularly however it is felt that it is too early to judge an overall reduction in risk in this dept., especially as we move into the demands of Winter (GG) Sept Ongoining monitoring of data and weekly briefings. JD attends ICO meeting and A&E Board now holding the improvement plan (GG) August Ongoing monitoring of data, incidents and complaints showing continued improvement in most of the areas being measured. Not yet seeing improvement in time to see clinician but 2 new clinical posts now filled with postholders expected to start work in late August. Other improvements in time to assessment/obs/sepsis etc appear to be sustained. Weekly briefings still being provided by the ICO (GG) July the ICO sends out a weekly briefing document which provides the latest quality, safety and performance headlines. Currently it is showing a sustained improvement against the ED/MIU target and remains ahead of trajectory. Improved flow in the department is reducing March none identified (LW) Nov none identified (GG) May none identified (GG) June none identified (GG) July The CCG continues to meet at exec level with the MD COO to discuss progress against the improvement action plan. T progress against plan is discussed at Quality Assurance Meetings the ICO (GG) May working with Commissioning Quality 10 28/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 113 of 282

114 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name briefings are being received from the CEO of the ICO re the ED improvement plan (GG) July Ongoing monitoring of the data from ED is showing improvement in many key performance areas (GG) overcrowding although attendances remain high. Obs within 15 minutes performance show an improvement trend although weekly performance fluctuates. Considerable improvements have been maintained since March with over 90% patients having Obs within 30 minutes. The major challenge remaining is medical review within 60 minutes where the trend is improving but challenges of achieving core workforce remain. Shortfall in access to senior clinical decision makers during the evening until the early hours results in reduced performance against this measure. Engagement with the medical workforce around potential changes to shift patterns is progressing. Sepsis management shows an improvement trend. Another PEWS audit has been undertaken - it was found that monitoring has become much more consistent and there was 100% compliance in all of the fundamental requirements. The ICO is has appointed a new Medical Governance Lead (an ED consultant) who will develop a new strategic framework. There is an Acute Pathways Group looking at how pathways can be changed to prevent specialty patients going through ED (GG) June As at 10/06/16 the CQC report has now been published & the full judgement on the Urgent & Emergency care service within the ICO has been received. The trust is gradually showing improvement in ED & is demonstrating executive & senior 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 114 of 282

115 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name leader focus on the issues of medical & nursing staffing in ED. The action plan is being monitored weekly & refreshed as new initiatives emerge. The middle grade doctors are becoming more motivated to initiate change/improvement ideas. The ICO has been to the ED department at RDE to see how the processes in the urgent care system work there. The ICO has also linked with North Bristol Trust who had similar CQC judgement & then improved to good - the CCG introduced the ICO to NBT & is monitoring progress of that buddying. The Dir of Commissioning & the Dir of Quality both meet with the ICO execs fortnightly to receive update & to challenge/request evidence of improvement. Audit continues in the ED department & is showing areas for improvement. A deep dive review in the ED department has indicated areas for change in medical staffing cover which is currently under discussion with the doctors (GG) May Quality team attendance at weekly monitoring meeting within TSDFT which is Exec led. This group reports into weekly Exec meeting within ICO which in turn reports to CCG Directors of Commissioning & Quality where progress / challenges are monitored. A weekly written briefing document is produced by TSDFT CEO & shared with the CCG. Extensive data received & reviewed daily & weekly (GG) The assurances to this is reports to GB and 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 115 of 282

116 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name to QC 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 116 of 282

117 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 171 There is a risk that the Orthotics service in Devon will continue to offer unacceptable waiting times for assessment and treatment. This is a consequence of failing to recruit and retain key members of staff. The service takes approx. 600 referrals/month /05/ /04/ /04/2016 Simon Tapley Vikki Cochran Gail Searle a- Reducing inequalities, b- Sustainable financial balance, c- Achieving national requirements, d- Excellent customer experience, g- Patient Experience, i- Safety, r- Community services, u- Urgent care Orthotics Service Temporary arrangement provided by a single FTE Band 4 Assistant Practitioner supported by a clinical lead Physiotherapist. none identified The proposal from the lead Provider is that having considered their options they would like to suggest an option to commissioners that the Orthotics service is procured externally and sub-contracted along with the Prosthetics service which is due for renewal in May This would include the new provider establishing an assessment centre. However, for providers to commit to this level of investment the duration of the contract would need to be longer than normal NHS contracts. Providers have indicated that a 7- year contract would be preferable. The lead provider will provide their proposal in writing to commissioners by the end of March 2016 in order that a decision of agreement or rejection can be made. Within the ICO tender for the community orthotic service we have asked for flexibility under future developments that we can increase the number of orthotists hours should we want to take advantage of that. August Devon: Work to review the EMC service will begin with the RD & E in September. The current RD&E service has high overhead costs which need to be understood before any view about a wider procurement is formed. The ICO has procured a new orthotics service which will launch in September. Commissioners have been involved in the development of the specification and the evaluation of the tender to ensure best value and processes to reduce the risk of overspend on devices (VC) none identified Dec Enquiries have been made with the relevant commissio arrange a meeting to discuss the ongoing procurement and curr waiting times and performance are being sought. This is an ongo piece of work which is now being prioritised. We have August Devon: Work to review the EMC service will begin the RD & E in September (VC) Enquiries have been made with th relevant commissioner to arrange a meeting to discuss the ongo procurement and current waiting times and performance are Positive discussion with TSDFT, they could offer an inte service well within the financial envelope with any balance being offered up to QIPP. TSDFT timeframe to tender is very soon so a decision needs to be made quickly. Paper going to OS Commissioning & Finance 9 08/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 117 of 282

118 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 172 There is a risk that the CCG is making poorly informed 12 11/04/2017 decisions when commissioning health and social care John Dowell appropriate, linked datasets. The impact of this is that services because it does not have access to the 3 01/04/2016 the CCG is often unable to adequately measure the successfulness of new services and care pathways or be 4 Sian Faulkes able to adequately identify need (including unmet need) 01/04/2016 in the healthcare system prior to commissioning new Emma Cane services. a- Reducing inequalities, b- Sustainable financial balance, c- Achieving national requirements, d- Excellent customer experience, g- Patient Experience, i- Safety, k- Sustainable health & care system, m- Children's services, n- Learning disabilities, o- Primary care, p- Planned services, r- Community services, s- Mental health services, t- Long term conditions, u- Urgent care Where possible the CCG try and use the data available to at least produce a proxy measure of activity it is trying to understand yet doesn t have the required or linked data to be able to accurately identify. Datasets that are required, yet aren t being flowed because of no national established flow (eg. ONS births and deaths) are outside the CCG s control as they are waiting on NHS England / HSCIC to establish legal basis. Discussed and reported via the IG Forum. No gaps identified The CCG is constantly working with service providers / NHS Engla HSCIC to ensure it receives the data required to perform its statu functions. The CCG are members of the Data Services for Commissioners Programme Board, where the lack of inform Quality 8 25/01/2017 CCG Datasets 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 118 of 282

119 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 178 There is a risk that patients referred to a Neurology consultant in Torbay will have to wait at least 7 months for an appointment and that patients waiting a follow-up will also have a significant delay. NHS England will not allow the list to close as it has not been possible to secure assurance from neighbouring Providers that they could manage the additional demand. The impact of this is that some patients will have a delayed diagnosis and the health of some patients may be adversely effected and their condition deteriorate whilst waiting for an /05/ /05/ /05/2016 appointment. Some patients may be unable to access services elsewhere. Neurology Service TSDFT Simon Tapley Gill Munday Gail Searle The Trust has now secured a locum registrar and appointed to a specialty GP role. They are continuing to advertise for substantive consultants and working with neighbouring Trusts to look at the potential for a networked solution and joint appointments. Information provided to GPs via the weekly update Exploring networked provision linked to RightCare work, now being led through STP vulnerable speialties review. All referrals are triaged by the team, and urgent requests are prioritised. The remaining consultants continue to provide the MS and MD service, and SAICO. The CCG placed a Neurology Prior Information Notice which attracted responses from 4 parties who could offer support. SLT agreed to pass this information to the Trust for them to progress Have signposted GP's in South Devon and Torbay to the Exeter headache GPwSI clinic and have become an associate to NEW Devon's contract to enable referral without prior approval. CCG have commissioned GP Care to undertake referral audit. Neighbouring trusts also currently struggling with capacity. Limited pool of neurologists nationally, difficult to attract neurologists to Torbay under current service model. Unable to close list to new referrals. Options paper discussed at CFC. Decision to close list taken at CFC. Regular meetings with ops manager at Torbay, and communication with counterparts in RD&E and Derriford. Meeting being arranged at the end of June for all local providers as part of Right Care and work on future sustainability of neurology across Devon. CCG Quality Committe have requested assurance from Rob Dyer and ICO Quality Review Meeting by 3 June June NHS E not able to allow list to close as neighbouring trusts are not in a position to manage the additional demand. Establishing escalation process to monitor TSDFT progress against action plan. August The Trust have secured a locum registrar for 6 months, due to start 22nd August. They are out to advert for substantive consultant post & will also be advertising a GPwSI post that will focus on headache patients. The CCG have issued a Prior Information Notice (PIN) calling for expressions of interest from any providers who may be able to provide some additional capacity to support the current service (GM) Paper is going to CFC on Thursday 18th August. Nov 16 - PIN process passed to Trust to progress, locum registrar clinics have helped with capacity. GP post has been appointed too. No gaps identified May 17 - Current position relatively stable, however RD&E contin see increased referrals from South Devon and Torbay and curren locum registrar contract is due to expire in August 2017 and no fi plans yet in place for how to replace that capacity. Jan Latest trajectory from the Trust describes a plan to bri waits down to 10 weeks by August 2017 by utilising existing reso Also pursuing NHSE RTT funding to support this work. Feb 2017 RTT funding awarded with criteria (activity Commissioning & Finance 8 07/11/ Risk 16 May register pdf Page of 42 of 42 Overall Page 119 of 282

120 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 185 There is a risk that the CCG will not be fully briefed on issues of primary care quality and safety of services, especially in respect of serious adverse events reported, and complaints made, until NHS England is able to provide regular quality monitoring and assurance information to the PCCG /05/ /07/ /03/2017 Primary Care quality Gill Gant Sam Holden Sue Drew May The Primary Care Web Tool development team have met to look at the data requirements for any future tool and the quality lead and senior business intelligence office will meet to discuss the qulaity assurance aspects (SH) November There is a primary care quality committee in place which SH attends. Quality is regular item on PCCC & NHSE report to that committee on high risk quality issues. NHSE is developing a quality dashboard (GG) The CCG has access to CQC reports. There is a yellow card system in place for the reporting of poor patient experience that other providers can use to inform the CCG of primary care quality issues, but this is currently poorly utilised. May The Primary Care Web Tool development team have met to look at the data requirements for any future tool and the quality lead and senior business intelligence office will meet to discuss the qulaity assurance aspects (SH) The CCG has no access to intelligence about safety or patient experience issues in primary care, where they are reported directly to NHS England, and there is currently no information fed through the quality reporting mechanism. May The CCGs quality lead for primary continues to be involved in the development of the primary care quality dashboard. GG is meeting with Dir of Nursing at NHSE regional team meeting to discuss the management of SIs & SEAs under delegated commissioning & there will then be clarity around future development of the dashboard (SH) May The CCGs quality lead for primary care continues to be involved in the development of the primary care quality dashboard. The quality lead will continue to present this at Quality Committee as it develops. The creation of the new Improving Experiences of Care Network will also have involvement from Primary Care. The Primary Care Quality & Sustainability Hub is also still running and this provides a good level of overview into quality issues across general practice and the wider primary care. Minutes from this meeting will now be shared with the CCGs Quality Committee (SH) March Discussions between CCG & NHSE about the development of a quality assurance dashboard covering complaints, patient experience and most quality measures being taken forward by primary care commissioning team with involvement from the Quality team. SH still attends primary care quality hub & report into primary care commissioning development meeting & QC as necessary. The yellow card system is well utilised. Delegated commissioning of September There is still uncertainty about the future of Serious Incidents and Events in terms of if the CCG is going to get this responsibility, this is being discussed at the Primary care Quality and Sustainability Hub which is attended by the CCGs quality lead for primary care as well as through contracting routes (SH) March None identified Quality 8 16/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 120 of 282

121 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name primary care has been delayed. (SH) February There is a primary care quality committee in place which SH attends. Quality is regular item on PCCC & NHSE report to that committee on high risk quality issues. NHSE is developing a quality dashboard which the CCG is part of the development of. The Quality MOU in being drafted and agreed with NHS England. The CCG has access to CQC reports. There is a yellow card system in place for the reporting of poor patient experience that other providers can use to inform the CCG of primary care quality issues, the use of this has increased in recent months and the CCG continues to promote it. December the patient experience lead is still part of the development team of the NHSE dashboard which, when operational will give an overview of complaints & feedback received in relation to NHSE services, specifically general practice. A MoU is being developed between NHSE & CCG which describes various roles & responsibilities for monitoring quality in primary care under delegated commissioning. There is a primary care quality & sustainability hub meeting in place which SH attends. Quality is a regular item on PCCC & NHSE report to that committee on high risk quality issues. The CCG is now sighted on limited information in relation to complaints & concerns received about general practice via these methods (SH) November A MoU is being developed 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 121 of 282

122 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name between NHSE & CCG which describes various roles & responsibilities for monitoring quality in primary care under delegated commissioning. There is a primary care quality committee in place which SH attends. Quality is regular item on PCCC & NHSE report to that committee on high risk quality issues. NHSE is developing a quality dashboard (GG) October The CCG is now sighted on limited information in relation to complaints & concerns received about general practice & the quality lead for primary care attended the quality & sustainability hub for NHSE where incidents that have a high rating are discussed. Discussions are on-going about being able to access NHSE databases (SH) September The CCG has received confirmation that it will not have responsibility for Primary Care complaints when the CCG takes over commissioning responsibility. The CCG will have visibility of the number of complaints in relation to primary care and their themes and trends through the new primary care complaints dashboard which we have been involved in developing (SH) 186 There is a risk that Medicines Optimisation pharmacists employed by the CCG are performing a clinical role, including prescribing medicines, in Primary Care and the CCG holds corporate responsibility for their actions whilst not directly supervising this work /04/ /07/ /08/2016 Mark Procter Larissa Sullivan Fiona Cartlidge Regular 121's and team meetings with practice pharmacist to monitor workload. No gaps identified Pharmacists have indemnity insurance and honorary contract with practices. Non-medical prescribing lead responsibilities to be included in job definition. Role to be advertised shortly. No clinical leadership in place for non-medical prescribers. Finalise draft pharmacy handbook and roll-out. Distributed Dece 2016 Meds Optimisation Team and Quality Team to meet to agre associated job description for NMP. Commissioning & Finance 9 24/02/2017 Practice pharmacists 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 122 of 282

123 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 191 Gaps in service identified following the re-procurement of the 111 and Out of Hours service (Out of Hours community hospital cover, referrals from MIUs and paramedic helpline). Decision to fund, at financial risk, for six months to understand impact and nature of service. Risk of not being able to reach agreement on mainstreaming of services going forward /04/ /04/ /09/2016 Devon Doctors Service Gaps Simon Tapley Christine Branson Gail Searle DDoc SOPs for services reviewed by provider leads. Risk impact assessment being undertaken by TSD based on DDoc activity figures. Discussed at SLT Approach discussed and agreed at Joint Exe meeting with TSD. Monthly GIS with NEW Devon CCG to discuss data and services. Provider meetings to take place in new year to agree way forward. No gaps identified Risk impact assessment being undertaken by TSD based on DDoc activity figures. 07/09/16 - Statement expected from SWAST within a fortnight. Monthly activity data discussed between two Devon CCGs, DDoc, and the Acute to understand need for services going forward. No gaps identified March costs available from DDocs; working with NEW Dev arrive at value for money set of costs for services going forward need for services remains into 17/18. Apr 17 - agreed to fund. Co to monitor activity. March costs available from DDocs; working with NEW Dev arrive at VFM set of costs for services going forward as need for services remains into 17/18. DDoc SOPs for services reviewed by provider leads. Risk impact assessment being undertaken by TSD based on DDoc activity figu Dec 16 - position statement thus far produced, and two months a data now available and being reviewed by HoUC. DDoc SOPs for services reviewed by provider leads. Risk impact assessment being undertaken by TSD based on DDoc activity figu Dec 16 - position statement thus far produced, and two months a data now available and being reviewed by HoUC. Jan Commissioning & Finance 8 08/09/ There is a risk that strategic development will be slowed 3 04/05/2017 down due to need to obtain NHSE approval for fit with directions 1 21/09/ /04/2017 Strategic Development Nick Roberts Nick Roberts Viki Kirby 06/04/2017 Director of Strategy now in post. Validated directions action plan at the quarterly NHS England assurance meeting No gaps identified Regular meetings with NHS England. Feedback received from Amanda Fisk via her letter dated Agreement to appoint a Director of Strategy. Feb 2017 NR has met with Amanda Fisk 30/01/2017 to review strategic direction of CCG and directions. Discussed STP collaberative board paper on strategic directions supported by AHSN work. No gaps identified 04/05/2017 no change Commissioning & Finance 8 08/02/ There is a risk that the CCG will see direct intervention if directions not implemented. 9 04/05/ /09/ /05/2017 Intervention re-directions Nick Roberts Nick Roberts Viki Kirby 02/03/ meeting between CCG, NHSE and NHSI where a plan of action was agreed to address the risk share agreement and financial plan. At the quarterly NHS England assurance meeting , no indication was given of further intervention. no known gaps NHS England were assured about the strategic direction and directions action plan at the quarterly assurance meeting Feb joint working with ICO and NEW DevonCCG Joint director of strategy Deputies in all directorates Leadership development i n progress no known gaps 04/05/2017 the CEP process and re-submission of 17/18 plan. NHS review meeting May /04/2017 reviewed NR no change Senior Leadership 8 08/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 123 of 282

124 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 199 There is a Risk that by not having an active Microsoft Windows Patch management solution, that the CCG is left vulnerable to a Cyber attack that could result in the loss of access to Network file shares, and important CCG confidential documentation stored on PCs/Laptops and on our network shared drive. The impact is the potential for loss of information and access to line of business systems /10/ /04/ /10/2016 Patch management solution Mark Procter Gary Kennington Fiona Cartlidge 08/03/ Microsoft Windows patch management risk, has been addressed, as reported. However, the risk that a critical update is not applied in a timely manner (Within 30 days) which could lead to a network compromise, still remains. Additional monitoring of PCs/Laptops has been introduced, via our Anti- Virus software, that mitigates the risk, but doesn t remove it. The impact of a breach is still high, but is mitigated by the addition of enhancements to our Anti-Virus software. User education is key to avoiding any issues, network firewalls are deployed and antivirus software is deployed and kept up to date. Neither of the above will protect against a zero day attack (this type of attack targets unpatched systems/ applications and is increasingly being used by cyber criminals) Discussed at the CCG IT operations meeting which is held with the HIS fortnightly. Discussed at the performance and development meetings also held with the HIS bi-monthly. Been advised it is on the TSDFHT risk register. Back ups are taken of data on shared drives nightly. Non compliance with the data protection principle 7 26/04/ no change 12/01/2017 Currently there is not an active management system for laptops and desktops. The server infrastructure gets patched on a monthly basis. Currently only ne laptops are patched. KK is pursuing a process whereby crit Quality 8 28/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 124 of 282

125 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 201 There is a risk that patient experience and safety may be compromised as Mt Stuart has failed to meet certain quality standards as set out by CQC, and as highlighted in the CQC unplanned inspection of their theatres. The impact of this is potential harm to patients etc, and potentially poorer patient experience than we would expect /10/ /04/ /10/2016 Mount Stuart CQC Rating Gill Gant Jennie Dodge Sue Drew April The CQC report has been received & rates Mount Stuart as 'requires improvement' overall. An action plan from Mount Stuart has been received and escalation meetings are being set up. Points as raised by CQC were those which the CCG was sighted on from the first report in March The CCG will monitor the action plan (JD) December Formal briefing between Mount Stuart and Director of Quality Assurance took place with continual communication and updates from Mount Stuart (JD) November Escalation meetings continue and Mount Stuart are formally briefing the Director of Quality Assurance on 22/11/2016. We are currently awaiting the full CQC report. (JD) October Fortnightly escalation meetings are in place to monitor the action plan against requirement notices from March visit. These meetings will continue and subsume the monitoring of action plan for full service review once received (JD) December still awaiting full CQC inspection report (JD) November A requirement of improvement notice has been issued as Mount Stuart did not satisfy CQC regulation 17- in regards to robust governance procedures an accurate monitoring of risks. We are currently awaiting the full CQC report (JD) October none identified (JD) April The CQC report has been received & rates Mount Stuart as 'requires improvement' overall. An action plan from Mount Stuart has been received and escalation meetings are being set up. Points as raised by CQC were those which the CCG was sighted on from the first report in March The CCG will monitor the action plan (JD) March Currently awaiting full CQC report and rating. Mount Stuart have received a draft copy for factural accuracy and returned their responses to the CQC. Report expected imminently (JD) December Mount Stuart have completed an action plan following 2xrequirement notices which has been returned to CQC (JD) November Escalation meetings continue and Mount Stuart are formally briefing the Director of Quality Assurance on 22/11/2016 (JD) October Rag-rated action plan monitored on a fortnightly basis via escalation meeting (JD) March Still waiting for the full CQC report & rating. Report expected imminently (JD) December still awaiting full CQC inspection report (JD) October Currently awaiting the full CQC inspection report (JD) April none identified Quality 9 04/04/ There is a risk of variable 111 call answering performance due to the rapid mobilisation of the new integrated Urgent Care Service. This could impact on achievement of national standards and patient experience /04/ /10/ /11/2016 Integrated Urgent Care Service Simon Tapley Christine Branson Gail Searle Twice weekly sit rep teleconference with lead provider (Ddoc) and subcontractor (Vocare) to review past few days performance agree adjustments necessary and forecast upcoming performance. Daily sit rep reporting on performance reviewed by CCG. No gaps identified Monthly commissioner assurance meeting to review progress and understand current performance against contract. Monthly monitoring of service activity through A&E delivery board. No gaps identified March call answering performance, and performance of th services, continues to be good. Apr 17 - as above 25 Apr 17 - Core performance continues to be good. Oct 16- Close monitoring of performance will continue through t days of the service, expected to be the first 3 months. Nov 16-Af changes and increases in staffing as more are recruited, perform continuing to improve through Novemb Commissioning & Finance 8 01/11/ Risk 16 May register pdf Page of 42 of 42 Overall Page 125 of 282

126 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 204 There is a risk that there may be a delay in responding to some life threatening and emergency calls (category 1: 8 minutes) The impact of this would be achievement of response standards and on patient experience and clinical outcomes /05/ /10/ /02/2017 Ambulance Response Simon Tapley Christine Branson Gail Searle Local response times monitored monthly at IQPMG (Integrated quality performance monitoring group). Red response times monitored daily and CCG seek underlying reasons from SWAST for performance issues. No gaps identified ARP (Ambulance Response Programme) is NHS England sponsored programme and subject to regular monitoring, review and change with stop criteria included if the programme compromises safety. Evaluation by University of Sheffield in built to programme, overseen by Prof Jonathan Benjer. Reported to monthly A&E delivery Board. No gaps identified March / Apr actions continue with review of poorer perfor days - mostly due to distance to travel, some excess demand in a Oct Daily and monthly monitoring of response times will co including waits outside target and very long waits which are sub critical review by SWASFT. Dec As previous. Jan As pr and daily individual incident review Commissioning & Finance 8 01/11/ There is a risk that NHSE will lose mission critical staff. The impact is that as we anticipate moving to a position of delegated commissioning, we have considered key work areas likely to be provided by NHSE under the terms of an MOU. Though for all areas, loss of NHSE capacity would cause a degree of adverse impact, there are some areas requiring expertise the CCG could not easily otherwise access, i.e., where we are likely to lack both capacity and capability, in which case we will continue to require NHSE's expertise /12/ /04/ /12/2016 NHSE loss of critical staff Mark Procter Paul Baker Fiona Cartlidge Review at PCJCC. No gaps identified NHSE operationally functioning on a 7 CCG footprint provides a degree of resilience. Partial mitigation is to have in place a robust MOU (memorandum of understanding) that would define NHSE actions. Joint agreement between the CCG and NHSE of the documents forming the MOU continues with the documents approved through PCJCC once finalised. No gaps identified Deputy Director for Primary Care to liaise with Head of Primary C (NHSE) to enquire as to mitigating actions either taken or planne noting that a related risk appears on NHSE's Risk Register. Acce the agreement of Memorandum of Understandin Joint Primary Care 8 21/03/ There is a risk to the CCG reputation following the 9 08/05/2017 decision to extend the re procurement of community children services by 12 months (2019). 3 03/01/ /01/2017 Children Service Procurement 1 Simon Tapley Siobhan Grady Gail Searle CCG internal reprocurement group established and meeting weekly. Project Plan in development and actively reported on. CCG attends and reports as part of the Joint Commissioning Board with New Devon and DCC. CCG Project group now meeting fortightly, risk reviewed at each meeting. This feeds in to the wider risk log of the Joint Procurement Board Impact not fully known if commissioning partners make individual decisions on scope and timeframes. In addition the strategic intent from Torbay Council remains unknown Outcome of PHN consultation will be known 15th March Contract negotiation on track. Partners confirming financial value which may impact on length of negoation to secure agreement. The impact of this delay will ensure a fluid and seamless process in 12 months time as well as testing out the impact of partners decision making regarding scope, budget and timeframes. Reports to CFC. Weekly updates to SLT via responsible Director and report to Governing Body Weekly commissioner debrief meetings to support the decision making for the detail of the contract and any risk to VCL not agreeing to contract. No gaps identified Feb 17 - notification given to VCL on 6th Feb 17. Comms team brie Commissioning & Finance CCG internal re-procurement group established and meeting wee Project Plan in development and actively reported on. Mar 17 - CC 9 Project group now meeting fortnightly, risk review 14/03/ Risk 16 May register pdf Page of 42 of 42 Overall Page 126 of 282

127 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 211 There is a risk that the CCG does not have sufficient assurance on the decision making and quality of children's complex care placements that it contributes across Torbay and South Devon. This includes both placements commissioned by providers on our behalf and direct payments/ personal health budgets given to families to organise delivery of all or part of a care package. The impact of this is potential financial overspend in packages of care and inappropriate care packages not meeting needs /02/ /05/ /02/2017 Children ComplexCare Placement Simon Tapley Siobhan Grady Gail Searle Task and finish group for complex care has been established jointly with NEW Devon CCG and VCL. Action plan has been updated and cross referenced with internal audit. IPP report action areas include: evidence to support application, basis for decision, recording, monitoring and audit of placement, package and finance. CCG attends joint agency panels. nternal CCG children review panel also meeting monthly for interim period whilst action plan is implemented. Gap remains with no current nursing input to the scrutiny of requests and attendance at decision making panels for Torbay. May 17 Paper being submitted to Quality Committee in May providing progress and update. Arrangements with VCL are on track and assurance provided. Meeting with TSDFT - agreed review of the existing process for Torbay children to strenghten paediatric / clincial expertise in to the process and the recording + reporting of information No gaps identified Reporting on progress of action plan through monthly contract review meeting of VCL Reporting monthly to Placed People Governance Group. Joint reporting with NEW Devon CCG to relevant Quality Committee- frequency to be agreed/ Service specification is drafted and with VCL provider. Action Plan on track working with VCL. The Torbay process does not replicate that which has been put in place recently in Devon - 'moderation/verification / panel step. Capacity needed for this = require 0.2wte Band 8a post. May 17 - contact made with NEW Devon CCG to discuss in house quality nurse provision capacity to support SDT : Joint (CCGs) Quality Nurse Band 6 has been advertised will provide a level of assurances with attendance and advice to commissioners at decision making panels. May 17 - contact mad NEW Devon CCG to discuss in house quality nurse p Quality 8 07/02/ Risk 16 May register pdf Page of 42 of 42 Overall Page 127 of 282

128 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 212 There is a risk that the Designated Nurses responsible for each statutory safeguarding function, namely Looked After Children, Safeguarding Children and Safeguarding Adults and MCA are unable to provide assurance that the Governing Body are fully conversant with their statutory responsibilities in relation to safeguarding, and therefore there is limited evidence that their duty to give regard to the need to safeguard and promote the welfare of the most vulnerable individuals within our footprint is being met. The impact /03/ /05/ /02/2017 is that there is currently limited evidence to demonstrate CCG compliance against statutory responsibilities. GB Statutory Responsibilities Gill Gant Linda Village Sue Drew May Confirmation from SLT that adequacy scoring can increase due to considerable controls in place (ie: GB training & presentation at all staff meeting with plans for directorate TNAs) (LW) April The GB has recognised the risk and the Designated Nurses have been invited to GB to deliver training on the 24th August 2017 (LV) April There is an internal audit for LAC scheduled May 2017, this will audit the CCG compliance against statutory LAC competencies including assurance of the GB compliance (LV). Risk discussed and monitored at the Safeguarding Assurance meeting (CG) March None identified March The GB was recently surveyed to test their knowledge of safeguarding Children & Adults & Looked After Children. The findings indicated that the GB was not compliant with the competencies required in the Intercollegiate Frame for Looked After Children (LV) May Confirmation from SLT that adequacy scoring can increase due to considerable controls in place (ie: GB training & presentation at all staff meeting with plans for directorate TNAs) (LW) April There is an internal audit for LAC scheduled May 2017, this will audit the CCG compliance against statutory LAC competencies including assurance of the GB compliance (LV). March None identified March The GB was recently surveyed to test their knowledge of safeguarding children, adults and Looked After Children. The findings indicated that the GB was not compliant with the competencies required in the Intercollegiate Framework for Looked After Children (LV) April Designated Nurses to deliver training to GB on 24th A 2017 (LV) April Safeguarding Adults and Children teams to to discuss potential options for the GB training (LW) March 2017 GB was recently surveyed to test their k Quality 10 11/05/ There is a risk that the provision of community pharmacy could decline due to a significant or geographically specific reduction in the number of community pharmacies. The impact is patients access to community pharmacy would be adversely affected due to the reduction of pharmacies and the location of remaining pharmacies /03/ /04/ /03/2017 Mark Procter Paul Baker Fiona Cartlidge Mitigation being agreed at CCG's LPC liaison that LPC will share in private session their assessment of vulnerability to inform understanding. No gaps identified CCG has suggested NHSE reviews their risk register in this regard. No gaps identified no actions recorded Joint Primary Care 6 21/03/2017 Access to community pharmacy 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 128 of 282

129 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 214 There is a risk that the deteriorating financial position within the health community whole system will have an adverse effect on patient safety and quality of care provided. There may be particular issues in respect of staffing levels throughout the Trust, but in particular in A&E, where staffing levels were increased in response to CQC judgements. The Francis report in Mid Staffordshire highlighted the link between a system focus on finance and performance, and possible deteriorating quality of /03/ /05/ /03/2017 care. The impact of this is that the cost improvement (savings) plans may result in changes to staffing or ways of working that may have a detrimental effect on care. Compromised Quality of Care Gill Gant Joanne Panitzke- Jones Sue Drew March Quality & Equality Impact Assessment tool, embedded within the PMO, ongoing monitoring of SIs, complaints and customer queries (PALS), ongoing monitoring of the yellow card system, quality team embedded in assurance system of ICO (sit on CMG, Quality Improvement Group as well as Infection Prevention & Control Group) and Quality Risk Surveillance group held monthly to monitor intelligence about quality of care (GG) March Identified need for more sophisticated quality dashboard for optimum surveillance (GG) April JPJ has been invited to sit on the Quality Assurance Committee which feeds into the ICO Board. The QAC will oversee all aspects of quality within and across the ICO. The CCG & the ICO also have a joint exec to exec meeting where finance & quality are discussed (JPJ) March reports to Quality Committee and to Governing Body (GG) March none identified (GG) none recorded Quality 8 04/04/ There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance may have compromised quality of care & safety. The impact of this is that patient safety might be compromised potentially resulting in harm or care error occurring (clinical incident) /05/ /03/ /05/2017 Patient risk in ED Gill Gant Lorraine Webber Sue Drew March ICO working towards the Improvement plan including monitoring of safe staffing levels and A&E board now holding the improvement plan. CCG monitoring of SI incidents (LW) March none identified May Confirmation from SLT that adequacy score can increase due to the initial feedback from CQC detailing improvements noted in ED (LW) April No evidence of increase in patient safety incidents. LW to check on progress against the ED improvement plan (LW) March ICO working towards the Improvement plan, JD attends ICO meeting and A&E board now holding the improvement plan. CCG monitoring of SI incidents (LW). March dependent on the successful implementation of the improvement plan (LW) March No actions identified at this time Quality 11 11/05/ There is a risk that the capacity of the CCG to respond to change is reduced following the introduction of the new recruitment process and joint working arrangements. The impact of this is the capacity to meet deadlines and attend appropriate meetings /05/ /04/ /05/2017 Nick Roberts Vanessa Dunn Fiona Cartlidge Managers will monitor through one to one meetings with staff and at PDR Staff council representatives can be approached Recruitment process and joint working arrangements no gaps identified Actions taken to address issues or trends by the review of workloads which can be highlighted through one to one meetings. no gaps identified 04/05/ risk has increased as the CCG is carrying vacancies an on going. Further shared working with NEWD will continue the v freeze. NR Senior Leadership 9 06/04/2017 Staff Capacity in CCG 4 Risk 16 May register pdf Page of 42 of 42 Overall Page 129 of 282

130 ID Risk description Risk Score Date risk reviewed Exec Lead Controls Controls gaps Assurances Assurances gaps Action Date of Action Added Committee reported to Likelihood Date risk opened Risk Owner Assurance Score Impact Risk Coordinator Date scoring done Date risk score set Plan On a Page Links Risk Short Name 217 There is a risk that the Trust may not be able to fully implement the four clinical standards for seven day 12 27/04/2017 services in urgent and emergency care by The 3 27/04/2017 impact of this is that the Trust would not be complying with national guidance to enable it to continue to 4 provide a safe and sustainable urgent and emergency care pathway. 27/04/2017 Seven Day Services Simon Tapley Christine Branson Gail Searle The Trust has appointed Dr Ian Currie, Deputy Medical Director, as the clinical lead for 7DS locally; he is supported by Liz Davenport, COO. A Trust working group has been established, and the CCG invited to join (Christine Branson to attend). The standards are clear and nationally mandated and audited bi-annually. No gaps identified Progress with seven day services is reported monthly to the SDT A&E delivery board. There is a deep dive planned for May The ability to comply with 7DS standards across the UEC pathway was a key consideration in the UEC arm of the Devon STP acute service review and is a gateway for the service configuration proposals. NHSE in contact with the Trust and CCG on progress inc telecons. No gaps identified Review of the last set of audit results from February to identify a strength (access to diagnostics and consultant led interventions) issues (consultant review within 14 hours of arrival). Commissioning & Finance 9 27/04/ There is a risk that the Trust are not able implement best practice for managing potential emergency admissions, including acute frailty and same day emergency ambulatory care. The impact of this is that the number and rate of emergency admissions will continue to rise beyond that which is sustainable /05/ /05/ /05/2017 Emergency Admissions Simon Tapley Christine Branson Gail Searle Implementation of ambulatory emergency care and acute frailty and assessment services mandated in 5YFV UEC delivery plan, by September Acute pathways workstream in place in the Trust, led by Andy Griffiths (Deputy MD), to improve admission processes; CCG in attendance (Sandi Clemo). Managing potential admissions paper prepared end Ambulatory emergency care (AEC) system saving plan priority project. None identified Emergency Care Improvement Programme Team (ECIP) visited 2nd March to review admissions processes and ambulatory facility, report back to Trust. Summary of recommendations to SDT A&E delivery board (April 2017). Monthly monitoring of number and rate of admissions at A&E Delivery board, on dashboard. None Identified Further modelling of potential for ambulatory care is underway w the Trust. Commissioning & Finance 8 03/05/ There is a risk that the number of 52 week waiters will continue to increase due to lack of capacity within the upper GI service. The impact of this is an increased risk to patient clinical safety from increasing number of 52 week waiters at TSDFT, position forecasting no improvement due to capacity issues in Upper GI and may attract scrutiny from NHS England /05/ /05/ /05/ week waiters Simon Tapley Beverley Parker Gail Searle The Trust monitors the waiting list on a daily basis to identify additional capacity to provide an admission date for the patients on this waiting list. It regularly reviews the status of patients on the list without a date to minimise the clinical risk. The gap within the upper GI speciality is that capacity does not match demand. The number of 52wk breaches continues to rise month on month, over all waiting list size December 16 compared to December 15 has not changed a great deal - complexity of patient and increases in 2ww and urgent patients has meant the numbers of routine Inpatients are increasing and form the bulk of the 52wk waiters. There is no scope to increase capacity. The list is regularly reviewed by the trust with action plans in place to minimise the risks. Action plans to control the rise is shared and reviewed with the CCG bi weekly at the RTT assurance meeting and through the contract monitoring process. None identified May 17 - Receipt of action plans and regular review through the contract monitoring process and RTT assurance meeting. Quality 8 11/05/ Risk 16 May register pdf Page of 42 of 42 Overall Page 130 of 282

131 GOVERNING BODY Report title: Quality Report Date of committee: 25 May 2017 Date report produced: 15 May 2017 Author (s): Gill Gant, Director of Quality Assurance and Improvement Executive Lead: Gill Gant, Director of Quality Assurance and Improvement JoAnne Panitzke-Jones, Head of Quality Jennie Dodge, Quality Assurance & Patient Safety Lead Sam Holden, Quality Assurance & Patient Experience Lead Contact Details: Contact Details: Report approved by Director: Name: Gill Gant, Director of Quality Assurance and Improvement Date: 17 May 2017 Summary of Purpose and scope of report: (Please also indicate if the report is for consultation, approval or information) Consultation Approval Information X Quality of Care (service quality and patient safety) Executive Summary: The purpose of this report is to update South Devon and Torbay CCG Governing Body with details of any key quality issues (risks, awareness and improvements) that have arisen over the past 2 months. A detailed review of the quality of all services commissioned is undertaken in South Devon and Torbay in the CCG Quality Committee. The last meeting of the Quality Committee was on the 11 May 2017, with the next meeting scheduled for the 8 June The Quality Committee is chaired by Dr Nick D Arcy, GB clinical lead for Quality, Patient Safety and Safeguarding. This report highlights only the most pertinent quality issues for the CCG currently. This allows board members to easily identify the issue and actions being taken by the CCG. There are currently no new issues the Quality Committee wishes to escalate to the Governing Body to action. Quality_GB report 25 May 2017_final.docx 1 P a g e Page 1 of 17 Overall Page 131 of 282

132 Strategic risk: (include risk number if on register) Risk 167: There is a risk that patients attending A&E during times of high activity and poor 4 hour wait performance, may have a poor experience of care. The impact of this having to wait overlong for assessment and treatment may result in patients and families/carers having poor experience during their time in ED. Risk 131: There is a risk to patient clinical harm with patients not being seen within defined RTT timescales and therefore may suffer further deterioration of their condition. Mitigating Actions: Demand still high on A&E, all monitoring continues. The trust has an internal action plan that is being reviewed through the clinical management group, which the CCG attend. Management of Conflict of interests: Conflicts of interests are recorded on the register of interests, at each committee a list of recorded declarations is provided and confirmations of declarations are requested and noted. Any new declarations must be fully recorded and included in the minutes of the meeting and notified to corporate.sdtccg@nhs.net to update the central register. Committees that have previously discussed/agreed the report and outcomes: The content of this report has been considered at Quality Committee, CCG Quality Risk Surveillance Group, TSDFT Quality Improvement Group, and assurance meetings with other providers. Corporate Impact Assessment Quality & Safety/ Patient Engagement/ Impact on patient services Finance, resources and QIPP What, if any, are the legal implications? Communication plan and stakeholder involvement Quality and safety issues identified connected with performance within the acute sector There are no financial and resource implications arising from this paper. There are no legal implications arising from this paper. Not applicable. Equality Impact Assessment: Are there any Quality or Equalities (including inequalities) implications of this report? (Please specify) None identified Have you carried out an initial Quality and Equality Impact Assessment (Y/N) and is it attached? (Y/N) If not, why not? Not relevant for this report Report is for assurance purposes Quality_GB report 25 May 2017_final.docx 2 P a g e Page 2 of 17 Overall Page 132 of 282

133 Key recommendations and actions requested: That the Governing Body note the content of the report. Accompanying paper(s): None Reason for reports inclusion in the confidential section of the Governing Body meeting: N/A Quality_GB report 25 May 2017_final.docx 3 P a g e Page 3 of 17 Overall Page 133 of 282

134 1. Introduction The purpose of this report is to update the Governing Body on key items relating to the quality and safety of provider agencies commissioned by South Devon and Torbay CCG. The Quality Team reviews and scrutinises data from a variety of sources and obtains local intelligence through dialogue and meetings with providers and lead commissioners. This report discusses the most recent quality issues being monitored and addressed by South Devon and Torbay CCG. The Governing Body is requested to review the report and consider any further actions for assurance. 2. Provider Quality Update Key to rating of providers: Action Routine Further Information required Enhanced Highest Level Survelilance Process No specific concerns identified, routine monitoring as per normal process. Potential concerns identified relevant lead to take action for next surveillance meeting. Concerns identified - JPJ or GG to take to Director level & via CRM Serious quality concerns or failures triggering request for a risk summit. 2.1 Torbay and South Devon NHS Foundation Trust (TSDFT) The CQC undertook an unannounced inspection on Wednesday 3 rd May 2017 looking at the Emergency Department (ED) and Medical Division. Anecdotal feedback is reported to be positive with changes in ED particularly noted. The full report is due to TSDFT in 50 working days, and final report publication is expected within 60 days. Performance against the 4 hour standard achieved the improvement trajectory of 92% in March with 94.2% however remains below the national standard of 95%. At the end of March, 87.54% of patients waiting for treatment have waited 18 weeks or less at the Trust. This is below the agreed STF trajectory and the 92% standard. RTT > 52 weeks. At end of Mar 17 patients were reported as waiting over 52 weeks for treatment. This is the same as February so a static position. Of the 17 patients being reported at the end of March, 14 are Upper GI, 1 Colorectal, 1 Neurology, 1 Pain Management. Current Quality Risk Rating: Green 2.2 Devon Partnership Trust (DPT) Ongoing work to establish risk around the levels of suicide by patients known to services Increasing levels of staff morale largely due to improved staff survey results Quality_GB report 25 May 2017_final.docx 4 P a g e Page 4 of 17 Overall Page 134 of 282

135 DPT have continued concerns around current staffing levels and bed availability alongside skill mix, volume of activity and inappropriate referrals. Additional beds are being sought across Devon. Current Quality Risk Rating: Amber (NEW Devon is the lead commissioner for this service) 2.3 South Western Ambulance Services NHS Foundation Trust (SWASFT) Performance metrics suggest that ambulance delays and handover delays are apparent across all call categories. A number of Serious Incidents have been reported across the SWASFT area in relation to delays, (1 incident reported in January 2017 for SDTCCG area).the 999 service is jointly commissioned with the South West region CCGs and Lead Commissioner responsibility was assumed by Dorset CCG from 1 April A report has been circulated for discussion at the NHSE Quality Surveillance group (8 May 2017). The report looks at serious incidents and patient experience data, the main concern is the number of reported serious incidents in Dorset when compared to other CCG areas. The service has seen an increase in reported incidents in particular unexpected deaths where there have been delays in allocating a response with subsequent delays in treatment and care. Workforce metrics are monitored however training rates have not been available to us for a number of months- this has been escalated to the Commissioning Support Unit. There have been two yellow cards in April for SWAST regarding ambulance delays Current Quality Risk Rating: Amber 2.4 Virgin Healthcare Services The CAMHS RTT (for Devon) is at 93% with a 6 week median wait time. The longest wait is 42 weeks there are no >52 week breaches. Within children s community nursing there is a consistent 100% RTT, with the longest wait at 13 weeks. LD nursing also notes good sustained performance with 95.65% of children waiting within 18 weeks. The median wait for ASD treatment is 8 weeks and 113 weeks is the longest week wait. Current Quality Risk Rating: Green (NEW Devon is the lead commissioner for this service). 2.5 Mount Stuart Hospital (Ramsey Health care) Following the September 2016 CQC inspection Mount Stuart were given an overall rating of requires improvement. The Care Quality Commission has published their judgment after the inspection of Mount Stuart Hospital in September This was a comprehensive announced visit of the hospital undertaken over 6th & 7th of September followed by an unannounced inspection on 15th September. The inspection focused on two core services: surgery, and, outpatients and diagnostic imaging. The hospital has been rated overall as requiring improvement with the breakdown per domain and area as below Quality_GB report 25 May 2017_final.docx 5 P a g e Page 5 of 17 Overall Page 135 of 282

136 *the effectiveness of the outpatient and diagnostic imaging service was not rated due to insufficient data being available to rate this departments effectiveness nationally. The inspection demonstrated that a number of legal requirements were not being met under the CQC registration and agreed regulated activity. These were Regulation 17 (good governance), Regulation 20 (Duty of Candour) and Regulation 12 (Safe). From the date of issue Mount Stuart had 28 days in order to provide assurance to the CQC that these unmet regulations were being actioned. An action plan has been received by SDTCCG and a briefing has been held with the Deputy Director of Quality Assurance & Improvement. Fortnightly escalation meetings will be ongoing to monitor the speed and timeliness of action completion and ensure the focus is on quality. The role of the CCG will be to ensure that actions have relevant leads, timeframes and are actions for which evidence can be provided to substantiate RAG rating against compliance. The inspection report noted a number of positive practices within Mount Stuart with a particular focus on staff attitude to patient, understanding of patient experience and compassionate care. There was also confidence in their safeguarding processes with Safeguarding & Deprivation of Liberty training in situ. Domains Caring and Responsive were rated Good across the board and the CQC noted flexibility in service planning to take into account patient need, positive complaint management and considerate planning and discharge incorporating families and carers in agreeing next steps. Updates from the Fortnightly Escalation Meetings will be escalated to the Quality Committee on a monthly basis. Sickness and Turnover trajectories have improved. Current Quality Rating : Amber 2.6 Integrated Urgent Care Services- NHS 111, OOH Doctors Good performance continues overall, with 98% of calls answered within 60 seconds In most cases patients are able to speak to a clinician within 20 minutes Reduction in Ambulance dispatch as a result of better screening of calls Current Quality Risk Rating: Green Quality_GB report 25 May 2017_final.docx 6 P a g e Page 6 of 17 Overall Page 136 of 282

137 2.7 Plymouth Hospitals NHS Trust (PHNT) A Never Event occurred in March 17- classified as wrong site surgery. A further Never Event was reported in April (relating to the wrong medication used in theatres). This brings the number of NE for PHNT to 5 in a rolling year (the remaining three were retained foreign objects postsurgery). NEW Devon are the lead commissioner for this service, and are therefore working with PHNT to seek assurance that a robust action plan is in place. RTT- there are currently 89 patients in March who have waited more than 52 weeks from referral to treatment. There are a very large cohort of time critical patients who have been identified as waiting beyond their to be followed up date. NHSI and NHSE are working with the trust to seek solutions and quality improvements. Friends and family inpatient & A&E response rates are high. Cancer waits continue to be below target: 2 week wait was 89.9% in March against a target of 93% YTD performance 93.2% 62 days GP urgent to treatment was 79% against a target of 85%, YTD performance 85% Cancer screening programme to first treatment 92% against a target of 90%, YTD performance 87% 2 week wait breast where cancer not initially suspected performance is 40% against a target of 93%, YTD performance is 77%. NEWD is the lead commissioners for PHNT and are monitoring this target and associated work. Current Quality Risk Rating: Amber 2.8 Royal Devon and Exeter NHS Foundation Trust 13 breaches of the 62-day standard for first cancer treatment, which is an improvement of 6.5 from the February position of Performance against the RTT incomplete pathway target was 90.57% against the 92% target, which is a slight improvement on the February position. Sickness absence rate had improved in Feb to 3.85% compared to 4.25% in January 2017 with the 12 month rolling position remaining static at 4.1%. Mental health sickness absence continued to be the main reason. Performance against the 4 hour ED target was 93.14% against the standard of 95% and the recovery trajectory of 94.5%. Current Quality Rating: Amber (NEW Devon is the lead commissioner for this service). 3. Quality Committee rating revision update From July 2015 the Quality Assurance Team has been using a self-devised tool to monitor the three quality aspects outlined in the Lord Darzi (2008) High Quality Care for all report; Safety, Experience and Effectiveness. At the monthly Quality Assurance Surveillance Meeting (QASM) quality and safeguarding leads provide information relating to the main providers; this information comes from provider board papers, contract review meetings and internal provider meetings which quality leads sit on. Further information is sought from our internal CCG systems, such as Yellow card, PALs and Complaints, Safeguarding intelligence and Serious Incident data. Quality_GB report 25 May 2017_final.docx 7 P a g e Page 7 of 17 Overall Page 137 of 282

138 From these discussions providers were scored and rated using a traditional Red, Amber, and Green (RAG) rating. The April 2017 Quality Committee (QC) discussed and agreed that a revision of the current tool was needed- therefore a comprehensive review has been undertaken, and the QC was asked to review the revised set of measures and the rating system. The review included an updated set of measures and clarity on performance metrics in relation to quality scoring. Alongside the new tool a new rating system is outlined below. This moves us away from the traditional RAG system and defines level of risk and the level of monitoring required on the part of the quality lead. This rating will inform QC members of how we will be assuring and mitigating against identified risk. This rating will also be used to inform section 2 of the Governing Body report from quality in future. Quality Assurance Tool Matrix: No elevated risk factors Actions: Routine monitoring No specific concerns identified, routine monitoring as per normal process. Low level risk factors identified Actions: Understanding of specific issues Identification of mitigating actions Further surveillance Discussion at Quality Committee Potential concerns identified CCG quality lead to work with responsible commissioner and provider lead to discuss concerns via most appropriate route. Moderate level risk of factors identified Actions: Understanding of specific issues Identification of mitigating actions Further surveillance Discussion at Quality Committee for consideration to escalate to Governing Body High level risk of factors identified Actions: Understanding of specific issues Identification of mitigating actions Escalation to Governing Body (or Senior Leadership Team) from Quality Committee. Consideration to escalate to NHSE for formal risk summit. Concerns identified - Quality leadership team to raise with provider at executive level. Serious quality concerns or failures triggering request for a risk summit. Next Steps: The tool will sit alongside the performance dashboard which will be based on Key Performance Indicators (KPIs). As part of the quality monitoring a metric will be in place for us to rate and score the Quality_GB report 25 May 2017_final.docx 8 P a g e Page 8 of 17 Overall Page 138 of 282

139 overall performance of providers. This will be discussed with the Business Intelligence Team and will allow for collaborative joined up working and to remove duplication of effort in sourcing and recording data. This work will progress over the next month. 4. Patient Safety Overview 4.1 Harm Free Care The NHS Safety Thermometer provides a temperature check on harm that can be used alongside other measures of harm to measure local and system improvement. The Safety Thermometer allows organisations to measure harm caused and the proportion of patients that are treated harm free, and provides immediate information and analysis for frontline staff. The tool is a snapshot with measurement taking place 1 day per month. The NHS Safety Thermometer records the presence or absence of four harms: pressure ulcers falls urinary tract infections (UTIs) in patients with a catheter new venous thromboembolisms (VTEs) These four harms were selected as the focus by the Department of Health s QIPP Safe Care programme because they are common, and because there is a clinical consensus that they are largely preventable through appropriate patient care. The concept of Harm Free Care was designed to bring focus to the patient s overall experience. The national Target is 95%. Data for key providers is shown below: Rolling Harm Free Care Apr_16 - Mar TSDFT DPT Mount Stuart RDE Plymouth Target Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 There was a significant dip for DPT in Harm Free Care rate in February DPT has reconciled these figures with the sample and serious incident data and can report that this equates to 5 patients. Of these patients harms suffered were PUs and Falls with only one reaching incident criteria- (this will be a Serious Incident for NEW Devon as patient not in our area). This figure has improved for March Quality_GB report 25 May 2017_final.docx 9 P a g e Page 9 of 17 Overall Page 139 of 282

140 TSDFT remain below the national target, the majority of harm is relatable to existing harms. These new harms are predominantly a mix of falls and pressure ulcers. SDTCCG will be monitoring for improvement over the coming months. 4.2 Serious Incidents: Organisation Serious Incident Month TSDFT 2 x slips/trips/falls January x maternity (mother only) February x diagnostic incident 1 x Apparent / Self-inflicted harm meeting STEIS criteria (drug and alcohol service) 1 x HCAI Event positive MRSA March x S/T/F Emergency Department 2 x diagnostic incident 1 x Apparent / Self-inflicted harm meeting STEIS criteria DPT 1 x disruptive / aggressive behaviour January x Apparent / Self-inflicted harm meeting STEIS criteria February x Apparent / Self-inflicted harm meeting STEIS criteria March 2017 All Serious Incidents (SI) are monitored by the Quality Team and the investigation reports are scrutinised at the SI panel before closure is agreed. Providers must demonstrate lessons learned, and duty of candour prior to closure being agreed. The graph below outlines total SI s reported on STEIS from 2013 onwards for comparison. The below figures are representative of incidents occurring to SDTCCG- they do not represent DPT or SWASFT for areas outside of our footprint SI comparison YTD 2013_ Total 2015_16 TOTAL 2013_14 TOTAL 2014_15 TOTAL 16_17 Total 17_18 0 April May June July August September October November December January February March Quality_GB report 25 May 2017_final.docx 10 P a g e Page 10 of 17 Overall Page 140 of 282

141 Over Q4 of 2016_17 Serious Incident reporting has mirrored that of previous years although remaining at a lower level. As part of our collaborative approach with Northern, Eastern and Western, (NEW) Devon CCG patient safety leads have worked together to scope the level of serious incident reporting across each CCG. The graph below demonstrates total STEIS reportable Serious Incidents for Devon, including combined total. Serious Incident Total Devon 2016_ Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 NEWD 2016_17 SDT 2016_17 Combined Total The peak (as noted in the Q3 report) was attributable to a number of falls occurring within TSDFT in October. There were 6 falls across TSDFT (all differing wards / areas). The trust have issued an internal patient safety alert to refresh staff on preventative falls actions and used the staff bulletin as a way to promote this. TSDFT have been invited to attend a Community of Practice event in May set up by the South West Academic Health Science Network (SWAHSN). This community includes the other acute hospitals in Devon and will be opportunity to discuss prevalence and mitigating actions. To gain meaningful data from this comparison our next CCG steps with NEW Devon are to work with performance to understand how these figures relate to activity per provider and prevalence of incidents occurring. A total provider comparison of SIs within SDTCCG is below; Quality_GB report 25 May 2017_final.docx 11 P a g e Page 11 of 17 Overall Page 141 of 282

142 SI's reported on STEIS Apr16 - Mar Apr-16May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Dec-16 Jan-17 Feb-17Mar-17 TSDHFT DPT SWAST SDTCCG 1 VCL The incident reported by SDTCCG in March 17 was a pressure ulcer entered on behalf of Rowcroft Hospice. This will be investigated using RCA Methodology and will be approved for closure via the Serious Incident Panel Process. 5. Clinical Effectiveness Update Eliminating Mixed Sex Accommodation (EMSA breaches): There have been 0 EMSA breaches reported to SDTCCG. Central Alerting System: There have been no breaches in relation to timeframe or completed actions reported to SDTCCG. Workforce: The data in the table below has been taken from provider board reports, using the most up to date information available. We monitor staffing as this can be an indicator of quality and safety of a service. Mount Stuart & Virgin Care Limited data is received quarterly. TSDHFT DPT SWASFT RD&E PHNT Mount Stuart Sickness (Target 4%) Turnover (Target 10-14%) Mandatory training (Target 100%) Appraisal rate (Target 100%) Feb 2017 March 2017 Feb 2017 March 2017 Feb 2017 March % 4.19% 6.07% 3.78% 4.14% 4.47% 12.39% 13.85% 9.22% 12.8% 8.69% 14.80% 85.% 95% 80% 87.% 88.75% 74% 79% 82% 74.14% 80.5% 81% 84% Quality_GB report 25 May 2017_final.docx 12 P a g e Page 12 of 17 Overall Page 142 of 282

143 6. Patient Experience Update (01 November January 2017) 6.1 Number of Formal Complaints compared to previous reporting period (Reporting period: 01 February April 2017).. Current 5 Previous 3 These are complaints which are about the CCG s business or where, as commissioners of the service, the complainant has requested that the CCG lead on the investigation. Complaint Summaries: The complaints received this reporting period are summarised below; Reference Number PE647 Organisation Domain Summary South Devon and Torbay CCG Information Communication and Choice Client feels that they are being denied access to a procedure to remove a benign skin lesion as they cannot have an appointment for 6 weeks. PE607 Muti-organisation Safe, High Quality Care Complainant has passed away, complaint by relative that the whole pathway of care did not offer the patient any dignity, compassion or respect and that parts of the patients care fell well below reasonable standards. PE594 TSDFT Access and Waiting Patient complains about hospital transport consistently arriving late for their appointments and on one occasion failed to arrive at all, meaning patient could not get to their appointment. Learning from themes from complaints: Access to treatment or medications A number of complaints during this period have been in relation to perceived or actual delays in accessing treatment or medication. However in two cases the delay was assessed to be reasonable when investigated as both patients were offered an appointment within 6 weeks (against the national target of 18 weeks). Quality_GB report 25 May 2017_final.docx 13 P a g e Page 13 of 17 Overall Page 143 of 282

144 6.2 Informal Enquiries: Number of Informal Enquiries compared to previous reporting period. Current 65 Previous 49 Learning from Informal Enquiries: Self-Care and Repeat Prescriptions The two initiatives by the CCG to encourage patients to purchase low value medications over the counter and to change the way repeat prescriptions are ordered, generated by far the most contact. The majority of clients say that they are unhappy with our proposals. Practice Merger Although the CCG is not responsible for commissioning general practice, we received a high number of comments about the merger of a local practice. 6.3 Yellow Cards: Number of Yellow Cards received compared to previous reporting period. Current 152 Previous 118 Newsletter: Each quarter a newsletter, Yellow Card Roundup is produced to summarise the key findings, issues, trends and themes, the latest Yellow Card Roundup can be found here Yellow Card Development: Since April 2014 the CCG has received 1080 Yellow Cards. Following development by the patient experience team the system is now open for use to all local providers, stakeholders and interested parties. 397 Yellow Cards were received for since January 2017 Quality_GB report 25 May 2017_final.docx 14 P a g e Page 14 of 17 Overall Page 144 of 282

145 Learning from trends: Discharge information for patients discharged from Torbay Hospital Torbay and South Devon NHS Foundation Trust. Themes: Information, Communication and Choice and Building relationships. We have seen a reduction in the number of Yellow Cards submitted about discharge summaries. Dr Nick D Arcy the CCGs clinical lead for Quality recently met with Dr Rob Dyer the medical director at Torbay and South Devon NHS Foundation Trust. Dr Dyer explained that performance and quality of discharge summaries are improving within the trust, and that this improvement is being monitored, and could account for the reduction in contacts regarding the discharge process. Non-Adherence to the Devon formulary Torbay and South Devon NHS Foundation Trust Themes: Information Communication and Choice, Safe High Quality Care and Building Relationships Non-adherence to the Devon formulary- we have had a number of instances reported via Yellow Card where the hospital have recommended a patient be prescribed with a medication that is either not the generic medication and so the cost is much greater or is a self-care medication that we are asking patients to purchase over the counter. This obviously impacts on GPs, pharmacists and patients alike. This has been raised with the trust and they will ensure that all consultants are aware of what drugs can be bought over the counter and which drugs are generic. 6.4 Strategic Development: Joint working The CCG s patient experience lead continues to work jointly with the feedback and engagement team at Torbay and South Devon NHS Foundation Trust and with the Patient Advice and Complaints Team at NEW Devon CCG to look at service development and improvement. This work is on-going. Key pieces of work The End of Life Experience of Care Survey closed on 01 April We received 165 responses. A report on its findings will be published in June. The patient experience lead has developed a new regional Improving Experiences of Care Network which will replace the previous Peninsula Patient Experience Network. 7. Quality Update: 7.1 Quality Assurance Arrangements The two executives in the wider Devon STP responsible for quality and safety are currently in discussion about the future form and function of the quality teams, and their role in any strategic commissioning body and Accountable Care Systems within Devon. There is work underway to align the respective Quality Committees so that the system can move more swiftly to a single joint quality overview. Draft terms of reference are being developed, led by both chairs, which will be with both governing bodies in due course. It is also anticipated that the SDT CCG GB will continue to receive a Quality Report pertinent to the South Devon and Torbay commissioning footprint only, whilst the two CCGs continue to operate as two distinct entities. The quality teams of both CCGs are beginning to work more closely and to align the more strategic policies and procedures, as well as looking at which functions would be best undertaken at a wider Devon level, and which within the developing Accountable Care Delivery Systems (as yet awaiting a more formal narrative). Quality_GB report 25 May 2017_final.docx 15 P a g e Page 15 of 17 Overall Page 145 of 282

146 Ultimately, the vision will be to have a single Devon Quality Strategy to support the STP and to cover off the functions that remain at strategic commissioning level. This strategy will be supported by a single Quality Directorate which holds the statutory functions on behalf of both CCGs, which will be more efficient and best use of resources. Some of the functions may be undertaken in future by the new ACDS(s) in Devon, and the quality teams will be instrumental in the design and set up of those, as well as being part of the future resource within the ACDS. Talks are already underway in South Devon and Torbay to think about what a local quality partnership might look like. These plans are being developed, with a view to the CCGs being in line with the recommendations of the Carter publication (NHS Efficiency and productivity review) and to being able to demonstrate the CCGs statutory functions are carried out either within the strategic commissioning element of the STP, or within the ACDS, and that whatever the design decided upon for the STP and ACDS, there remains a focus on quality assurance and quality improvement across Devon, and specifically within our footprint. Quality_GB report 25 May 2017_final.docx 16 P a g e Page 16 of 17 Overall Page 146 of 282

147 Glossary of Abbreviations TSDFT DPT SWASFT CAMHS SI HCAI IPC DIPC NDHT PHT RD&E LAC UASC QEIA TB Torbay and South Devon NHS Foundation Trust Devon Partnership Trust South Western Ambulance Service NHS Foundation Trust Child and Adolescent Mental Health Services Serious Incident Health Care Acquired Infection Infection Prevention Control Director of Infection Prevention Control NORTHERN DEVON HEALTHCARE NHS TRUST Plymouth Hospitals Trust (Derriford) Royal Devon and Exeter NHS Foundation Trust Looked After Children Unaccompanied Asylum Seeking Children. Quality and Equality Impact Assessment Tuberculosis Quality_GB report 25 May 2017_final.docx 17 P a g e Page 17 of 17 Overall Page 147 of 282

148 Overall Page 148 of 282

149 Primary Care & the STP: Developing a Primary Care Strategic Framework Dr Sonja Manton, Joint Director of Strategy, South Devon and Torbay CCG / NEW Devon CCG Mark Procter, Joint Director of Primary Care, South Devon and Torbay CCG / NEW Devon CCG / NHS England South (Dr Nick Roberts, Chief Clinical Officer, South Devon and Torbay CCG - Primary Care STP lead for Devon) 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 1 of 43 Overall Page 149 of 282

150 STP Primary Care Workstream: High quality sustainable general practice Presentation content 1. Case for change 2. Primary care s role in the STP 3. Priorities for primary care 4. Progress with Strategic Framework 5. Next steps 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 2 of 43 Overall Page 150 of 282

151 1. Case for change 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 3 of 43 Overall Page 151 of 282

152 Case for change People are living longer / high proportion of elderly people / more complex care needs / greater use of health & social care services Care needs to be better co-ordinated / joined up especially for multiple long-term conditions and mental health People don t get enough support to be independent / hospital admissions could be prevented Too many people are inappropriately in hospital (c. 40%) Longer hospital stays increase complications Difficulties with staff recruitment and retention High levels of vacancies, turnover and sickness Many staff are due to retire, especially in the next 10 years Predicted 37k more emergency admissions over next 5 years (an increase of 30%) if nothing changes Doing nothing is neither affordable nor clinically sustainable 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 4 of 43 Overall Page 152 of 282

153 5 GP Age Distribution South Devon & Torbay 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 5 of 43 Overall Page 153 of 282

154 6 Practice Nurse Age Distribution South Devon & Torbay 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 6 of 43 Overall Page 154 of 282

155 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 7 of 43 Overall Page 155 of 282

156 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 8 of 43 Overall Page 156 of 282

157 2. Primary care s role in the STP 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 9 of 43 Overall Page 157 of 282

158 The public relies on general practice services for the health and wellbeing of themselves and their family. It is one of the great strengths of the NHS, and is recognised time and again in international comparisons. Dr Arvind Madan, GP, Director of Primary Care, NHS England 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 10 of 43 Overall Page 158 of 282

159 Key STP Priorities / Workstreams Primary care Prevention and early intervention New models of integrated care Mental health and learning disabilities Acute and specialist services Children and young people Financial sustainability 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 11 of 43 Overall Page 159 of 282

160 How primary care can contribute to the STP? Support all priority workstreams Address the financial and activity demands Create new ways of working Be a significant partner in place based accountable care delivery systems 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 12 of 43 Overall Page 160 of 282

161 How primary care can contribute to the STP? It is vital to the success of the wider health system, particularly one facing financial challenges Health systems with a strong focus on general practice deliver better outcomes at lower cost Unique benefits of general practice can be built on, e.g. gatekeeper role, continuity of care, registered population Primary care is the interface between the majority of health and social care providers. 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 13 of 43 Overall Page 161 of 282

162 Changes to the model of care can reduce acute activity and release resources to fund care at home, in the community and in primary care 14 Admissions 12% bed reduction in beds from planned NEL and EL IP activity changes + Length of stay 16% reduction in acute, 62% reduction in community Beds beds Gross savings 71.6m-74.0m Primary Care contributes to both reducing demand for acute care and improved management & care coordination of patients in primary & community settings The reduced hospital activity will release savings and enable investment in better care for more people, in more appropriate settings Net savings 42.1m-59.6m Integrated Primary & Community Care in colocated community site 2.1k hours of care per day (+/-1.2K) Care delivery at home 2.1k hours of care per day (+/-1.2K) Staff 500 (+/- 200) staff at fully loaded cost 30k- 60k New spend 14.4m-29.5m Reinvestment = 20-40% SOURCE: Devon Success Regime phase 1 Strategic Financial Framework 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 14 of 43 Overall Page 162 of 282

163 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 15 of 43 Overall Page 163 of 282

164 STP Priority Sustainable, high quality primary care Prevention and early intervention Integrated care model Acute and specialist services Mental health and learning disabilities Children and young people services Productivity 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Draft Strategic Objective for General Practice 1.Build on the strengths and benefits of the general practice model in Devon with its registered populations 2.Address current pressures and create a sustainable primary care sector 3.Enhance patient access to care 4.Promote self-care 5.Ensure that primary care addresses health inequalities for Devon residents 6.Manage and co-ordinate the health of a population by working in partnership with other providers to care for high risk patients with complex needs and increasing multiplemorbidities 7.Provide alternatives to hospital based care (subject to resources following the shift of care from secondary to primary) 8.Improve mental illness prevention & early intervention in primary care 9. Enhance effective collaboration between primary care and other childrens services 10. Contribute to improved cost-effectiveness of the care page number delivered per head of population 16 Page 16 of 43 Overall Page 164 of 282

165 Prevention and early Intervention: ensure that primary care addresses health in-equalities for Devon residents 17 Prevent ill-health / timely diagnosis of ill-health / improve community health and wellbeing. Promote healthier lifestyles to support mental and physical health & well-being and intervening earlier when needed in line with JSNA and Health & Wellbeing Strategy Focus on immediate priorities: smoking cessation, alcohol control, healthy eating, early intervention in mental health problems and supporting social connectedness and combatting loneliness Make every contact count: an opportunity to detect early-warning signs that prevent illness and disease. There is a significant body of evidence of the impact GPs and their practice teams can play in brief interventions and signposting to other support services Address the widening inequality gap in Devon that is resulting in health inequalities by focusing on the needs of relatively small population groups Reduce unwarranted variation and improve quality and clinical outcomes which can adversely affect access for different patient group Build community resilience through education and providing tools for selfmanagement Bring together primary care and community assets e.g. through innovative models such as social prescribing Work with communities to co-produce solutions that build on community assets 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 17 of 43 Overall Page 165 of 282

166 3. Priorities for primary care 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 18 of 43 Overall Page 166 of 282

167 Challenges in General Practice 19 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 19 of 43 Overall Page 167 of 282

168 What does primary care need? Workforce issues addressed Workload challenges addressed Sustainability created: Morale Estates IM&T Financial GPFV implemented 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 20 of 43 Overall Page 168 of 282

169 21 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 21 of 43 Overall Page 169 of 282

170 Collective Accountability The overall responsibilities of the Programme Board is to guide achievement of the differing elements of Primary Care workforce sustainability, provide strategic leadership and supervise delivery of the programmes through the CEPNs in a collaborative and coordinated way. Ensure that each programme related to Primary Care workforce sustainability within regional bodies is not duplicating. 22 LPN SHEDK SWAHSN HEESW University of Exeter Devon LMC NHS England Cornwall LMC Primary care workforce sustainability Programme Board University of Plymouth Somerset LMC NEW Devon CCG SCN SD&T CCG Somerset CCG Kernow CCG SPH Vocare Practice Action learning sets CEPNs IPC regional workforce group 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Nursing page Workforce number Community of Practice Page 22 of 43 Overall Page 170 of 282

171 23 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 23 of 43 Overall Page 171 of 282

172 10 high impact actions 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf 24 Page 24 of 43 Overall Page 172 of 282

173 What does this mean for patients Social Prescribing Care navigation Minor ailment scheme Redirection Open Access Services e.g. physio Additional GP/nurse capacity Locality MDTs Community Clinics See the GP Consider Self Care nhs.uk Patient Activation for LTCS Apps and wearables 111 Online and 111 Hubs New Consult Models Phone triage and care Advanced Nurse Practitioner Physician Associate Online triage and care Clinical Pharmacist Mental Health Therapist Attend A&E Specialist support Enhanced Advice and Guidance / Consult 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf #GPforwardview Page 25 of 43 Overall Page 173 of 282

174 26 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 26 of 43 Overall Page 174 of 282

175 27 Benefits of working at scale GPs and practice staff have a more manageable and rewarding workload Access to a broader, more in-depth range of services True multidisciplinary working that reduces handoffs to and from general practice Wider development opportunities for GPs and other staff that enable greater job satisfaction, the ability to support students and more effective peer support and mentoring Potential to increase recruitment and improve retention for general practice Better patient outcomes through pooling of clinical expertise, offering a greater range of generalist and specialist services Better value through economies of scale in administrative and business functions 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 27 of 43 Overall Page 175 of 282

176 28 Working at scale does not necessarily have to involve a change in organisational form Practices can come together in networks or federations or as part of a more integrated model of provision There is no right answer to what this should look like Decision about the scale of joint working from loose collaboration to formal merger to an integrated multidisciplinary accountable care system (MCP) will depend on local circumstances No one model will be prescribed Practices may want to bid for contracts to deliver services outside core primary care (e.g. as part of an integrated service for frail and complex patients) - they will need to be part of an effective legal entity in order to hold the contract 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 28 of 43 Overall Page 176 of 282

177 4. Progress with the Strategic Framework 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 29 of 43 Overall Page 177 of 282

178 GPFV (National & Local funding) GPFV & CCG support Commissioning new integrated care models 30 General Practice : Sustainability and Transformation Alleviating current pressures, building resilience & sustainability Identifying ways of working together at scale that make sense locally Developing new models of primary care integrated with health & social care Resources, investment and organisational development support 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 30 of 43 Overall Page 178 of 282

179 Current STP Primary Care Structures 31 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 31 of 43 Overall Page 179 of 282

180 32 Identify new models of integrated care The strategic framework will need to help identify how general practice responds to the STP out of hospital vision - shifting focus of care, and resources, away from a bed-based model Needs to identify also how general practice can work in an integrated way with other community health and care providers, and the voluntary sector Nationally and locally there are moves to accountable care systems based on the total health and care budget for a defined population The MCP model is a key part of the national strategy to deliver the vision of the GPFV Primary care development in Devon will vary according to needs of local communities and different starting points The practical implementation plans for delivering the strategy will be developed in conversation with local primary care providers within the different localities 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 32 of 43 Overall Page 180 of 282

181 33 Outline Investment GPFV national and local funding Commissioners are committed to ensuring that as we develop models of care which will see increased provision within community settings - that such services are appropriately resourced CCGs are committed to reinvesting an appropriate element of released funds as new STP models of care are implemented and the bed base reduced This will enable resources to be freed up to follow the patient, resources that will include clinical staff 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 33 of 43 Overall Page 181 of 282

182 Defined Objectives 2.Address current pressures and create a sustainable primary care sector Evidence of support from the CCGs & NHSE to provide immediate assistance to vulnerable practices Increased staff engagement including reduced burn out STP/CCG/NHS England wide programme to support general practice workforce development & redesign in place & working GPFV funding & deliverables aligned to the STP general practice strategic direction Reduction in vacancies within practices, application rates improved as primary care is seen as a more attractive place to work. Alternative models of provision in place in response to GP vacancies Evidence that general practice working at scale has more resilience and can cope with fewer GPs working more intensively to their expert skill set Primary care multidisciplinary workforce diversified to include increasing numbers of pharmacists, community nurses, therapists and physician associates. Evidence that multidisciplinary and joined up arrangements in place for preregistration training and continuing professional development Primary care premises strategy in place as part of the overall Devon Estates Strategy Services provided outside of core contracts are resourced appropriately. Improvement in integrated IT systems across practices that support collaboration Aligned clinical and financial incentives with appropriately shared risks and rewards Page 34 of 43 page number 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf 34 Overall Page 182 of 282

183 35 Engaging with Primary Care 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 35 of 43 Overall Page 183 of 282

184 Local engagement 36 Draft framework defines system outcomes Needs to make sense at a local community level Practical implementation plans for delivering the strategy to be developed in conversation with local primary care providers within the different localities South Devon & Torbay are further ahead in their discussions with practices and provider groups than some areas of NEW Devon CCG CCGs are keen to work closely with general practice to co-design a sustainable future for primary care that can make a vibrant, high quality and material contribution to our vision for Devon Three initial GP provider engagement events Feb-April 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 36 of 43 Overall Page 184 of 282

185 Working with the STP Voice being heard Shaping, but not being done to Long term sustainable and stable general practice Need appropriate representation Best quality care for patients in a financial envelope Maximise potential of general practice Leadership from primary care Engaged with Understood and understands Service redesign and strategically Strategic & sub locality 37 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 37 of 43 Overall Page 185 of 282

186 General Practice Offer Adaptable fleet of foot (smaller scale) Aware of the money Take clinical responsibility (for what, how much more?) Local leadership for local populations Better dialogue Focus on mutually beneficial issues Reduce overall pressure Commit time Redesign specialist services Defragmenting the community Represent communities Best manage demand (with the right resources) 38 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 38 of 43 Overall Page 186 of 282

187 Summary Agreement that the framework is a good blueprint and the basis to refine for use for a wider Devon and Locality Collaborative Boards. Agreement that there needs to be a 2 year commitment to funding, based on realistic achievement of outputs each year, backed by a Memorandum of Understanding. The recurrent costs would be picked up by emerging accountable care system. Agreement equal amount of CCG released funding with locally agreed investment of at scale funding will ensure all 4 local Collaborative Boards can function effectively with cross subsidy. Local structures must be effective and this will require a n agreed amount to funded per patient to be invested, though there may be some small amount of variation depending of final structures. Agreement Some of the agreed funding a Local and Wider Devon structure represents a good balance with the much larger element of the funding for project implementation. Agreement This structure focused on representation does not cover the same ground as SHED which is focused on service delivery. Agreement Focus energy and majority of work at local Collaborative Board level. Small group (2 per patch) to meet in development sessions for 3-6 months to determine if a Wider Devon structure is required STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 39 of 43 Overall Page 187 of 282

188 5. Next steps 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 40 of 43 Overall Page 188 of 282

189 41 NEXT STEPS Complete initial engagement with General Practice Present completed Strategic Framework to PDEG Undertake wider stakeholder engagement to evolve General Practice strategy into a full Primary Care Strategy (e.g. Pharmacy / Optometry) Ensure outcomes of strategy are embedded across the system Populate primary care delivery team Implement clinical leadership development programme for primary care Align system primary care groups activities to delivery of framework Ensure regular monitoring and reporting of progress 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf page number Page 41 of 43 Overall Page 189 of 282

190 STP Strategic Framework Summary Identify the challenges and opportunities ahead, and outline the direction of travel for general practice in Devon Agree system and population outcomes that primary care can deliver as part of STP. Sustainability support primary care to develop models of delivery that are financially viable and attract new recruits Transformation - in the face of rising demand and workforce issues redesign services accordingly. Ensure all primary care stakeholder groups are aligned to framework. 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 42 of 43 Overall Page 190 of 282

191 Questions? 1 STP Coll Board Emerging Primary Care Strategy SDTCCGGB May17.pdf Page 43 of 43 Overall Page 191 of 282

192 Overall Page 192 of 282

193 Draft Strategy for General Practice: Foreword The challenges facing general practice across Devon are well articulated. Increasing demand, difficulties in recruitment and retention of practitioners, a demoralised workforce and a historic lack of financial support that includes estates and information technology are all contributing factors. It is acknowledged there are no quick fixes for these issues; however, if we are going to deliver improvements for patients and providers of primary care services, then we need an agreed plan of how this can be achieved. This strategic framework aims to develop such a plan and will be the starting point for engaging with all those involved in general practice. This General Practice strategy which is part of the Primary Care Strategic Framework brings together the enablers that will see the evolution of general practice to meet the challenges. Implementing the General Practice Forward View and delivering the integrated community services transformation will be the cornerstones of out of hospital care. Supporting practices, developing GP leadership and working across key stakeholders will be part of how the Sustainability and Transformation Plan (STP) will facilitate implementation of the framework. NEW Devon CCG and South Devon & Torbay CCG, as part of the STP, aim to use the strategy to engage fully with general practice to transform in the ways that are appropriate for the diverse populations and geographies that we have across Devon. This document focuses on the delivery of general practice. It must be recognised that primary care is serviced by a much more diverse workforce than just those within GP surgeries. Developing integration and involvement of all providers such as pharmacists, optometrists, allied health professionals and the voluntary sector will need to be undertaken alongside this work. Dr Nick Roberts Chief Clinical Officer, South Devon & Torbay CCG Primary Care Lead, Devon Page 1 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 1 of 26 Overall Page 193 of 282

194 Draft Strategy for General Practice: Contents Foreword...1 Introduction...3 Background and general context...4 Local context...4 Demographic change...4 Inequalities...4 Financial pressure...5 Workforce...5 Primary Care Workload...5 Primary Care Workforce...6 Resources...6 Primary Care Quality...6 What is our vision for General Practice?...7 What are our overarching aims for developing primary care?...8 Positioning to proactively meet the challenges of future development...9 Access and seven-day-a-week delivery...10 Collaboration...12 Workforce...13 Education and leadership development...14 Premises...15 Unplanned care...16 Funding flows...17 Quality...18 Prescribing and Medicines Optimisation...19 Patient and public participation...19 Self-care...20 Voluntary and third sector...20 Information management and technology infrastructure...21 Stakeholders and professional representation...22 Page 2 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 2 of 26 Overall Page 194 of 282

195 Draft Strategy for General Practice: Conclusion...22 Introduction Primary care continues to be the foundation on which healthcare has been provided since the inception of the NHS in We know that high-quality primary and community services is the key that unlocks the potential for preventative, proactive management of patients, reducing the need for acute and bed-based care, and addressing many of the health inequalities that exist across our population. In short: if primary care fails, we all fail. However, there are significant challenges being faced by primary care and General Practice in particular. The growing workload and need to manage increasing numbers of patients with multiple and complex health needs, coupled with the uncertainty of future workforce, means we need to radically rethink the model of General Practice if we are to make it sustainable beyond the current decade. This strategy sets out our vision for General Practice and describes we will support and enable practices to obtain the necessary skills, workforce and infrastructure to deliver an efficient, resilient and sustainable service for our population. This strategy is part of our transformational vision for out of hospital services, by shifting the focus (and resourcing) of care away from a bed-based model. Instead, we will seek to commission integrated pathways of care that are firmly rooted in primary and community services. We also expect to see an increase in our responsibility for holding our member practices to account in terms of the quality of locally provided General Practice. This strategy sets out how we plan to strengthen our mechanisms for measuring quality and supporting development within practices including, where appropriate, accountable care systems and localities. It is important to clearly explain what we expect of ourselves and our provider partners in terms of this strategy. It is difficult, and perhaps not helpful, to capture our strategic vision in a single statement, but we can say that we intend to commission locally defined and outcome-based care, rather than nationally prescribed and process focussed services. In 1996 the Institute of Medicine offered the following definition for primary care: Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Page 3 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 3 of 26 Overall Page 195 of 282

196 Draft Strategy for General Practice: Though now 21 years old, the message remains highly relevant to the stated intentions and aspirations for easily accessed and integrated pathways that place great emphasis on provision occurring as close to the patient as is possible and in a manner that empowers them. Page 4 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 4 of 26 Overall Page 196 of 282

197 Draft Strategy for General Practice: Background and general context There are many current and future challenges, but General Practice continues to be one of the cornerstones of NHS provision. It manages a huge workload which continues to grow, with more than 300 million attendees seen and treated, or otherwise managed, by General Practice teams each year. General Practice continues to be recognised as one of the most cost-effective means, anywhere in the world, of delivering high-quality care, as identified by the Commonwealth Fund. Primary care offers direct and prompt entry into the healthcare system and continues to account for approximately 90 percent of all patient contacts. Demands on General Practice have never been greater, with particular challenges resulting from the growth in numbers and complexity of co-morbidities, an ageing population, rising patient expectations in a world where consumer perspective changes rapidly and, when expressed as a percentage of total health-based spend, a declining financial resource. In the UK, the number of people with multiple long-term conditions remains on trajectory to rise by approximately 50 percent between 2008 and The majority of challenges to meeting these patient demands exist already, but without carefully planned and proactive action these are expected to become more acute in the short and mid-term. These would include workforce morale, recruitment and retention, challenging public sector finances and associated need for efficiency savings, changing delivery models within other providers and related sectors, broadening range of treatments, therapies and technologies, and enabling systems reform. Local context Demographic change The population of Devon is growing rapidly with an increasingly high proportion of elderly people with higher co-morbidities and increasingly complex care requirements leading to greater use of all NHS services. People in Devon are living longer, with increasingly more complex care needs that require more support The number of very elderly people is high, with 3.1% people in Devon over the age of 85 compared to 2.3% on average across England. The greatest growth is expected in the number of people aged 85 or older the most intensive users of health and social care. Inequalities Although Devon is generally affluent, it has deprived areas and there are quite big differences in health outcomes or health inequalities between some of these areas, particularly between Plymouth and the rest of Devon. Page 5 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 5 of 26 Overall Page 197 of 282

198 Draft Strategy for General Practice: There is a difference of 15 years in life expectancy across wider Devon and differences in health outcomes or health inequalities between some areas, particularly Plymouth Spending per person on health and social care differs markedly between the locality areas. Over 10% less per year is spent on each person in west Devon compared to east Devon even after age and deprivation have been taken into account. Financial pressure Local health and social care services are under severe financial pressure, and are likely to be 442m in the red by 2020/21 if nothing changes Doing nothing is neither affordable nor clinically sustainable. The cost of providing health and social care is increasing due to demand from the increasing ill health of local people and the costs associated with keeping pace with new technology. Funding for health and social care is limited, as it is across England Pressures are growing on the prescribing budget through the cost of existing and new drugs and increasing co-morbidities. There is significant growth and variation of prescribing costs across Devon Workforce There are high levels of vacancies, turnover and sickness amongst the workforce in Devon. This is a problem because of the costs of recruiting and training new people, and covering vacancies with temporary staff. It is also a problem because of the pressure it puts on other staff to fill gaps and train new staff members Almost a quarter of GPs in Devon intend to leave the NHS in the next 5 years. (HSCIC General and Personal Medical Services, England , South West AHSN analysis, 2015). There are higher GP vacancy rates in Plymouth than elsewhere in Devon (currently a shortfall of 30 GPs) There are high vacancy rates for registered nurses in the community with 10% of posts vacant Many other staff are due to retire in the next 10 years. The workforce in Devon is getting older which is a problem because the NHS and social care lose trained and experienced workers when people retire. For example, 1 in 3 GPs (HSCIC General and Personal Medical Services, England ) and 2 out of 5 nurses in practices, the community, mental health and social care are over the age of 50 (Success Regime Trust data returns, Carnall Farrar analysis, 2015). Primary Care Workload Workload in primary care is high and in many areas becoming unmanageable, especially as the impact of the aging population bites and demand increases. There are increasing expectations of the role primary care has to play in supporting accessible and appropriate urgent care, including 7 day services, out of hours services Page 6 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 6 of 26 Overall Page 198 of 282

199 Draft Strategy for General Practice: and in working with other local partners to meet urgent care demand in the most appropriate setting. There is a sense that primary care is expected to do more but the money for doing so does not always follow the patient. Current workload pressures inhibit the capacity for practices to think creatively about change. A mechanism is required to break this cycle. Primary Care Workforce Overall Devon has not experienced the same level of difficulty in maintaining GP numbers as other areas of the country with recruitment & retention levels sitting above the national average. However, the number of vacancies for GP posts across Devon is increasing and the concomitant workforce pressures are set to increase. The Plymouth area is already experiencing practice resilience issues resulting from a drop in GP numbers (with currently 30 GP vacancies). The older age profile of GPs will see a peak in retirements over the next 5-10 years, which is not being matched by the rate of recruitment. Almost a quarter of local GPs in Devon plan to leave the NHS in 5 years (HSCIC General and Personal Medical Services, England , South West AHSN analysis, 2015). A gradual increase in the proportion of GPs working part time is also creating longerterm sustainability pressures Within the wider general practice workforce there has been only a marginal increase in the number of practice nurses. Some smaller practices are not sustainable from a workforce perspective and need a different model of workforce design Resources A significant proportion of primary care estate is not fit for purpose or is in need of modernisation. Practices lack support and headroom for change there is variable and limited capacity in general practice to improve sustainability and enable system wide developments without support High demand and lack of capacity does not enable the voice of general practice to influence strategic change Primary Care Quality Overall the quality of primary care in Devon is of a very high standard Overall general practices in Devon deliver high quality outcomes and score well for patient experience and patient satisfaction indicators when compared to the England average e.g 90% of people were successful in getting an appointment when they wanted it (compared to 85% nationally), 95% were satisfied with the convenience of an appointment (compared to 92% nationally, July 2016 figures). Of the CQC inspections undertaken in Devon to date all practices, bar just 1, were rated either good or outstanding. Page 7 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 7 of 26 Overall Page 199 of 282

200 Draft Strategy for General Practice: However there are a few quality outcome indicators where overall practices in NEW Devon and South Devon & Torbay perform less well than the England average e.g. for flu vaccinations for at risk patients (45.91 & vs England average of 51.17) and depression assessment rates (84.42 & vs England average of 88.95). (NHS England Quarterly General Practice Outcome Standards). There is also variation in quality outcomes between practices with a few practices in NEW Devon performing less well than the England average with 6 or more outlier indicators, outcomes unlikely to be due just to chance. There is also high variation at practice level for elective care (77% between top and bottom decile). What is our vision for General Practice? Our vision is of course presented as that of a commissioner, and specifically as a commissioner of services provided by General Practice. We hope though that this document and the implementation plans, which either align to it or develop as a result of it, are owned not only by the CCGs, but by local General Practice. In addition, we hope that it resonates with the professional representatives of General Practice as well as complementary providers within the local health and social care system. We are very much of the opinion that high-quality General Practice will continue to be the foundation from which we will ensure provision of the best possible healthcare for the population of Devon. In order to achieve this we will need to increase, and also optimise Page 8 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 8 of 26 Overall Page 200 of 282

201 Draft Strategy for General Practice: capacity and capability within primary and community services, such that we continue to increase our focus on delivering preventative and proactive care models, particularly for those identified as being at greater risk of poor health within our population. The vision we propose is for consistent, high-quality and sustainable models of primary care, one in which primary care teams are and feel supported and valued in their role. This is not based around the assumption that care is delivered by a GP, or indeed by a member of the General Practice team rather that care is provided by the person best able to meet the needs of the individual. However, we do see GPs as being very much at the centre of patients care, coordinating and overseeing other clinicians and healthcare providers, as well as providing care directly to patients. We are pleased to highlight the necessary strong alignment here to the Five Year Forward View and General Practice Forward View. Partnership with patients, as well as fellow clinicians, to optimise health and wellbeing will continue to be important, as will pro-active identification and subsequent management of illness, and in particular long-term conditions. Currently, local teams generally deliver high-quality General Practice, and we intend to take advantage of greater influence in terms of the commissioning of primary care to increase the suitability of commissioned services to local communities and populations. This will allow us to vary some specifications, as the focus shifts away from compliance with delivery model and towards outcome-based patient-centred care models. The new care model will always be mindful of the local variations in terms of need, demography, geography and other identified factors. Thus the term local community may be applicable at CCG, accountable care system, locality or practice level depending on the specific nature of the situation and service under consideration. We do not though see the CCGs as commissioners being the only drivers of change. We wish to support, as far as we are able, innovative approaches developed by practice and localities which propose better and sustainable ways of meeting the health needs of their populations. This should not be limited to services and specifications, but should encompass provision at its broadest interpretation, including working with unconventional partners, where appropriate, and taking different approaches to infrastructure development. What are our overarching aims for developing primary care? As made clear within the preceding section, we do not consider that any contractor group within the primary care sector should be commissioned or developed in isolation to the broader health and social care system. Page 9 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 9 of 26 Overall Page 201 of 282

202 Draft Strategy for General Practice: Rather, we will pursue an approach to development that is grounded in genuine multi- agency team approaches. Though the model will vary, principally as a result of variations in factors such as population specific needs and geography, this will increasingly see us realise the benefits of models operating at scale. While in some cases this might result in a reduced number of GP sites and/or fewer contractor entities, we aspire to models that physically bring together as many of those provider groups involved in providing care to the communities they serve as is possible. We see this as being the most effective way of providing holistic and GP-led care to patients, by optimising combined capacities and capabilities, while reducing the need for handoffs as patients needs are more appropriately managed by bringing services together. This model will also increase the likelihood of localising elements of care that is traditionally provided in hospital settings. We would expect these to include things such as a wider range of diagnostic tests and locally accessed specialist opinion. However, it is important to make clear that while we do not have a pre-determined outcome in terms of the changes we envisage, we believe the pace of change will be considerable. We are clear about the need to be proactive, and to support the development of alternatives that increase the resilience and sustainability of local healthcare provision. We firmly believe that, wherever possible, change should occur as a result of planned process rather than crisis management. Positioning to proactively meet the challenges of future development This document takes into consideration current and anticipated changes in the needs and behaviours of our existing population, including General Practice. A key thrust in achieving this will be ensuring locally available and accessible services are in place such that wherever possible and practicable care can be delivered within communities rather than from more remote centres. Therefore it will be important that when either planning service model changes or taking advantage of opportunities that arise, we consider carefully local development plans that will either create or relocate centres of population. This will extensively impact on estate and workforce capacity planning, particularly in understanding the scale and nature of the development and assessing how service delivery models might need to be appropriately tailored. As well as providing challenges, such developments will provide opportunities to work with Page 10 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 10 of 26 Overall Page 202 of 282

203 Draft Strategy for General Practice: local planners and developers to establish communities that from a health and social care perspective are self-resilient. We will therefore seek to engage at as early a stage on planning as is possible and influence the nature of development, with a particular focus on ensuring the adequacy of health-related infrastructure. Access and seven-day-a-week delivery The overall local position continues to compare favourably against the national picture, but we know from patient satisfaction surveys that there continues to be variation in patients abilities to access General Practice. We will work with local providers to identify and develop solutions that allow patients to access care through alternative means where clinically appropriate, including via community pharmacists, the voluntary sector and by using technological solutions. This might also include patients seeing members of the General Practice team in settings other than their registered practice, or by seeing other professionals involved in their care within GP premises. Local engagement that is undertaken to develop our Urgent Care Strategy shows how patients increasingly expect General Practice to be a key local offering in terms of accessing the healthcare system to meet their unplanned or urgent needs. We are clear that meeting expectations in terms of responding promptly, extending the working day and taking a 7-day approach are likely to require a different model of primary care than is currently in place. We Page 11 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 11 of 26 Overall Page 203 of 282

204 Draft Strategy for General Practice: will support provider development of alternative care models, including those structured on greater integration with associated health and social care teams, and develop our commissioning approaches accordingly. In developing or varying our approach to 7-day access to General Practitioners specifically, we will be guided by evidenced local need, where possible at locality level, to ensure that there are solutions to actual patient requirements, as well as offering the best use of available resource, in terms of finances and available workforce. It is clear from work undertaken by local Healthwatch teams that there is some concern among people locally about the difficulty in accessing General Practice, and it seems that this view varies across the area, which requires better understanding. This applies not simply to availability of face-to-face time with a clinician, but also to the process of accessing General Practice provided services. As understanding develops, this will inform work to try to ensure that local delivery is well aligned to local need, and it builds on established good practice. We fully accept that reasoned variation of models of care provision may exist, being dependent on factors such as geography and demographics. We are aware that the current model of provision includes 7-day and 24-hour (24/7) access to General Practice when bringing together in-hours mainstream surgery-based provision and that provided by the out-of-hours GP service. The out-of-hours service provides care where a level of need is identified that is most appropriately met by primary care, but which cannot wait until mainstream General Practice is next available. As we seek to extend or otherwise adapt the General Practice/primary care offering such that a wider range of patient needs can be met locally, we will be careful to take a whole system approach by making such changes in conjunction with both in and out of hours providers. While recognising that an appropriate 24/7 model of General Practice will not need to be based on absolute consistency at all times, rather than continuing to work along in hours / out of hours lines, we intend to commission with greater focus on patient needs and expectations. This will result in a more integrated approach more akin to ensuring the adequacy of all hours provision. It is quite probable that changes sought will be met in different ways in different communities and involvement in design including all current providers of GP services, as well as associated service providers, will be key. Indeed we believe local providers and local communities are best placed to determine and define what 7 day provision means based on locally identified need rather than nationally prescribed models, being mindful of available workforce resource and the importance of not simply diluting Monday to Friday provision. Therefore we will work to maximise the opportunities available to allow a flexible Page 12 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 12 of 26 Overall Page 204 of 282

205 Draft Strategy for General Practice: approach to be taken that is both realistic and achievable. In recognition of the nature of the current out of hours specification and its focus on meeting peoples more urgent needs, it will be vital that alignment of intentions with the urgent care strategy and associated implementation programmes is embedded as part of our primary care commissioning and contracting processes. In this regard we will in collaboration with urgent care partners establish challenging but achievable measures for improvement within primary care that provide assurance of contribution to provision of a robust and responsive system. This is likely to result in consideration of models that bring together the component part of the urgent care system, particularly where injury, accident or emergency services are provided. We would expect to see the development of primary and acute care models, either bringing providers closer together or operating fully integrated urgent care models providing a wide range of services. Collaboration We know from the work undertaken so far within our localities that there is considerable appetite for increased collaboration between practices, as well as with associated health and social care providers, the voluntary and third sectors, and of course patient populations. We want to support the continuance of this, so that the opportunities for innovating and sharing learning are fully grasped. Various organisations including NHS England, Royal College of General Practitioners, General Practitioners Committee and The King s Fund have spoken about a broadly aligned direction for General Practice, and we will continue to support our member practices by having discussions about a broad range of models of collaborative working that will help to develop a sustainable and patient-focussed future for General Practice. This is not grounded in the belief that a specific model is preferred locally. Rather, we believe that there must be adequate flexibility to enable ground-up development to deliver models best able to achieve the outcomes which are sought. We will develop productive engagement and encourage innovation and inclusivity among our practices, commissioning in ways that support and enable this, where appropriate. This is likely to include encouraging flexibility of provider configuration by commissioning some services on a community or wider basis, enabling General Practice to develop alternative Page 13 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 13 of 26 Overall Page 205 of 282

206 Draft Strategy for General Practice: provider entities that present opportunities to contract for and deliver care differently for example, not always requiring practice-specific arrangements. Such re-configuration, or comparable modification to ways of working, will typically occur within discrete populations and communities. We will not place artificial restrictions on the pursuit of innovative approaches, and will encourage and support those who are likeminded or who have a shared interest in effecting change irrespective of apparent boundaries. This will include collaboration extending beyond the boundaries of the CCG or other structures, wherever benefit to our population is likely to result. In saying this, we are aware that list-based care will often provide the best way of ensuring a holistic and coordinated approach to patient wellbeing is achieved. But as collaboration develops and is supported by positive enabling changes, such as technology, we envisage alternatives being considered more often than is currently the case. We have piloted collaborative models of care for frail patients. Care has been provided by clusters of GP practices supported by and working closely with a multi- disciplinary team. Learning from this pilot and other models of collaboration currently delivered in the area and neighbouring areas will be used to inform the future model of collaboration within but also extending beyond General Practice. Our acute and community provider partners will work with primary care providers to develop more holistic, patient-centred care with a strong preventative focus and closer working between established secondary care specialties and the community. This will of course require working far more closely with GPs and their teams. It is, and will remain, important that GPs are actively engaged in proposing, developing and refining care model changes that extend beyond the traditional parameters of General Practice or primary care, to enable effective management in an increase in the care delivered closer to where people live. The new care model will reduce the approach of repeated and specialised opinion to one better equipped to deliver patient-centric generalist care within communities, being better aligned to the increasingly complex patient-level needs previously described. We expect that this cross-system multiagency collaboration will be most visible at the point of care delivery, but enabled by organisational commitment to joint working that provides an environment in which it is the default for deliverers of care to optimise combined skills and capacity. This commitment will stretch itself from strategic-system-level planning to patientspecific contacts. Workforce To take forward this Strategy, it is essential that we have access to a primary care Page 14 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 14 of 26 Overall Page 206 of 282

207 Draft Strategy for General Practice: workforce, both clinical and non-clinical, that possesses a broad range of well-honed skills suitable for meeting current and projected patient needs. Workforce is of course an area where we must seek opportunities to influence and work with others. In doing so, we need to consider national-level influencers that will guide the thinking of us and our partners. At the time of writing, the In-Depth Review (published by the Centre for Workforce Intelligence) and The Future of Primary Care Creating teams for tomorrow (Primary Care Workforce Commission), are at the fore, and key themes are reflected in sections of this strategy, dealing with workforce and also models of care. We will continue to work closely with partners, including the Academic Health Science Network, both Exeter and Plymouth Medical Schools and Devon Community Education Provider Network, to take forward emerging action plans drawn up in response to our improving understanding of anticipated workforce needs and also barriers to commencing a career within primary care settings. This will include actions to address career attractiveness, recruitment to and retention within associated professions, and the offering of opportunities that vary from the traditional models. Our aspiration will be to first stabilise then future-proof work force, and this will require embracing new and different roles and associated qualifications, including but not being limited to associate physicians, revised nursing roles and varying the application of pharmacists skillsets. Application of these roles is covered in more detail within sections of this paper, focussing on delivery and associated models of provision. We will, within available financial resource, appropriately support training, re-training and qualification-based programmes that enable optimisation of the workforce and help people in realising their aspirations. To ensure careers within primary care, whether in isolation or as part of a portfolio, are appealing we know that we need models of care that at an individual clinician level are of acceptable intensity and operating within reasonable parameters. We will continue to work with our patients, members of the public, member practices and commissioning teams to identify those services that could be provided closer to home. We will then ensure that consideration is given to ensuring that appropriate resources (including workforce) follows the patient when services move to primary care settings. Education and leadership development We recognise that supporting development of our General Practice and broader primary care workforce to deliver high-quality care, particularly in an environment requiring the implementation of new ways of working, is underpinned by access to high-quality training Page 15 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 15 of 26 Overall Page 207 of 282

208 Draft Strategy for General Practice: and education and the need to establish and maintain a truly multi-professional workforce. This is important not only for General Practice and services traditionally delivered by GP teams, but also to ensure development and maintenance of a coherent system wide workforce. We will demonstrate a commitment to training and development and, where appropriate, will look to share resources to maximise training and learning opportunities across and within the full health and social care family. In doing so we will seek to ensure education and training is matched to the identified and anticipated needs of the local population, recognising that General Practice has, and will continue to have, an increasing role in providing, arranging and directing care for complex patients. During the past year there has rightly been increased emphasis on the value and importance of effective and local clinical leadership. We remain committed to supporting those leading design, development and implementation, whether at practice, locality or wider system level. We will continue to seek to enable up skilling of such people, as well as supporting effective successor planning to ensure forward momentum is maintained. Premises We work very closely with the NHS England team and have a joint responsibility for General Practice premises, but its development, in line with our fullest aspirations, will remain challenging given the material nature of recurrent costs to commissioners that are generally involved where premise development is concerned. Therefore, our focus is expected to be on identifying and supporting opportunities that bring providers together in a manner that supports the development of new ways of working as previously articulated, as well as enabling optimisation of total available premises and/or associated funding. We recognise that we do have a responsibility to work with and support General Practice in identifying areas of concern, as well as opportunities to improve. We will continue to work with the NHS England Area Team to agree a process of prioritisation for practices that need new premises or improvement grants to enhance those they already occupy, and to support practices in positioning themselves to take advantage of opportunities that arise, such as current and future iterations of the Estates, Technology and Transformation Fund. As the models of delivery vary we will increasingly be mindful of the opportunities afforded by considering greater co-location of services, the sharing of premises, and joint development projects. In particular we expect national and local opportunities to increasingly require communitylevel focus on enabling a broader range of out-of-hospital services. We recognise that in Page 16 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 16 of 26 Overall Page 208 of 282

209 Draft Strategy for General Practice: many cases delivery of standalone General Practice is made harder by inadequate premises, but it will become increasingly rare and, generally speaking, less appealing to achieve solutions that focus solely on established General Practice. Premises and associated infrastructure will vary in its form, reflecting a range of impacting factors such as community-level capacity and balancing economies of scale with proximity to patients. To ensure that premises and associated model development are not overly skewed towards existing arrangements, we are developing a Strategic Estate Plan (SEP). This will be used to benchmark, develop and assess practice-specific and community plans. Though we will not be bound rigidly to it, we will increasingly use it as a reference point to ensure changes to our premise landscape move us towards, rather than away from, that deemed by nationally determined best practice to be optimal for our populations. The scope of the SEP will be wide-ranging in line with our desire to view the system in broad rather than narrow terms. Unplanned care Primary care, and in particular General practice, is pivotal in the delivery of urgent and unplanned care, with approximately 95 percent of unplanned care episodes being delivered within in and out-of-hours GP-led settings. Urgent care is provided by a wide range of services and providers, including A&E, ambulance service, minor injury units, General Practice (both in and out of hours) and NHS 111. Our focus over the next year to two years will be to better support patients and the public to make the right choices in accessing urgent care services, for example, we will continue to develop and implement our local communications and awareness plan, building on the work already undertaken. A high proportion of patient contacts occur within General Practice so we will continue to undertake co-ordinated campaigns and awareness. Such information will be as clear and concise as is possible, including being available in all means and forms appropriate to the circumstances. We will also seek to maximise the opportunities provided by technology to improve information-sharing between professionals about patients operating across all care settings. This will take the form most suitable to the specific situation being mindful of start point in terms of existing systems, but may include single record, shared access, interoperability or shared system. Ultimately, our ambition is to ensure the right information is available in the right format and at the right time to the right person. It will often be the clinicians responsible Page 17 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 17 of 26 Overall Page 209 of 282

210 Draft Strategy for General Practice: for the provision of care, but will also include patients and, where appropriate, other groups such as carers. In line with established strategic and operational plans, we will seek to shift the focus of unplanned care away from hospital-based services to those within community settings, including those provided or coordinated by General Practice. This will require increased capacity and capability being available to General Practice, achieved by workforce expansion and realignment, so that the unplanned care system is better placed to focus on preventative and proactive care, particularly for the most frail and vulnerable within our communities. The current network of out-of-hospital care remains typically more fragmented and less well aligned than we would like, often with barriers between GP practices and the large range of other services that are currently available to support people outside of traditional hospital settings. These include community health services, mental health services, social care, and the community in general and voluntary sector. The system is not yet adequately positioned to coordinate care as effectively as it might, particularly for people with multiple or complex needs. There remain some gaps in the system, and duplication (such as multiple assessments) sometimes occurs as patients are referred between services that do not always allow for a positive patient experience, or are not the most effective use of available resource. The current system of care means that, on occasion, patients end up in hospital because the right service is not available at the right time in the community. Our vision, and that of our partners, is for General Practice to be part of a network of integrated care that better links General Practice to the wider health and social care support services, building on work already undertaken in this regard, principally at locality level. Typically at locality level, primary care teams have changed the way they work, as individual entities, with each other, and with other providers to improve pro-active care and support to some of the more vulnerable members of our population. We want to build on this work and better enable practices to work together and with other providers of care to develop integrated services to provide support in a better way with less organisational barriers. Funding flows We recognise that too often in a complex landscape where providers seek to do the right thing funding associated with care has not always followed the patient. Page 18 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 18 of 26 Overall Page 210 of 282

211 Draft Strategy for General Practice: This will become no easier to achieve in a climate of growing demands and expectations during a period of extended constraints on public sector funding. Nonetheless, we are committed to ensuring that as we pursue models of care which will see increased provision occurring within community settings, these are appropriately and adequately resourced. It is expected that this will require resource transfer of budget and personnel, as well as challenging decisions about decommissioning of services to fund emerging or changing priorities. Within General Practice, and during the life of this strategy, there will be a prescribed alignment of funding associated with delivery of core contracts. We are committed to reinvesting any released funding resulting from this exercise within General Practice, to fund new or revised services and, where appropriate and in agreement with General Practice, to fund transitional costs associated directly with changes to the practice model. Taking a broader perspective in terms of general financial allocations, we are committed to making best possible use of the available resource, and we would not wish to place any restriction on potential review and realignment of budgets. Indeed, we expect to press for and take advantage of changes to funding mechanisms and payment systems, which we hope will support the required new delivery models to achieve improved outcomes for populations. This will likely require a move away from activity driven provider specific pricing towards capitation models that will support and enable more holistic delivery. Logically, therefore, not only will commissioner-side design and payment methodologies change, but so will the nature of relationships between providers, in terms of delivery and business planning. This will take varying forms, ranging from closer collaboration to formal integration. Quality We are supporting GP practices to improve quality of patient care and in working to reduce variation. This will extend to holding a degree of contractual responsibility as we pursue our intention to move to delegated commissioning of primary care. Quality and safety is a responsibility of all healthcare organisations, whether commissioner or provider in nature. We view quality as comprising the following components: clinical effectiveness, patient experience and patient safety. We will be open and transparent about the quality of primary care in the area and, where appropriate, will publish robust and reliable quality-focussed information. We will work with commissioning and assuring partners to triangulate where appropriate to Page 19 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 19 of 26 Overall Page 211 of 282

212 Draft Strategy for General Practice: do so, and would expect this to include NHS England, the Care Quality Commission and Local Authorities. Much work has been undertaken to establish highly useable quality-focussed tools that identify actual, emerging and possible areas of concern, so that remedial action can be taken on a proactive basis. We intend to explore how best to extend this to include General Practice. It is probable that our approach will be incremental, seeking to use existing and established tools to identify apparent issues, which we will then prioritise before exploring more fully to ensure completeness of understanding. We will look to engage with contractors as part of the ensuring completeness of understanding, including involvement of contractor professional representatives where that is either agreed between us or felt by either party to be required. Though we do not and will not take on full responsibility for all aspects of contractor performance, we will where necessary seek to agree approaches with contractors to achieve the required remedial actions where the need is identified through robust assessment of performance. This will include, but won t be restricted to, review of Care Quality Commission (CQC) evaluations. Prescribing and Medicines Optimisation Our overarching aim is to ensure high-quality and safe prescribing in primary care that takes into account national and local guidance. The strategy for medicines optimisation includes using medicines management resources to support GP practices in improving diagnosis, addressing unmet pharmaceutical need, reducing unsafe prescribing and improving patients use of medicines. To this end, practices will continue to receive regular feedback on their prescribing, enabling benchmarking and agreement of key work areas and, where applicable, associated success measurement. Where clinically appropriate and safe, we envisage a transfer in patient management and associated prescribing from secondary care settings to those closer to the patient. These will be reviewed carefully prior to pathway revision and will, where appropriate, result in funding transfer that reflects the nature and complexity of the work undertaken. Within primary care we recognise and intend to continue to use the opportunities provided by enhancing the roles of pharmacists and medicine optimisation teams, wherever appropriate driving greater integration between these roles and General Practice. Specifically, we intend to continue to invest in medicines optimisation to ensure that the right patients get the right choice of medicine, provided to them at the right time. By increasingly Page 20 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 20 of 26 Overall Page 212 of 282

213 Draft Strategy for General Practice: focusing on patients and their experiences, our goal is to help patients to improve their outcomes, principally through taking their medicines correctly, avoiding taking unnecessary medicines and improving medicines safety. Ultimately, effective medicines optimisation will assist us in ensuring that patients have appropriate ownership of their condition and their treatment. Patient and public participation Patient Participation Groups (PPGs) are based within local GP practices and provide a mechanism for those using NHS services to engage not only with their GP practice but also to feedback on wider issues around health and wellbeing across the local healthcare system. We have established ways for PPGs to come together in forums to share ideas and support each other, as well as influence their locality commissioning group and the CCG as a whole. To make this as effective as possible, face-to-face meetings between practices and their PPGs are recommended. All patients will have access to a mechanism for feeding back about their practice as they do for all other commissioned services and a conduit for feeding back on services and associated redesign plans. We aim to work with partners, including Healthwatch, to support robust and effective PPGs in all practices. The patient experience and engagement leads have a remit to work with commissioners to ensure feedback and intelligence from PPGs in our area influence our commissioning priorities and processes. Local Healthwatch organisations are also active in this area and are committed to establishing innovative ways of enabling and analysing patient feedback that will encourage patient and public feedback, as well as help us to learn from trends or patterns far more easily. We will also work with organisations to better engage with people we don t often manage to talk to direct. The community and voluntary sector is another vital part of that way of helping us to understand as wide a range of views and experience as possible. We will seek to actively engage with local communities to ensure that commissioning plans and decisions represent and seek to address actual local views and needs. Similarly we will, where appropriate, consult on specific proposals and intentions, demonstrating alignment to what our populations have told us, and offering the opportunity for enhanced understanding of and further influence to the care we put in place on their behalf. Self-care Developing truly effective preventative approaches means helping people take more control of their own health, improving their life experience and reducing the need for reactive Page 21 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 21 of 26 Overall Page 213 of 282

214 Draft Strategy for General Practice: intervention by healthcare professionals in future periods. We will empower patients who are willing and able to self-care with support and information. We will also strive to reach those most vulnerable in our population and work with them to improve their health. We want to enable self-care so that patients take greater control over their health and wellbeing, while being able to readily access the right services conveniently located when they need them, and this will be a cornerstone of developing a healthcare system that is sustainable as a result of using our available resources in an optimal way that adequately and appropriately supports a population in which a growing number of people have complex healthcare needs. To achieve this we will make available to GPs a wider range of easily accessed and readily available alternatives to GP provided care. This will have GPs at the heart of the care model, but they will not be responsible for the delivery of each patient interaction. These alternatives for delivering each patient interaction will include other healthcare professionals, whose voluntary provision will be supported by onsite and remotely available information systems. Delivery will, naturally, though not exclusively, be most effectively delivered where multiagency teams are co-located or otherwise in close proximity. Voluntary and third sector Much work has been undertaken locally in recent years to bring together statutory and voluntary entities, and to better align effort such that we complement rather than duplicate, all in pursuit of optimising our combined efforts to assist and support members of our communities. We will seek to continue the development of these working relationships between primary care (and also the wider health and social care system), and the third sector as we recognise still more can be achieved as a result. This will include exploring how we could better work with our third sector partners to support delivery of primary care provision, particularly where patient expectation extends beyond that which we are able to meet through traditional means. This will be grounded in learning from past experience and pilots. It will remain important to understand the difference between entirely voluntary provision and that which is provided by voluntary sector providers as a result of commissioned and contracted activity. As a commissioner we recognise the opportunities and values that both offer to patients as well as the wider health and social care system. We acknowledge though that our planning, reliance and expectations must be different for wholly voluntary provision as opposed to that for which we formally contract. Page 22 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 22 of 26 Overall Page 214 of 282

215 Draft Strategy for General Practice: We will actively engage in forums that brings together members of the third sector, as well as patient participation groups and Healthwatch. We will also seek to further strengthen their input within our commissioning bodies where the value of doing so is identified. In particular we hope to learn from the voluntary and third sector as regards their successes in working with identified communities and groups which for statutory health and social care have been identified as being hard to reach. Information management and technology infrastructure It is recognised that General Practice has the most complete patient record within the health and social care system. We will work with practices to ensure that this continues to be the case and that it is capable of being shared with or accessed by other professionals involved in delivering patient care, as well as patients and their support networks. We know that we can provide a higher standard of care and deliver efficiency benefits to busy professionals by making better use of combined information systems. To support practices in this regard, we will look to work with all providers and their professional bodies to implement record-sharing within robust and auditable governance arrangements, which include giving due attention to patient consent. Where appropriate, this may extend to full access or shared record systems, but might also be restricted to only being able to view clinically justifiable information such as multi-agency care plans. We will particularly support practices to make better use of theirs and others systems where we identify benefit in terms of achieving greater collaboration, developing more innovative ways of working, achieving improved system efficiency, and enhancing the patient experience including better equipping them to self-manage. These changes will take place within the parameters established by the Caldicott principles. As well as using technology to improve efficiency of the healthcare system by enabling provider-to-provider interfaces, we will seek to support change that introduces or extends ways in which patients access the healthcare system and interact with clinicians other than by traditional face-to-face means. This will include the implementing Patient Online which includes things such as patient access to their medical records, ability to book consultations directly, and provision of appropriate and relevant information to better enable self-care. In taking such developments forward, we will seek to ensure pragmatic interpretation and implementation of associated nationally determined initiatives to ensure they act as effective enablers for our population. This would include, but not be limited to, the development of 111 as a broad-base entry portal to the healthcare system. Page 23 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 23 of 26 Overall Page 215 of 282

216 Draft Strategy for General Practice: In addition, we expect to see growth in non-face-to-face contacts with primary care teams, such as telephone, and web enabled consultation. Stakeholders and professional representation In taking forward our vision for General Practice we will of course be aware of the complete health and social care system, and appropriately engage and involve stakeholders, including other providers, commissioners and service-users where appropriate and/or where likelihood of benefit in doing so is identified. We would wish to specifically identify Devon s Local Medical Committee (LMC), which, as the representative of local General Practice, we see as being well placed to contribute to the design of workable solutions, while respecting its need to represent individual contractors, the profession generally, and to formally negotiate with commissioners. Conclusion Primary care, and in particular General Practice, is facing a huge challenge because of the number of demand and supply side pressures. In order to ensure we have a model of care that is sustainable, and which serves the needs of our population into the future, we have set out our vision for consistent and high-quality care that is provided through close partnership with other practices, with patients, and with partner providers. We have described how we will support practices in continuing to deliver high-quality care and in being as well placed as they can be to meet the challenges identified. This will require developing a revised relationship with patients and the public, one where there is a greater focus on prevention and self-care, and where patients can be directed to credible alternative sources of support and advice. We recognise the need for practices to collaborate more formally than has been typical in the past, and we will provide support to make this happen, including investing in IM&T systems, workforce development and premises where return on investment can satisfactorily be demonstrated. We will continue to commission integrated pathways of care that shift the focus of care from a bed-based model to one that is primary and community focussed, and realign funding to enable this to happen. As the commissioning of General Practice transfers from NHS England to the CCGs, we will always explore how the increased flexibility it affords us can be used to support varied ways of working that support our localities in optimising outcomes for their population(s). Page 24 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 24 of 26 Overall Page 216 of 282

217 Draft Strategy for General Practice: Our ambition will no doubt be challenging to deliver, as we do not expect to see material growth in our funding, which is currently full committed. Nonetheless, we believe firmly that this challenge is best met by having a more active leadership role in the commissioning of General Practice. STP Priority Sustainable, high quality primary care Prevention and early intervention Integrated care model Acute and specialist services Mental health and learning disabilities Children and young people services Productivity Draft Strategic Objective for General Practice 1.Build on the strengths and benefits of the general practice model in Devon with its registered populations 2.Address current pressures and create a sustainable primary care sector 3.Enhance patient access to care 4.Promote self-care 5.Ensure that primary care addresses health inequalities for Devon residents 6.Manage and co-ordinate the health of a population by working in partnership with other providers to care for high risk patients with complex needs and increasing multiplemorbidities 7.Provide alternatives to hospital based care (subject to resources following the shift of care from secondary to primary) 8.Improve mental illness prevention & early intervention in primary care 9. Enhance effective collaboration between primary care and other childrens services 10. Contribute to improved cost-effectiveness of the care delivered per head of population Mark Procter Director of Primary Care May 2017 Page 25 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 25 of 26 Overall Page 217 of 282

218 Draft Strategy for General Practice: Version Control Version Date Summary of changes Author and contributors 1.0 May 2017 Initial document Mark Procter, Director of Primary care Footnote In this document, reference to primary care focuses principally on aspects of care delivered by or directly linked to General Practice, and does not include in fullest interpretation community pharmacies, optometrists and general dental practitioners, although we recognise these services as being integral to primary care delivery. This is principally as a result of the nationally prescribed progression leading to NHSE England delegating its commissioning responsibilities to Clinical Commissioning Groups. In the first instance, this delegation is restricted to General Practice provided services. For the avoidance of doubt, General Practice, community pharmacy, community optometrists and dentistry are generally considered when viewed collectively to comprise primary care. Page 26 of 26 devonwide-strategy-for-general-practice draftv1.docx Page 26 of 26 Overall Page 218 of 282

219 COMMISSIONING & FINANCE COMMITTEE MINUTES Date: Tuesday 18 th April Time: Location: MR3, Pomona House Item 1 Introduction & Apologies Apologies and attendance noted (see attendee list below). Action 2 Declarations of Interest Simon Tapley declared that his spouse now works for the ICO. 3 Risk Register There are no new risks to look at and no risks recommended for closure. The recovery plan in place states to achieve 90% by 31/03/2019, which requires reducing demand by 24% over two years and also states that 14 consultant appointments in various specialties are needed before that time. 18 week RTT is likely to deteriorate as choice has been removed to attend Mount Stuart Hospital has been removed. 4 hour A&E performance has increased. Ambulance handover improvement in performance. The medium term financial plan is completed. Neurology waiting times are reducing. 4 Minutes & actions from the previous meeting It was agreed that the minutes of the meeting held on 16 th March 2017 were a true and accurate record with no amendment/s: From the action list, the following updates were noted: Action 189 is completed and action to be closed. Action 190 appendix has been added and DB to discuss attendance at the ICO Finance meeting later this week. Action closed. Action 191 to take effect from May Action 192 ST has spoken with Hugh Groves. Action closed. 5 Finance Update SF took the committee through the performance section of the Finance, Performance and Contracting report. The following points were noted: The CCG achievement against the RTT incomplete standard is 83.7%. Within this achievement the ICO is at 87.8% and R.D& E is at 90.39%. The main specialties causing the back log are T&O, Upper GI, Urology, Respiratory, Cardiology and Pain. The ICO figure for March which has yet to be validated is 87%. There were seventeen 52 week waiters in February from the ICO and sixteen are Upper GI patients. ST confirmed that the Quality Committee is dealing with this issue around 52 week waiters. 1 Ratified CFC Minutes 16th April 2017.pdf Page 1 of 3 Overall Page 219 of 282

220 February cancer targets have been achieved but data is not yet available. There is a risk of deterioration in the two week wait performance due to Dermatology and Breast Care. There is a risk with 62 day waits for Upper GI, Neurology and Colorectal in Q1. At a Risk Assurance meeting at the ICO recently it was noted that 350 two week wait patients had been incorrectly added to PAS due to an administrative error. SF flagged this with the Quality team and has been informed that this issue has been dealt with and there should be no delays in any treatment. There are 111 breaches of the six week standard for diagnostic tests this month. There could be a potential problem with surveillance scopes, as one of the consultants has resigned, which has reduced the endoscopic sessions down to one list per week. A&E performance has been improving with the April performance to date at 95.1%. Performance is ahead of the local trajectory for improvement of 92%. The overall performance for has been 84.0% for ED and 88.9% including MIUs. With regard to Finance the committee was informed that the report contains the provisional year end position that will be presented in our Annual Accounts and submitted to NHS England and our Auditors on 26 th April The year-end deficit position of 4,018m incorporates the CCG s contribution to the risk share forecast overspend and savings from the current Quality Innovation Productivity and Prevention (QIPP) plans and is also NET of the release of 1% headroom as instructed by NHS England. The committee requested that a table confirming delivery against each element of the QIPP programme be added to section 4.6 of the report (Action DB). DB requested formal approval from the committee of the FP&C report for the Governing Body meeting. The report was approved by the committee. DB 6 Commissioning Updates ST highlighted the Operational Response Report. The following points were noted: A pilot has started for a triage of foot and ankle referrals using podiatrists which has only being running for two months but is showing a conversion rate of 10%/ Under the Mental Health section the Psychiatric Liaison bid has been granted for funding in 2018/19 but it will need funding from the CCG from 2019/2020. A number of schemes are progressing to influence planned care demand including how patient choice is offered. Cancer Services two week wait referrals have increased which ST has been assured is due to adopting the new NICE guidelines earlier than NEW Devon CCG. Urgent Care - McCallum ward has been closed and some beds have been re-provided on Forrest ward. Community Service Transformation - There are no longer any in-patients in Dartmouth, Ashburton and Bovey Tracey Hospitals. As of the end of this week there will be no inpatients in Paignton Hospital. The judicial review period will end next Wednesday 26 th April. Social Care investment is still being worked on with local authority colleagues in terms of investment to support health. PB highlighted the Primary Care Prescribing Report to the committee and noted that it is fully expected to deliver the QIPP target as anticipated of 2.5m and a further 1m or 1 Ratified CFC Minutes 16th April 2017.pdf Page 2 of 3 Overall Page 220 of 282

221 so, in terms of achievement. 7 Risk Register - addition of risk flagged during the meeting was the increasing number of 52 week waiters at TSDFT, position forecasting no improvement due to capacity issues in Upper GI. 8 AOB None. Attendees (attended* / apologies A Name - initials Paul Baker (PB)* Nick Ball (NB) A Derek Blackford (DB) * Sharron Cox (SC)* (Minute Taker) John Dowell (JD)* Sian Faulkes (SF)* Siobhan Grady (SG) A Paul Johnson (PJ) David Greenwell Dr (DG) A Brian Mackness (BM)* (Chair) Chris Peach (CP) Mark Procter (MP) A Nick Roberts Dr (NR) A Ellie Rowe Dr (ER)* Simon Tapley (ST)* Jo Turl (JT) A Title, organisation Deputy Director for Primary Care Non-Executive Director (NED) Deputy Chief Finance Officer PA to Chief Finance Officer Chief Finance Officer Head of Performance Deputy Director of Wellbeing & Family Services Commissioning Clinical Chair of South Devon & Torbay CCG Clinical Lead for Integration Non-Executive Director (NED) Non-Executive Director (NED) Director of Corporate Affairs & Medicine Optimisation Chief Clinical Officer Clinical Lead for Commissioning Director of Commissioning & Transformation Deputy Director of Commissioning & Planning In Attendance 1 Ratified CFC Minutes 16th April 2017.pdf Page 3 of 3 Overall Page 221 of 282

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223 COMMISSIONING & FINANCE COMMITTEE MINUTES Date: 16 th March 2017 Time: Location: MR1a & 1b, Pomona House Item 1 Introduction & Apologies Apologies and attendance noted (see attendee list below). Action 2 Declarations of Interest There were no new declarations of interest. 3 Risk Register The committee agreed to close risks 179, 188, 196 and 210. The following risks are currently being monitored: 4 hour performance plan - more assurance to be gained. The bed situation doesn t seem to be having an effect on the 4 hour performance. NB visited the Emergency Department recently and was assured on the safety factor. Ambulance handovers are still a risk but has improved with a new procedure now in place when a patient arrives by ambulance. The South Devon statistics show that more 999 calls are made here than other areas. RTT is continuing to breach. The recovery plan has six different scenarios of how to get back to 92%. Investment is needed to outsource. There have been escalation meetings for neurology and locums and consultants vacancies have now been filled. The 18 week wait is planned to be in place by the summer and the waiting time has been reduced to 20 weeks. Children s and Adults Mental Health Service (CAMHS) - the referrals for children are now seen within 18 weeks in Torbay. The medium term financial plan is now sorted. 4 Minutes & actions from the previous meeting It was agreed that the minutes of the meeting held on 16 th February 2017were a true and accurate record with the following amendment/s: Paragraph 7.1 should read agreed not a green From the action list, the following updates were noted: Action 151 closed. Action 168 closed. Action 169 closed. Action 171 closed. Action 172 closed. DB to arrange a separate session if required. Action 176 closed. Action 178 closed. The planning for the STF for the Trust is clear. Action 179 closed. Included in the standard finance report for this month. Action 180 closed. 2 Ratified CFC Minutes 16th March 2017.pdf Page 1 of 6 Overall Page 223 of 282

224 5 i. ii. iii. iv. Action 181 closed. Action 182 closed. Action 183 closed. Action 185. The outcome of the review is that the EQIA tool was found to be adequate but training and guidance/advice is needed on how to use it. Action closed. Action 186 closed. Action 187 closed. Action 188 closed. Finance Update Finance Performance & Contracting Report: including risks & mitigations DB took the committee through the performance section of the Finance, Performance and Contracting report. The plan was approved by the committee. The following points were noted: The position is the same as reported for the last couple of months. The forecast deficit is 7.97m this is prior to release of 1% headroom. The forecast deficit will be changed to 4m. Financial Recovery Plan & Performance Improvement Plan: progress update including system savings plan Planning: update Approval of recommendation of financial plan to GB A plan was shared with the committee to be presented at the Governing Body (GB) meeting next week for approval, which is the same date for the resubmission plan i.e. 30 th March A discussion was held around the format of the paper for the GB meeting as it will need to be published to the public. A summary of the full paper is recommended to be used by the communication team as this is such a detailed report. BM thanked DB for writing an invaluable report. The committee agreed that this is a deliverable plan but it is non-compliant as the position has deteriorated. ST raised that the recorded underspend at Mount Stuart in section 2, page 3 of the plan should be shown as a greater QIPP saving. DB explained that this doesn t change the impact of the plan. Action - JD & DB to review amending the QIPP saving of 21.9m to 22.5m to allow for the Mount Stuart underspend as proposed by ST and agreed by the committee. NR noted that NHSE have informed the CCG that assurance meetings will be STP based in the future. NR suggested that a section will be needed in the future to report the STP position. JD agreed in principle to add this to the report. DB noted that the position needs to be clear from this organisation how STP is driving the plan forward. Action - JD/DB to include a section about STP but to ensure that it is contextual. ST felt the importance of including a system report and performance report as an appendix. JD/DB have been invited to attend the Trust Finance Committee. NB asked if the invite could include a NED. DB to ask Richard Scott, Trust Secretary when he meets him next week. Action - ST and JD to ensure that the committee were updated on risk share and negotiations each month with effect from May JD/DB JD/DB DB ST/JD 2 Ratified CFC Minutes 16th March 2017.pdf Page 2 of 6 Overall Page 224 of 282

225 6 Break The draft submission presented will be the same plan submitted unless there are any changes between today and 31 st March NB suggested that this draft paper should be discussed as a specific agenda item at next week s GB meeting. The committee approved for the report to be used for the public meeting. 7 i. Commissioning update Commissioning & Transformation update a. Operational Response Report - Right Care update presented by JT. Triage model has been implemented for MSK and consultant operation rates are being worked on. Neurology in STP is progressing well and some initial conclusions have been found in working together across the whole of Devon for the neurology service. Some of the QIPP plans around mental health are progressing well, sex therapy service has now been decommissioned and GP s have been informed of the alternatives that are in place. There will be a mental health strategy update by the end of March. Secondary care drugs overall the financial position is slightly worse but contained within the financial positon for the Trust. Planned care work programme ongoing work with completing the paperwork/documentation and the implementation plans around the elective care systems saving programme. ST updated the group around how the independent sector can be removed from the choose and book (CAB) system. NEW Devon is also looking at this issue with their independent sector. The CAB narrative is to be amended across Devon. Urgent care is doing well in terms of pressing the systems saving plan with five large project areas. A piece of work being undertaken at present will try and turn savings into actual cost. Ambulatory care model has been implemented but admittance is higher as the hours that the unit is open are limited. ST presented an updated paper re Community services at the Senior Leadership Team (SLT) recently and followed up with direct contact with providers. This highlighted that all the parameters are being met for all of the bed closures to take place. Also the parameters have been met for the clinic arrangements as alternatives have been found. A rota for the radiographers in the minor injury units (MIU s) is still outstanding due to a member of staff resigning just after3 a new rota was completed. b. No service risks highlighted. c. Devon Doctors Additional Services - JT presented a procurement for OOH service and the 111 service. A Devon Doctors service was agreed for six months only so that it could be reviewed after this time. This will come to an end at the end of March The local system requires these services although Devon Doctors has presented a new set of costs to both CCG s but our CCG s costs have increased considerably from last year. 5% has been removed to allow for the closure of the community hospitals but discussions are needed around this figure as it is felt that it should be increased to 15%. The recommendation needs to be signed off for this service at this cost for the next 2 Ratified CFC Minutes 16th March 2017.pdf Page 3 of 6 Overall Page 225 of 282

226 six months. This proposal was accepted by the committee subject to further investigation over the next six months. d. SG joined the meeting at 10.40am and presented on Children s Short Break/Complex Care. Virgin Care Contract run four units with a block contract arrangement with Devon County Council social care and it is not viable for our CCG to continue with this arrangement when the contract ends. A spot purchase is recommended over a block contract. The recommendation is to set aside 25,000 for any new cases and also 150,000 to be set aside as a contingency for other areas of care. The committee agreed to this proposal. Complex Care negotiations have been ongoing for children in the whole of Devon and there is the need to look at a contingency plan with NEW Devon CCG and South Devon & Torbay CCG. Action - ST to write to Hugh Groves regarding this issue. The committee accepted the recommendation. e. Negotiation of one year extension of Virgin contract for 2018/19. The red lines for the Best Alternative to Negotiated Agreement (BATNA s) for our CCG are that savings must be taken out of short breaks and out of complex care. ST requested that four BATNA s are to be put forward to the Procurement Board in two weeks time to discuss and agree the extension. The deadline to formalize with our partners is 30 th June 2017; if this is not met then the contract will have to go out for procurement. The BATNA paper was accepted by the committee. f. Enteral Feeds Devon Cornwall - CARR JT informed the group that this item wouldn't be discussed in any great depth or detail, as she thought that it was discussed at the last CFC. JT explained that it was a potential cost pressure to the system with the new contract and discussions are still ongoing with acute trusts. ST ii. Primary Care & Medicines Management update a. Primary Care Prescribing Report PB presented the Primary Care Prescribing Report to the committee. b. Proposal regarding QALYS as means of prioritising use of finite resource Proposal regarding Quality Adjusted Live Years (QALYS) as means of prioritising use of finite resource JR presented three proposals for discussion. Following discussions the committee recommended that this needs to be presented at the Clinical Cabinet meeting; as it needs discussion at Sustainability, Transformation plan level. JR will amend the paper prior to presentation for the next Clinical Cabinet meeting c. Recommendation regarding purchase of prescribers decision making tool IR presented a recommendation for the purchase of Optimise; a new prescribers decision making tool which would replace Script Switch which is the existing product. Discussions were held around the pros and cons of both systems. The current contract expired in September The committee approved to 2 Ratified CFC Minutes 16th March 2017.pdf Page 4 of 6 Overall Page 226 of 282

227 iii. continue with Script Switch in the short term and to look at Optimise in the future. Clinical Policy Committee recommendations for approval The recommendations for Brivaracetan and Ulipristal acetate were approved by the committee. 8 Risk Register review. Addition of risks flagged during the meeting. No new risks were flagged at today s meeting. 9 AOB Audiology AQP narrative to be amended. The meeting closed at 12.20pm. Attendees (attended* / apologies A Name - initials Paul Baker (PB)* Nick Ball (NB)* Derek Blackford (DB)* Sharron Cox (SC)* (Minute Taker) John Dowell (JD)* Sian Faulkes (SF) A Siobhan Grady (SG)* part of meeting only Derek Greatorex (DGx) A David Greenwell Dr (DG)* Brian Mackness (BM)* (Chair) Sam Morton (SM) A Chris Peach (CP) A Mark Procter (MP) A Nick Roberts Dr (NR)* Ellie Rowe Dr (ER) A Simon Tapley (ST)* Jo Turl (JT)* Title, organisation Deputy Director for Primary Care Non-Executive Director (NED) Deputy Chief Finance Officer PA to Chief Finance Officer Chief Finance Officer Head of Performance Deputy Director of Wellbeing & Family Services Commissioning Clinical Chair of South Devon & Torbay CCG Clinical Lead for Integration Non-Executive Director (NED) Head of Contracting & Performance Non-Executive Director (NED) Director of Corporate Affairs & Medicine Optimisation Chief Clinical Officer Clinical Lead for Commissioning Director of Commissioning & Transformation Deputy Director of Commissioning & Planning In Attendance Jo Roberts* 11.30am pm Iain Roberts* 11.30am pm GP Clinical Lead Lead Medicines Optimisation Pharmacist 2 Ratified CFC Minutes 16th March 2017.pdf Page 5 of 6 Overall Page 227 of 282

228 2 Ratified CFC Minutes 16th March 2017.pdf Page 6 of 6 Overall Page 228 of 282

229 Governing Body Report Committee Title Commissioning & Finance Committee Date 18 th May 2017 Chair Brian Mackness Recommendation For Approval For Discussion x For Information x Key points for the Governing Body to note: One risk to be closed and no new risks to be added. The committee noted month 1 progress report on the system savings plan and further work on risk mitigation The committee noted good performance of medicines optimisation team in 2016/17. Decisions made by the Locality Leads: None Minutes are enclosed for the meeting/s 16 th March 2017 and 18 th April Committee GB report for CFC 18th May 2017.doc Page 1 of 2 Overall Page 229 of 282

230 Governing Body Report Revised Conflicts of Interest statutory guidance The Audit Committee on 14 April 2016 received a paper summarising the revised Conflict of Interests, statutory guidance which has been issued for consultation in April NHS England published on 31 March 2016 a consultation document to further strengthen the statutory guidance for clinical commissioning groups (CCGs) on how conflict of interests should be managed. This report provided a summary of: The current processes in place within South Devon and Torbay Clinical Commissioning Group (the CCG) for the management of conflict of interests and gifts and hospitality. An overview of the proposed changes to statutory guidance Impact on primary care co-commissioning Transparency of the management of conflicts in decision making is vital to maintain confidence in the integrity of decision making. The statutory guidance proposes a set of rules for all organisations who will be expected to develop internal mechanisms to ensure compliance. The key changes proposed are: The recommendation for CCGs to have a minimum of three lay members on the Governing Body The introduction of a conflicts of interest guardian in CCGs The requirement for CCGs to include a robust process for managing any breaches within their conflict of interest policy and for any breaches to be published on the CCG s website; Strengthened provisions around decision-making when a member of the governing body, or committee or sub-committee is conflicted Strengthened provisions around the management of gifts and hospitality, including the need for prompt declarations and a publicly accessible register of gifts and hospitality A requirement for CCGs to include an annual audit of conflicts of interest management within their internal audit plans and to include the findings of this audit within their annual end-of-year governance statement; A requirement for all CCG staff, governing body and committee members, and GP members to complete mandatory online conflicts of interest training, which will be provided by NHS England. Other supporting measures include rationalising medicines optimisation committees, the aim being that local medicines formulary committees will be far less involved in processes that the pharmaceutical industry may seek to influence. This will be supported by industry led codes of practice. A response to NHS England on the revised guidance was agreed. 3 Committee GB report for CFC 18th May 2017.doc Page 2 of 2 Overall Page 230 of 282

231 PUBLIC PRIMARY CARE JOINT COMMISSIONING COMMITTEE (PCJCC) MINUTES Date: Thursday 03 March 2017 Time: Location: Pomona House ATTENDEES Name Kevin Muckian (Chair) Paul Baker Linsey Redstone Julia Cory Nick D Arcy Mark Procter Barrie Behenna Melissa Redmayne Kevin Davis Clive Coleman John Whitehead Jenna Ray Jo Panitzke In attendance; Fiona Cartlidge Siohban Cambridge Roger Pearson Dr Kevin Dixon Simon Culley Title Non-Executive Director (Non-Medical Clinical Member) (SDTCCG) Deputy Director for Primary Care (SDTCCG) Primary Care Project Officer (SDTCCG) Head of Primary Care (NHS England) Clinical Lead for Patient Safety and Quality (SDTCCG) Director of Primary Care and Corporate Services (SDTCCG) Patient Representative (Health Watch Devon) Change Manager (SDTCCG) Head of Finance (NHS England) Deputy Head of Finance (NHS England) Clinical Lead for Primary Care (SDTCCG) Primary Care Project Officer (SDTCCG) PA Primary Care & Corporate Services (Minute Taker) Contract Manager (NHS England) Senior Project Manager (SDTCCG) Healthwatch Torbay Chair Healthwatch Torbay Communications Officer APOLOGIES/ABSENCE Name Virginia Pearson Caroline Dimond Gill Gant Chris Peach Nick Ball John Dowell Amanda Fisk Derek Greatorex Mark Kealy Title Director of Public Health (Devon County Council) Director of Public Health (Torbay Council) Director of Quality Assurance and Improvement (SDTCCG) Non-Executive Director for Patient and Public Involvement Non-Executive Director for Finance and Governance (SDTCCG) Chief Finance Officer (SDTCCG) Director of Assurance and Delivery (NHS England) Clinical Chair (SDTCCG) Consultant in Public Health (Devon County Council) KEY POINTS Item 1 Welcome and Apologies The Chair welcomed everyone to the meeting, and formally opened the meeting 09: PUBLIC PCJCC Approved minutes FC.docx 1 Page 1 of 10 Overall Page 231 of 282

232 The apologies received were noted as above. The Chair welcomed Siohban Cambridge newly appointed Contract Manager for NHS England to the Primary Care Joint Committee, introductions from all those in attendance at the meeting were made to Siohban. 2 Declaration of conflicts of interest There were no new declarations of conflicts of interest made. 3 Approve the minutes and actions from previous meeting The minutes from the last meeting held 2 February 2017 were reviewed; it were noted as an accurate reflection of the meetings contents. The Chair requested an update status on actions, the Chair was made aware that actions 81 and 55 are still ongoing, 102 is itemized within the agenda, actions 104 and 105 are complete, and action 103 is in progress and will be updated on within the next meeting. 4 Healthwatch Rate & Review System Committee members welcomed both Dr Kevin Dixon and Simon Culley from Torbay Healthwatch, Simon Culley proceeded to present their presentation on a rate and review system developed by the team, Simon explained public consultation highlighted a demand to be able to rate and review the services accessed within health and social settings which would be comparable in its functionality to Tripadvisor. Heathwatch Torbay worked with the Academic Health Science Network (AHSN) and NHS England South West to develop and introduce improved patient involvement using the innovative public feedback centre June 2014, also to implement this across South West Peninsular local Healthwatch's, Simon explained that they are still awaiting Devon to implement the service. The system allows patients to rate the service out of 5 stars, whilst also leaving narrative to support their review; this offers the opportunity for service providers to gain a unique insight into their service user experience. Service users search online for the provider and leave a review of their experience, feedback will them be moderated, dependant on the content the review is either published or escalated, negative reviews will not be published until sufficient information and data is gathered, contact will be made with the service user, and providers are able to respond accordingly. The data retrieved can be manipulated into differing themes to allow for individual use and interpretation. Simon explained that locally to date the system has received over 1650 reviews of the 160 different Torbay health and social care services, and of this amount a total of 42 safeguarding alerts have been raised, allowing for swift responses to be made. The Care and Quality Commission regularly contact the team to contribute towards rate and review data to their inspection reports. The retrieved data is used by a number of providers and commissioners to enable improvement and efficiencies within services, including its use by NHS England and the General Medical Council. Nationally over 50 local Healthwatch s in England have adopted the rate and review system, amounting in the retrieval of over 49,815 service user experience, of which 32,101 reviews were categorised in detail with themes, 1,233 providers gave responses PUBLIC PCJCC Approved minutes FC.docx 2 Page 2 of 10 Overall Page 232 of 282

233 The system has received recognition for its achievement working with NHS England and Healthwatch Torbay, and as such this has allowed Healthwatch Torbay to build strong relationships with local Health and Social Care partners. The South West peninsular rate and review collaboration project, led by Heathwatch Torbay was also a finalist in the Commissioning for Patient Experience category of the 2015 PEN National Awards celebrating the delivery of outstanding patient experience. In addition to this the project was successful in gaining the Excellence in Technology award in 2016 Simon explained that feedback can be inputted directly onto the provider website by way of an embedded widget, this promoted transparency, and collects data you need for the provider. Also feedback centre kiosks can be featured within the provider location. The Committee noted the contents of the presentation and were very impressed with system, and its ability to collect usable data for analysis. The Committee were keen to see this system adopted across a Devon wide footprint. The Chair and Committee thanked both Dr Kevin Dixon and Simon Culley for attending the Primary Care Committee. 4 Risk Register Mr Paul Baker presented the risk report; there are currently three risks reporting to the Primary Care Joint Commissioning Committee. Mr Baker highlighted that there are currently no recommended closures or new risks for consideration at this point, current risk scores remain. 208 the risk regarding the loss of mission critical staff from NHSE, current adequacy score remains red, Mr Baker noted the planned work to mitigated this risk with the work up of an MoU with NHSE. The Committee noted the risk register. 5 NHS England (South West) SDTCCG Medical Contract Overview Report February 2017 Mrs Julia Cory presented the Medical Contract Overview report and highlighted that all 24 PMS practices have been offered new contracts, the contracts reflect the changes to funding following the PMS review. 17 signed contracts have been received, work being undertaken to agree and gain signatories for the further 7, it has been noted that practices maybe experiencing some complexities in signing contracts, NHSE will follow up on this work and report on progress at next meeting. Those who are still outstanding will be included within the private section of the meeting. Two practices highlighted have single handed contracts, and will be monitored for potential vulnerability (change manager work) Julia Cory informed the Committee that Greenswood Surgery, Brigham branch surgery to St Lukes Medical Centre have requested to close with effect from 1 st April 17, the main reason for the request is that the leased Greenswood premises lease ends on 31 st March The main surgery is less than 1 mile from the branch site and will require no catchment area changes; the main site has better accessibility. The majority of services and telephone lines are manned by St Lukes requiring no change to appointment bookings. The practice has engaged with patients, the outcome being PUBLIC PCJCC Approved minutes FC.docx 3 Page 3 of 10 Overall Page 233 of 282

234 that patients support their rational and recognise that the practice has been stretched. Julia Cory informed the committee that NHS England recommendation is to support the request to consolidate of the St Lukes estate and resources. Recognising that St Lukes is currently 37% undersized and would be nearly 60% undersized with this closure, there may be future potential for St Lukes to expand their current operating model within Brixham Community Hospital and build on their model of access utilising the hospital as a hub. The Committee noted the request from St Lukes Medical Centre to close their Greenswood branch surgery and support NHSE recommendation for closure and consolidation. Julia Cory reported on the GMS contract negotiations for 17/18, noting the contents on the included NHSE letter which sets out the main points and further work to be undertaken, with the inclusion of the key changes to the contract, Julia highlighted the changes to be made to DES s payments will start from 31 st March 17, noting that the identification and management of patients with fraility new contractual requirement will be introduced from 1 st July 17. Dr Whitehead raised a question connected the a potential rise in indemnity costs for General Practice linked to personal injury, Julia acknowledged that NHSE recognise there may be a potential issue and will be exploring this but currently has no further information to be shared. A change to the Statement of Financial Entitlements SFE should allow for easier access to payments, also new conditions being introduced from October 17 in relation to core opening and extended hours DES will mean that practices who regularly close for half on a weekly basis will not ordinarily qualify for the payment. The General Practitioners Committee have agreed that Local Medical Committee should work with local commissioners to ensure practices fulfil their contractual obligations. Following discussion, the Committee agreed to support the recommendation from NHS England regarding the closure of Greenswood branch surgery Brixham. The Committee noted the NHS England South (South West) South Devon and Torbay CCG: Medical Contract Overview Report March Temporary Practice Closure Request Mayfield Medical Practice Lindsey Redstone presented the two requests from Mayfield Medical Centre for temporary closures, to undertake staff training on 8 th June and 2 nd November 2017 both from 12:00-14:00. In order to ensure patients can access essential services, Mayfield intend to direct patient s calls via voice mail to Devon Doctors, there will be an on call GP, on site pharmacy services will remain open, communications will be advertised to patients in the form of posters situated on the surgery door. The Committee agreed to Mayfield Medical Centre request for practice closures. 7 Managing Temporary Practice Closures Paul Baker presented the submitted management process for practice close down requests; this is following several recent requests received from practices for temporary closures and discretionary support towards funding. Confusion and queries have arisen from practices regarding historic discretionary funding arrangements, contractual obligations and process. The Committee noted the contents of the paper and approved the recommendations, PUBLIC PCJCC Approved minutes FC.docx 4 Page 4 of 10 Overall Page 234 of 282

235 adding that temporary closure applications are to be received 3 months prior to the planned date of closure. 8 ETTF Report/ Update Paul Baker presented an update in regards to the status of current Estates, Technology and Transformation Funding ETTF schemes and Minor Improvement Grant MIG schemes. Paul noted that all ETTF schemes are currently RAG rated green for delivery of scheme within required deadline. Currently Buckfastleigh MIG request regarding a noted storage area has not been approved by NHS England due to not meeting the eligibility criteria, although this may be considered within the 17/18 grant application process based on the anticipated publication of new Premises Cost Direction. Paul explained that a decision on Old Farm and Barton Surgery Torquay s grant submission pending with NHSE before work can commence, deadline for completion before 31 st March 17. Both Chilcote and Mayfield Medical Centre MIG schemes are rated green currently for completion by deadline. Paul Baker noted that the deadline for MIG 17/18 schemes occurred at the end of February 2017, a total of 5 applications have been received from practices. It was highlighted that from the submitted applications there is a move towards collaborative working amongst practices, further information on the received applications will be submitted at the next PCJCC meeting for information and review. ACTION: To bring further information on the submitted MIG 17/18 schemes to April 17 meeting, information to include total value, system of ranking, and potential process for due dilliegence. The Committee noted the contents of the Estates, Technology and Transformation Fund update. 10 Minor Surgery DES Jenna Ray updated the committee on recent correspondence received from NHSE in relation to minor surgery directed enhanced services DES. NHSE South West propose that the management of the DES is transitioned over to South Devon & Torbay CCG over the coming months to align with planned national delegation timescales by 1 st April 2018, the minor injury DES was issued nationally in 2004 and has not been updated or reissued in recent years. Jenna presented the recommendations to the committee, noting that as aspiring delegated commissioners the committee responds positively to this presented proposal. The planned intentions are seek confirmation on budget and spend with NHSE, primary care team to engage with planned care team to explore opportunities in regards to local pathway alignment, also to engage with local providers exploring alternative models of delivery. Dr Nick D Arcy highlighted to NHS England that under section 2 scope of services to be provided, exsistion of leasions Keratoacanthoma s should be removed from the list as this should be referred on a two week wait pathway as per new guidelines. Julia Cory explained that the planned national delegation will come into action from 1 st April 18, a transfer of approximately 510k will be available to cover this work, the transfer of funds could be made as soon as 1 st April 2017 to enable work to progress. It was acknowledged that this item was agenda d for information and consultation, PUBLIC PCJCC Approved minutes FC.docx 5 Page 5 of 10 Overall Page 235 of 282

236 both the Primary Care team and NHS England will undertake further work together on budgets and viability of commencement by the new date. Action: Primary Care team to work with NHS England on minor surgery (DES) management transition budget and new date. NHSE to provide budget and projected activity information. The Committee noted the contents of the correspondence received in relation to minor surgery (DES). 11 Change Manager Update Melissa Redmayne presented the primary care change manager report, presenting an update on implementation of GPFV planned and taken actions. Melissa explained that as part of the GPFV for SD&T the next stage was to develop a detailed operational plan, specifically in relation to extended access across the CCG footprint. A key requirement is to deliver 45 minutes of additional bookable appointments per 1000 population, which has changed from the previous expected 100% coverage by March A plan was submitted to NHS England by the February 2017 deadline, Melissa explained that work will now continue to put together a trajectory looking at demand, development of the delivery model according to plan ensuring local and personal care are maintained, a working group will be established to identify the key milestones for delivery for 2017/18. Melissa confirmed that the resilience fund MoU has been agreed with NHS England, funding is currently in the process of being transferred to SD&T CCG, this funding will be made available to those practices identified as in need of support by way of the heat map work. Melissa explained that she is working with the Primary Care team on a number of grouped practices who are in the midst of developing collaborative working models. Melissa reflected on the previous quick start programme cohorts 1 and 2 and visits undertaken with those practices by facilitators who aid by spotting areas for efficiencies, but also by sharing information of improvements implemented elsewhere. Melissa noted one practices in particular that has investigated how to implement improvements into clinical correspondence management, to reduce GP time. There is currently 3 cohorts totalling 27 practices, of those practices not involved have specific reasons for noting having done so, feedback received from practices and those involved with the programme has been positive in terms of it being a great opportunity to share learning across South Devon and Torbay footprint. Melissa noted that a meeting held yesterday with practices highlighted continually future progress review opportunities with the cohorts to identify where practice are 6 months from now, Julia Cory emphasised that NHS England would be expecting to see on going momentum with this programme due to the allocated national funding therefore providing adequate assurance. Melissa explained that a Time for Care workshop an exploration of opportunities across SD&T CCG boarders partnership working has been secured to take place on Thursday 30 th March location to be confirmed. Also an away day is currently being planned for the 14 th March in conjunction with SD&T CCG and time to care for Brixham and Paignton Alliance. Melissa provided an update on the current position of reception and clerical training, as part of the Health Navigator training 3 training providers have been invited to attend the practice manager meeting on the 9 th March, and evaluation template is being PUBLIC PCJCC Approved minutes FC.docx 6 Page 6 of 10 Overall Page 236 of 282

237 developed to allow practices to score and choose their preferred provider. Melissa updated the Committee on the further funding opportunity to be made available for clinical correspondence training, which will aim to save up to 40 minutes of GP time per day. Melissa explained that GP online consultation software is now live at Chelston surgery in Torquay, which can be seen on their website. The Committee noted the update provided Melissa Redmayne. 12 Devon Doctors Project re Access to Patient Notes Roger Pearson senior project manager for shared care records attended the Primary Care Joint Committee to provide an overview on shared access to GP records project. Roger explained that information sharing is based around the interface between comparable systems using the Medical Interoperability Gateway (MIG) which can link Primary Care and Out of Hours/ Urgent and Emergency systems. Information sharing agreements have been signed by organisations, the viewable data is provided in a read only format, with the patient giving consent at the point of care, all information accessed will be subject to an appropriate audit process. Roger explained how the systems works in terms of connectivity, with the MIG sitting centrally allowing information to be accessed from the differing systems in use, the information will never leave its original system and once viewed will not be stored, the data cannot be amended therefore additional information must be documented accordingly elsewhere. A screen shot shown to the Committee showed how an out of hours clinician will be presented a patient consent screen before data can be retrieved, although in the case on an emergency this can be bypassed, and the clinician will need to provide justification for having done so, which will also be audited. NEW Devon currently have this system for accessing GP patient records, an audit is to be undertaken on current usage and how its use has contributed to admission avoidance. Roger explained that 85% practices have signed data sharing agreements, 80% was the required amount necessary, 5 practices have had concerns in terms governance and accessibility, and the team have met with those practices and expect to receive signed agreements. Roger highlighted the potential for further development with inclusion of additional datasets especially in regards to end of life care plans. The Committee noted the contents of the presentation, providing positive comments on the work to date, and the potential for positive impact this will have on improving patient care. 13 Primary Care IT Strategy Roger Pearson remained to present the draft SD&T CCG Primary Care IT Strategy which aims to outline the direction of travel the CCG will take to improve the current IT landscape for Primary Care, whilst acknowledging and taking into account other wider initiatives such as the STP and the Local Digital Roadmap, Roger explained the strategy was submitted for review, comment and approval. Julia Cory commented that from an NHS England and GPIT perspective, the strategy contains good main points; Julia questioned the perusal of a single system and whether the strategy is as brave as it could be? Roger explained whilst a single system is the most utopian choice, with the availability of interface options, it allows for a choice of systems which function interoperable providing the same availability of PUBLIC PCJCC Approved minutes FC.docx 7 Page 7 of 10 Overall Page 237 of 282

238 data. The Committee noted and approved the Primary Care IT Strategy, without recommendation. 14 AOB Both Paul Baker and Julia Cory rose to the Committee s attention two additional temporary practice closure requests. Old Farm practice submitted a request to close for half a day in order to celebrate the retirement of one of their GP s, subsequently an additional request was submitted to request the same date for a half day team building event. The Committee declined their request, due to insufficient timing, information and nonconfirmation of appropriate practice process. Chelston practice submitted a request for a half day closure on Friday 3 rd March 17, the request was received on Monday 28 th February 17, the request was received so that their emis system can be inputted. Julia and Paul raised concerns as to why the practice need to be closed for this to take place, when reception could remain open to sign post patients, and also have potentially have some staff on site. Julia explained that she is still awaiting further clarity from the practice contract manager; Julia plans to say NHS England would support a light service provision, but not a closure; the Committee supports this plan for the non-full closure of the practice. 15 CLOSE The Chair formally brought the public section of the meeting to a closure at PUBLIC PCJCC Approved minutes FC.docx 8 Page 8 of 10 Overall Page 238 of 282

239 Meeting actions the following meeting actions were agreed: Action number PU -55 PU- 81 PU-103 Action The committee agreed to contribute towards the peninsular wide piece of work around understanding the pathway which exists for the patients when practice closures take place to ensure consistency. Julia Cory to take this piece of work forward. Gill Gant to review current governance arrangements and the links between the Primary Care Quality Group, the Complaints Pilot and the PCJCC and also the resourcing issues for the Quality Team. Gill Gant to also liaise with Julia Cory in the first instance to discuss future monitoring of primary care quality and the CCG responsibilities going forward. Mr Procter/Miss Redmayne to provide a more detailed report regarding the Practice Resilience Support Team and the template MoU agreement document at the next meeting. Person responsible Julia Cory Gill Gant Mark Procter/ Melissa Redmayne Status This is an ongoing piece of work therefore the action will remain open to track progress. Outstanding, Gill provided apologies for this meeting action to be followed up. Target date Ongoing Ongoing March 2017 PU Primary Care team to bring further information on the submitted MIG 17/18 schemes to April 17 meeting, information to include total value, system of ranking, and potential process for due diligence. PU 107 Primary Care team to work with NHS England on minor surgery (DES) management transition budget and new date. NHSE to provide budget and projected activity information. Linsey Redstone Paul Baker / Kevin Dixon April 2017 April PUBLIC PCJCC Approved minutes FC.docx 9 Page 9 of 10 Overall Page 239 of 282

240 Actions complete at last meeting: Action number PU-102 Action Mr Procter to arrange for Mr Roger Pearson to update the Committee regarding the project for Devon Doctors access to patient notes. Person responsible Mark Procter/ Roger Pearson Status Complete PU-104 PU-105 Miss Linsey Redstone to alert project leads for each MIG scheme of the deadline for submission of invoices to NHS England by 8 March 2017 Miss Linsey Redstone to send a reminder to practice managers regarding MIG scheme ideas for 2017/18. Linsey Redstone Complete; sent 03/02/17 Linsey Redstone Complete; sent 03/02/17 Complete Complete PUBLIC PCJCC Approved minutes FC.docx 10 Page 10 of 10 Overall Page 240 of 282

241 PUBLIC PRIMARY CARE JOINT COMMISSIONING COMMITTEE (PCJCC) MINUTES Date: Thursday 06 April 2017 Time: Location: Pomona House ATTENDEES Name Kevin Muckian (Chair) Chris Peach Paul Baker Linsey Redstone Julia Cory Nick D Arcy Mark Procter Andrew Cory Melissa Redmayne Kevin Davis John Whitehead Paul Johnson Gill Gant In attendance: Pam Smith (part) Oksana Riley (part) Ray Chalmers Title Non-Executive Director (Non-Medical Clinical Member) (SDTCCG) Non-Executive Director for Patient and Public Involvement Deputy Director for Primary Care (SDTCCG) Primary Care Project Officer (SDTCCG) (minute-taker) Head of Primary Care (NHS England) Clinical Lead for Patient Safety and Quality (SDTCCG) Director of Primary Care and Corporate Services (SDTCCG) Patient Representative (Health Watch Torbay) Change Manager (SDTCCG) Head of Finance (NHS England) Clinical Lead for Primary Care (SDTCCG) Clinical Chair (SDTCCG) Director of Quality Assurance and Improvement (SDTCCG) Project Lead (NHS England) Medicines Governance and Community Pharmacy Development Lead (NEW Devon/SDT CCGs) Head of Communications and Strategic Engagement (SDTCCG) APOLOGIES/ABSENCE Name Virginia Pearson Caroline Dimond John Dowell Nick Ball Amanda Fisk Mark Kealy Fiona Cartlidge Title Director of Public Health (Devon County Council) Director of Public Health (Torbay Council) Chief Finance Officer (SDTCCG) Non-Executive Director for Finance and Governance (SDTCCG) Director of Assurance and Delivery (NHS England) Consultant in Public Health (Devon County Council) PA Primary Care and Corporate Services KEY POINTS Item 1 Welcome and Apologies The Chair welcomed everyone to the meeting, and formally opened the meeting at 09:00. The apologies received were noted as above. On behalf of the Committee, Mr Muckian formally noted the departures from PUBLIC PCJCC Approved minutes.docx 1 Page 1 of 8 Overall Page 241 of 282

242 Committee for Dr John Whitehead, Julia Cory and Barrie Behenna. Their contribution, experience and insight were remarked upon and members wished them well for the future. Mr Muckian also took the opportunity to welcome Andrew Cory and Dr Paul Johnson. 2 Declaration of conflicts of interest There were no new declarations of conflicts of interest made. It was noted that the practices of Dr Johnson, Dr D Arcy and Dr Whitehead were named within the temporary practice closure requests in item 9 and all three would therefore absent themselves for the duration of this discussion. 3 Approve the minutes and actions from previous meeting The minutes from the last meeting held 2 March 2017 were reviewed and agreed as an accurate reflection of the meetings. Mr Mark Procter questioned whether there was any progress within Devon Healthwatch in adopting the rate and review system demonstrated at the March meeting. Action: Mr Andrew Cory to seek an update regarding Devon Healthwatch adopting the rate and review system. The Chair requested an update on actions outstanding. Actions 55 and 81 remain ongoing whilst actions 103, 106 and 107 are complete. 4 Risk Register Mr Paul Baker presented the risk report noting that SDTCCG currently has 42 open risks. Mr Baker recommended risk 206 for closure explaining that this risk relates to the due diligence process for transition to fully delegated commissioning, which is not taking place this year as per aspiration. However, there is continued effort between NHS England and CCG colleagues to agree a Memorandum of Understanding for future use. The Committee approved closure of risk 206. Mr Baker outlined a proposed new risk, risk 213, regarding potential loss of community pharmacy. Mr Baker explained that this has been discussed with a number of local community pharamcies to guage their perspective regarding the degree of risk; some have confirmed this is a concern and they are undertaking business viability assessments. Mrs Gill Gant questioned whether there is sufficient encouragement to attract pharmacies onto the site of new practices, however, Ms Julia Cory explained that pharmacy regulations are tightly governed with regard to locating sites. NHS England colleagues continue to be supportive of proposed pharmacy relocations when they arise. The Committee approved the addition of risk 213. Risk 208 regarding loss of mission critical staff from NHS England was discussed and Mr Kevin Davis confirmed that either he, or his colleague Ann Stone, will attend future Committee meetings to cover finance representation. Amanda Fisk will continue in her designated role to cover the medical contract overview report as required. It was therefore agreed that the mitigation and score for this risk should be amended to reflect these cover arrangements. Action: Mr Paul Baker to review the risk score and mitigation for risk PUBLIC PCJCC Approved minutes.docx 2 Page 2 of 8 Overall Page 242 of 282

243 The Committee noted the risk register and agreed the changes proposed. 5 NHS England (South West) SDTCCG Medical Contract Overview Report March 2017 Mrs Julia Cory presented the Medical Contract Overview Report and highlighted a practice merger request and branch surgery closure request. The practice merger related to Corner Place Surgery and Withycombe Lodge Surgery in Paignton, who have requested merger of their PMS contracts with effect from 1 June The lease on the premises of Withycombe Lodge Surgery terminates on 23 June 2017 and the practice will have to vacate the premises by this date. Consequently there have been a number of options explored by the Paignton practices resulting in the Corner Place/Withycombe merger proposal. Corner Place currently has 13,000 registered population whilst Withycombe has under 2,850. Both are PMS contracts and shared values with regards to patient care. Post-merger, patients will still have the same choice of GP they currently have and the same access to appointments, but will have a greater choice of healthcare professional owing to ongoing recruitment of GPs and other health professionals at Corner Place. Ms Cory recommended approval of this merger, which will provider greater resilience and the Committee approved the merger of Corner Place and Withycombe Lodge surgeries. Ms Cory then presented the site closure request from Pembroke House Surgery to close their Grosvenor Road branch site with effect from 1 June It was noted that the same landlord owns both the Grosvenor Road site and the Withycombe Lodge site and has similarly terminated the lease. The two sites are 1.1 miles apart and patients of Pembroke House Surgery have been accessing services from both sites since July Committee noted the extensive building works that have been ongoing at Pembroke House for some time and are now at completion, which will provide additional clinical rooms. The surgery is also on an established and frequent bus route with nearby parking and an onsite pharmacy. It was noted that the practice boundaries will remain unchanged by this closure. The Committee noted the significant amount of engagement that has been undertaken by the practice, both in terms of patient engagement and among neighbouring practices and it was felt that this level of engagement was exemplar. The Committee approved the closure of the Grosvenor Road site. The Committee noted the NHS England South (South West) South Devon and Torbay CCG: Medical Contract Overview Report and approved the merger request and site closure request. 6 Enhanced and Extended Access Mrs Pam Smith was welcomed to the meeting for this item and delivered a presentation with Ms Melissa Redmayne regarding the requirements, criteria and timeline for delivering enhanced and extended access. Ms Redmayne informed Committee of the Government mandate to the NHS, which is to ensure everyone has easier and more convenient access to GP services, including appointments at evenings and weekends. The funding from GPFV provides a good opportunity to truly transform and make the best connections for patients and staff. CCGs will be required to commission and fund the additional capacity, which may require undertaking a procurement process PUBLIC PCJCC Approved minutes.docx 3 Page 3 of 8 Overall Page 243 of 282

244 In terms of timescales it was noted that evening and weekend access must be delivered for the entire population by March However, there is a gap in the funding in the year 18/19 owing to the fact that the 6 funding contribution per head is only available from April 2019 onwards. Ms Redmayne outlined the 7 core requirements that CCGs have to demonstrate they are meeting in order to receive funding. These requirements are: Timing of appointments to provide an additional 1.5 hours between 18:30-20:00 and at weekends Capacity commission on a minimum additional 30 minutes consultation capacity per 1,000 population per week, rising to 45 minutes per 1,000 population Measurement; ensure usage of a new tool to measure appointment activity by all participating practices Advertising and ease of access Use of digital approaches Issues of inequalities in patients experience of accessing general practice identified and actions in place to resolve Effective access to wider whole system services Mrs Smith commented that the additional hours must be clinical time, however, this does not necessarily mean just GPs, but could include nursing time as well. This presents a significant opportunity for transformation to provide a resilient primary care service that is fit for the future. Mr Baker added that this also presents an opportunity to eliminate inconsistencies and there is a clear role for the CCG to help coordinate this. The Committee discussed the impact of the extended access Directed Enhanced Service and Mrs Smith commented that it is expected that this will be phased out from April 2019 but there are opportunities to use this in a more joined up way and gearing up for delivering extended access. The Committee noted the contents of the presentation and thanked Mrs Smith and Miss Redmayne for providing the information. The views expressed by the Committee will be taken into account in the future planning of the service, together with examples from neighbouring CCGs. It was also noted that there will be a high level of scrutiny of investment on GPFV from NHS England. 7 Minor ailment provision Mrs Oksana Riley was welcomed to the meeting and presented the Service Level Agreement (SLA) for the Pharmacy First Minor Ailments service. This service via Patient Group Directions is to ensure that patients can access self-care advice for the treatment of specific ailments and, where appropriate, can be supplied with a prescription only medicine. The specific ailments included are bacterial conjunctivitis, impetigo, nappy rash and uncomplicated urinary tract infections. Mrs Riley explained that up until 31 March 2017, the service was commissioned by NHS England, however, NHS England have ceased to commission the service after this date. SDTCCG has therefore agreed to commission from 1 April 2017 and this has been approved thorugh the Commissioning and Finance Committee with a budget assigned. Devon LPC has been consulted with regard to the contents of the SLA and minor amendments to the document have been made in line with their comments PUBLIC PCJCC Approved minutes.docx 4 Page 4 of 8 Overall Page 244 of 282

245 Mr Chris Peach questioned how patients will be made aware of this service and Mrs Riley confirmed that new material will be placed in pharmacies and GP practices to inform patients, although it was noted that this is an established service already. However, before additional media communications are made, clear sign-up by pharmacies will be recorded so as to ensure clarity over where patients can access the service. The Committee noted the contents of the paper and approved the SLA for Pharmacy First Minor Ailments via Patient Group Directions service. 8 ETTF/MIG report Mr Baker presented the above report, informing members that the ETTF schemes are either complete or on track for completion within the proposed timescales. Similarly, the MIG schemes for 16/17 are either complete or nearing completion, in which case pro-forma invoices have been submitted to NHS England for accrual purposes. The five proposed MIG schemes for 17/18 were then reviewed by the Committee. It was noted that the Primary Care Team wrote to every practice to explain the MIG process and to encourage practices to work as groups to agree minor improvement priorities for their area. The 17/18 MIG allocation for SDTCCG is just under 70,000, against which the total amount of the five proposals equates to just under 69,000. Dr Nick D Arcy voiced concerns regarding conditions associated with MIG schemes that may tie practices in to their premises for several years. Mr Baker confirmed that practices are aware of these conditions and potential associated penalties. The Committee acknowledged that the proposed schemes would provide immediate benefit to those practices and as such all five were approved for submission to NHS England. 9 Temporary Practice Closure Requests Owing to potential conflict of interest, Dr Paul Johnson, Dr John Whitehead and Dr Nick D Arcy left the meeting for this item. Ms Linsey Redstone presented a request on behalf of 16 practices for temporary closures on three afternoons of 15 June 2017, 14 September 2017 and 16 November 2017 for staff development and training. The cover arrangements were described within the application form submitted by the practices; it was noted that this includes Devon Doctors covering with an on-call GP available at each practice. Ms Julia Cory questioned whether each practice had submitted an individual application and voiced concerns regarding accountability. It was agreed that individual assurances from each practice will be sought to confirm their continued responsibility towards patients. Practices will also be reminded that, in the event of exceptional circumstances, it is possible that this approval may be rescinded. Action: Linsey Redstone to write to all 16 practices to confirm approval for the temporary closures on the dates specificed and request confirmation from each that they acknowledge their responsibility. On the conditions outlined above, the Committee agreed to the three temporary closures on behalf of the 16 named practices PUBLIC PCJCC Approved minutes.docx 5 Page 5 of 8 Overall Page 245 of 282

246 10 Change Manager Update Melissa Redmayne presented the Change Manager report and informed members that the resilience fund memorandum of understanding has been agreed with NHS England and includes a clause outlining the requirement for practices to evidence tangible results from the support they receive. Ms Redmayne then provided an update on the work achieved to date with practices through the Quick Start Programme. The Committee was pleased to note the progress and hear that the practices highly value this programme. Health Navigator training; Ms Redmayne informed members that a procurement exercise was undertaken on 9 March 2017 where three training providers presented to the practice managers who then rated the presentation against agreed evaluation criteria. CEPN was announced as the winning provider and work is now underway with CEPN to agree next steps. GP Online Consultation Software update; Ms Redmayne reported that econsult is now live at both Chelston Hall Surgery and Kingskerswell and Ipplepen Health Centres. Feedback from Chelston Hall has been very positive with 80% of patients who used the system confirming that they would recommend it to friends and family. Dr D Arcy provided some early feedback from his practice, stating that increasing numbers of patients are using it and it had already saved a number of GP appoinements. It was acknowledged, however, that wide promotion of the service is necessary to encourage higher uptake from patients. The Committee thanked Ms Redmayne for her report and it was agreed that this monthly update report will be included within the papers for the Governing Body meeting for information. The Committee noted the Change Manager report. 11 Primary Care Finance Update Mr Baker provided a verbal update regarding the current Primary Care financial position. It was noted that Finance Directorate colleagues are finalising the 16/17 position; a small underspend on the CCG commissioned services budget is anticipated. The final position will be available for the next meeting. 12 MoU for Delegated Commissioning Finance Section Mr Baker presented the finance section of the MoU for delegated commissioning, which has been agreed through meetings with finance colleagues from SDTCCG and NHS England. Mr Baker acknowledged with thanks the input from all parties and reminded Committee of the importance of preparing a suite of documents to establish the developing relationship between the two organisations with regard to future delegated commissioning. The equivalent documents for communications and engagement, quality and contracting will be brought to the Committee once finalised. The Committee approved the finance section of the MoU document. 13 CLOSE The Chair formally brought the public section of the meeting to a close at 10: PUBLIC PCJCC Approved minutes.docx 6 Page 6 of 8 Overall Page 246 of 282

247 Meeting actions the following meeting actions were agreed: Action number PU -55 PU- 81 PU- 108 PU- 109 PU- 110 Action The committee agreed to contribute towards the peninsular wide piece of work around understanding the pathway which exists for the patients when practice closures take place to ensure consistency. Julia Cory to take this piece of work forward. Gill Gant to review current governance arrangements and the links between the Primary Care Quality Group, the Complaints Pilot and the PCJCC and also the resourcing issues for the Quality Team. Gill Gant to also liaise with Julia Cory in the first instance to discuss future monitoring of primary care quality and the CCG responsibilities going forward. Andrew Cory to seek an update regarding Devon Healthwatch adopting the rate and review system. Paul Baker to amend the risk score and mitigation for risk 208 to reflect cover arrangements in place for NHS England staff. Linsey Redstone to write to the 16 practices requesting temporary closures to confirm Committee s approval for the dates specified and request confirmation from each that they acknowledge their continued contractual responsibilities during the periods of closure. Person responsible Julia Cory Gill Gant Status This is an ongoing piece of work therefore the action will remain open to track progress. Outstanding, Gill provided apologies for this meeting action to be followed up. Target date Ongoing Ongoing Andrew Cory May 2017 Paul Baker Complete May 2017 Linsey Redstone Complete April 2017 Actions complete at last meeting: Action Action number PU-106 Primary Care team to bring further information on the submitted MIG 17/18 schemes to April 17 meeting, information to include total value, system of ranking, and potential process for due diligence. PU -107 Primary Care team to work with NHS England on minor surgery (DES) management transition budget and new date. NHSE to provide budget and projected activity information. Person responsible Linsey Redstone Paul Baker/ Kevin Davis Status Complete Complete PUBLIC PCJCC Approved minutes.docx 7 Page 7 of 8 Overall Page 247 of 282

248 PUBLIC PCJCC Approved minutes.docx 8 Page 8 of 8 Overall Page 248 of 282

249 Governing Body Committee Report Committee title Date Chair Primary Care Joint Committee Public Meeting 04 May2017 Kevin Muckian Recommendation For Approval For Discussion For Information x Key points for the Governing Body to note: The Primary Care Committee reviewed the Committee s Risk Register and Report for March 2017, which was approved.. The Committee received and noted NHS England South (South West) Medical Contract Overview Report for May The Committee received an update on NHSE Finance Report, which informed the Committee of expected outturn for 2016/17 Primary Care allocation and the Medical allocations for 2017/18 The committee received and noted the submission of an update on SD&T CCG Primary Care Finance position 2016/17 and projection for 2017/18 The Committee received and approved the amended Insulin Initiation service specification to include GLP-1 medication. The Committee received and noted the update on ETTF and MIG schemes for 2016/17 and 2017/18.. The Committee received an update report from SD&T Change Manger, in terms of GPFV implementation update including planned and actions taken.. The Committee received and approved Standard Operating procedure for managing closed lists and changing practice boundaries in relation to transitioning to delegated commissioning.. The Committee received and approved a communications and engagement MoU related in relation to transitioning to delegated commissioning. to Delegated Commissioning communications Decisions made by the Primary Care Joint Committee: Agreed to support the recommendation from NHS England regarding the closure of Greenswood branch surgery Brixham. Agreed to the temporary closure requests received from Mayfield Medical Practice. Approved the guidance and process for managing temporary practice closures. Approved Primary Care IT Strategy Declined the temporary practice closure for Old Farm and Chelston practice. The Committee approved the amended Insulin Initiation service specification to include GLP-1 medication. The Committee approved Standard Operating procedure for managing closed lists and changing practice boundaries in relation to transitioning to delegated commissioning. PCJCC Public Committee Rpt May17.doc Page 1 of 2 Overall Page 249 of 282

250 Governing Body Committee Report The Committee approved a communications and engagement MoU related in relation to transitioning to delegated commissioning. Minutes are enclosed for the meetings of: April 2017 PCJCC Public Committee Rpt May17.doc Page 2 of 2 Overall Page 250 of 282

251 ENGAGEMENT COMMITTEE MINUTES Date: Tuesday 07 March 2017 Time: 10:00-12:00 Location: Pomona House Item 1 Introductions and apologies JT is chairing. Apologies are listed in the attendance list at the end of the document. 2 Declaration of Interest None to declare. Action Minutes and action plan from the previous meeting Minutes The minutes of the previous meeting were approved as an accurate record. Actions All actions are complete with the following comments and/or exceptions below: Act.1 Act.2 Act.3 Action Summary Action 1 Person Responsible Laura Voisey Act.2 LV to ask FG or Paul Hurrell for an update on their meeting regarding support for the self-care and prevention work. Update from Paul: Felix and Julian have no additional capacity to give practical support on this at the moment as they are concentrating on the wider piece of evaluation work on the new model of care. Paul has escalated the issue of support via the Prevention Board. Closed. Act.3 It was agreed that the need for a clinical member on the Engagement Committee is reviewed. JC to discuss requirements with ST and CP Jo Curtis, Simon Tapley & Chris Peach CP/ST to provide the committee with an update on the forthcoming Governing Body s review of its members roles. Act.4 JC to review the committee self-assessment comments made Jo Curtis and identify areas for improvement. JC met with CP and identified key things: 1) July meetings are often cancelled. Need to ensure good attendance at meetings. Audit is going to keep an eye on this. There were no other actions that came out of this that we aren t already addressing. Close. Act.5 JC to speak to Theresa Farris About adding the question Does it comply with the NHS Constitution? to the template for reports for the Governing Body. Not complete but in hand. Close. Act.6 As part of a recent course JT had to look at how her role links to the NHS constitution and found this really useful. JT suggested this be discussed at an all staff meeting. Jo Curtis Jo Turl sent to Adam Bowles asking that the NHS Constitution and how it relates to people s roles is added to the agenda of the next meeting. Close. Act.9 JT to follow up with Rob Dyer, chair of the task and finish group regarding their plan of action for tacking discharge issues that have been highlighted in SH s report. Jo Turl Gill Gant has raised this with Rob Dyer. JT is happy that appropriate escalation has happened. Close. Act.10 Jo Turl CP emphasized that this committee needs evidence for assurance. He suggested that DPT should inform us of their engagement work at contract review meetings and a report should be submitted to the Engagement Committee on this every 6 months. JT to action. JT will schedule to do an update on DPT s engagement reporting to the CCG for the Engagement Committee agenda. Act.12 RC to circulate the communications and engagement plan for STP when approved Ray Chalmers This has not been finalised yet. Andrew Millwood, the new Director for STP communications EC FINAL minutes 07 March 17.docx CP/ST JT RC Page 1 of 5 Overall Page 251 of 282

252 Act.4 4 Act took up his post last week and will be reviewing this. He has met with Healthwatches and is calling a meeting for communications leads next week. Keep open. Act.13 RC explained that there is a document that sets out roles and responsibilities of acute services, based on the questions. RC to circulate this document when approved. Ray Chalmers Same as above. Waiting for Andrew s approval. Keep open. Act.14 JC to record the individual work streams of the STP (including the acute services review) and the system savings plan areas that JT has mentioned. Jo Curtis JC met with JT to discuss this. Covered in JT s report. Close. Community services consultation update (Ray Chalmers) The governing body set a range of parameters that need to be met before any changes are made to existing services. There is a stakeholder update due to go out in the next few days that will give an update on the progress that has been made. This will go out to staff first. RC gave an update on the progress on the parameters that have been met so far. Devon Scrutiny will be briefed on the current position this afternoon. TSDFT is setting up implementation groups in local towns and inviting members of local groups to attend to ensure that their local knowledge and input is fed into this. KD highlighted that it is going really well in Dartmouth and Sarah Wollaston and others are confident that the plans will be an improvement to the current situation. Healthwatch Torbay has been meeting with the chair of Paignton League of Friends as it is important to keep them involved. KD emphasised the need to publicise that things are moving on and convince people that they will be getting something better. Healthwatch would like to be involved in these implementation groups and KD is happy to give time to chair it too. RC to feed this back to Torbay and South Devon Health and Care Trust. Review of the consultation process The community consultation project board will meet within the next two months to discuss the lessons learned from the process. NEW Devon CCG has already done this. JC highlighted that it will be important to compare our reflections with NEW Devon and discuss this together. RC RC 5 Engagement plan for the STP - Joint Committee Meeting with NEW Devon CCG Acute services review engagement events to discuss service criteria started yesterday. Three have been organised in each quadrant of Devon. Healthwatch is chairing the events. Torbay Scrutiny has been briefed on progress. RC has highlighted to Andrew the need to be more specific about how we follow up after the meetings. It is essential that those that take part are kept informed about the issues raised and next steps so they know their input was valuable and appreciated. An STP brochure has been published that RC will share at the end of the meeting. RC has not yet had a further discussion about the two engagement committees coming together. CP is meeting Andrew in the next few weeks so will likely mention this. They are working on a clearer plan for communications including ideas like inviting Healthwatch to join a regular telecom meeting. MS added that a conversation about closer joint working has been had between Healthwatch branches. They are looking to ensure that everything that Healthwatch currently does is covered even if this is done in a different way. JC thanked the Healthwatch chairs on behalf of the CCG as they have been willing and actively involved in developing how the events are going to run. In North Devon town councils are very much engaged in the STP process compared to this area. The communications team will be discussing whether engagement with groups like town councils and scrutiny panel members should be consistent across the STP footprint. Barnstaple s Town Clerk is chairing their acute services review engagement event who is also the chair of their save our community hospital meeting. 6 Systems savings plan and the plan for engagement EC FINAL minutes 07 March 17.docx 2 Page 2 of 5 Overall Page 252 of 282

253 This paper should be treated as confidential. JT reviewed the areas of work that will likely need future engagement. The CCG have employed someone who will be focused on care home and domiciliary care. They will be working on finding out what people want. KD noted that Healthwatch would like to link up with this person when they have been appointed as they have been carrying out a lot of enter and view processes in care homes recently. Healthwatch Devon has also been conducting more enter and view processes than they have previously. It is a very time consuming process as it is important to be clear with the care home how Healthwatch s role differs to that of CQC, having multiple one to one discussions with staff and writing up the report. They are only carrying out enter and views when they feel there is a good reason to. They are currently reviewing which areas should be targeted. Caroline Lee leads the process and coordinates the support of up to 11 volunteers who each review. They will have had training and be briefed on each case. Healthwatch Torbay has a target to meet for enter and views that is specified in their service level agreement with Torbay Council. KD would argue that the money that is going to the provider to review their own services should go to an independent org such as Healthwatch as it would then be a more reliable review. Some of the work on the systems savings plan will be covered under the STP. There are also potentially more things needing engagement that will arise over the next six to 12months. It is important to manage and integrate even local pieces of work as once a question is raised it will be asked elsewhere. Mental Health will be added to the plan soon. A mental health strategy is currently being developed. JT is a member of the group that monitors public health engagement Engagement reporting template STP: Acute Services Review (ASR) RC is concerned that there isn t a clear timeline for STP. Without this it is more difficult to plan communications, engagement and assign resource effectively. This is one of Andrew s main priorities. The idea of developing a survey like the primary care survey on general rather than specific questions has been discussed. This could be promoted widely across engagement groups such as PPGs. JT thinks this would be a good idea to do across services. The feedback from this survey would create a good background for more specific discussions about specific services. 7.2 Children s services pre-procurement There are different work streams for each of the project areas. JC is chair of the Devon wide engagement working group. Pat Teague from HW came to the last meeting. The group have reviewed prior engagement work of each organisation and pulled this together to identify where the gaps are and where we need to focus next. In our area the gaps in engagement include community nursing, therapies, learning disability and hearing from children and young people themselves. The strategy for South Devon and Torbay CCG was published a few weeks ago and sent to key stakeholders along with a survey about the strategy. This closes on 17 March Public Health has been consulting on which commissioning model they should adopt. KD is aware of a large youth group called youth genesis who have several LGBT members. He feels they would be interested in this. JC has been liaising with Play Torbay who are picking up that there are a number of young people who need support but don t meet the criteria for CAMHS. JC has been informed that Dartington Research Unit isn t following through on the plan for EC FINAL minutes 07 March 17.docx 3 Page 3 of 5 Overall Page 253 of 282

254 Act.6 engagement with schools. JT will get an update on this. KD highlighted that the voluntary sector have heard about how much the Dartington research programme has cost and it is a sensitive issue in light of many losing funding. JT 8 Children s Services Pre-Procurement Covered above 9 Healthwatch reports 9.1 Healthwatch Torbay A copy of the annual report was handed out. Engagement activity is listed in the report. They have produced a guide to Health and Social Care and copies have been sent to the CCG. IT has been confirmed that current funding is being reduced by 10%. Negative feedback about the care provider Mears UK are still being received. KD has been putting a lot of energy into anything regarding the Health and Wellbeing Centre in Paignton as he thinks this will solve a lot of issues that people are telling Healthwatch about. Healthwatch currently have 38 volunteers and now have to turn away future applicants as they do not have the capacity to give them support. 9.2 Healthwatch Devon The decision has been made regarding the retendering of the Healthwatch Devon contract. The statutory element of the role (lot 1) has been awarded to the current Healthwatch Devon. The engagement by spot purchase element of the contract (lot 2) has been awarded to Living Options Devon. MS handed out copies of Healthwatch Devon s recently published information booklet about NHS consultations. It explains what you can do to have your say and if you disagree with the process, the role of Healthwatch and what to expect. The three local Healthwatch organisations recently wrote to Angela Pedder. They feel they have seen a big difference between the success regime and the way SDT CCG events went, as opposed to how the acute services review has been organised. JT went to the most recent urgent care meeting for the acute services review and was reassured to see that there were several attendees from Healthwatch present. KD chairs the NHS Clinical Senate s citizens assembly for the south west which will also monitor STP progress. RC explained that there is a commitment across the STP to do things better. With the new communications lead in post for the STP things will change for the better. MS is leaving Healthwatch Devon at the end of March. They are interviewing for his replacement in the next few weeks. JT thanked MS for his help and support over the years. 10 AOB - CCG wide patient representatives meeting minutes attached. The CQC are looking for experts by experience which is a paid role for patients. Next Meeting: 09 May 2017, 10:00-12:00, Pomona House Action Summary Action Act.1 CP/ST to provide the committee with an update on the forthcoming Governing Body s review of its members roles. Act.2 JT will schedule to do an update on DPT s engagement reporting to the CCG for the Engagement Committee agenda. Act.3 RC to circulate the communications and engagement plan for STP when approved Act.4 RC explained that there is a document that sets out roles and responsibilities of acute services, based on the questions. RC to circulate this document when approved. EC FINAL minutes 07 March 17.docx 4 Person Responsible Chris Peach / Simon Tapley Jo Turl Ray Chalmers Ray Chalmers Page 4 of 5 Overall Page 254 of 282

255 Act.5 Act.6 Healthwatch would like to be involved in these implementation groups and KD is happy to give time to chair it too. RC to feed this back to Torbay and South Devon Health and Care Trust. JC has been informed that Dartington Research Unit isn t following through on the plan for engagement with schools. JT will get an update on this. Ray Chalmers Jo Turl Attendance List (attended* / apologies A ) Name - initials Title, organisation Members * Kevin Dixon KD Chairman, Healthwatch Torbay A Chris Peach CP Non-executive Director - Patient and Public Involvement, SDTCCG (Meeting Chair) A Pam Prior PP Trustee, Healthwatch Torbay A Ellie Rowe (Dr) ER Clinical Lead for Commissioning, SDTCCG *Miles Sibley MS CEO, Healthwatch Devon A Simon Tapley ST Chief Operating Officer, SDTCCG Regular attendees * Ray Chalmers RC Head of Communications and Strategic Engagement, SDTCCG *Jo Curtis JC Patient Engagement Lead, SDTCCG *Laura Voisey LV Engagement and Equality and Diversity Administrator, SDTCCG (Minute Taker) Attendees when required Marisa Cockfield MC Equality and Diversity Lead, SDTCCG Sam Holden SH Patient Experience Lead, SDTCCG Sam Morton SM Head of Contracting and Procurement, SDTCCG *Jo Turl JT Deputy Chief Operating Officer, SDTCCG Invited in regards to an agenda item Glossary Abbreviation SDT CCG Or the CCG NEW Devon CCG STP ASR PPG DPT TSDFT (ICO) CAMHS CFC Definition South Devon and Torbay Clinical Commissioning Group Northern, Eastern and Western Devon Clinical Commissioning Group Sustainability and Transformation Plan Acute Services Review Patient Participation Group Devon Partnership Trust Torbay and South Devon Foundation Trust (Integrated Care Organisation) Child and Adolescent Mental Health Service Commissioning and Finance Committee EC FINAL minutes 07 March 17.docx 5 Page 5 of 5 Overall Page 255 of 282

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257 Governing Body Report Committee Title Engagement Committee Date 9 May 2017 Chair Chris Peach Recommendation For Approval For Discussion For Information x Key points for the Governing Body to note: Sustainability and Transformation Plan (STP) All the main work streams of the STP are nearly up and running. Central comms & engagement team is developing a plan to encompass all workstreams. Feedback was given on the draft engagement section of the annual report. It was suggested that the report should make it clearer where engagement has influenced change. Jo Curtis (Patient Engagement Lead) is leading the engagement steering group for the children s services re-procurement across the STP area. Work is being done with Devon County Council and Torbay Council to see how representation and voice of people with learning disabilities can be strengthened to feed into the health sub-groups of the Partnership Boards. It was suggested that an annual assessment be completed to assess the reach of engagement on social media. Healthwatch Torbay has been asked by Torbay Council to carry out enter and views in care homes. Healthwatch Devon has a new chief officer and is looking at how things can be done differently. All three local Healthwatches are looking to ensure they have access to specialist staff to support the STP. The CCG s AGM is being advertised via the Participation Update and at each patient representatives meeting. Devon Doctors and the 111 service are looking to form their own patient representatives group. Decisions made by the Engagement Committee: The review of the community consultation process was shared with the group. It was agreed that a public facing version should be created and shared with the CCG-wide patient representatives group. It was agreed that we should look to have a joint STP Engagement Committee and this will be raised at the next joint STP communication leads meeting. Committee GB report Template - Engagement Committee May 2017.doc Page 1 of 2 Overall Page 257 of 282

258 Governing Body Report Sam Holden (Patient Experience Lead) to be invited to the next meeting to discuss the results of the End of life strategy survey. Minutes are enclosed for the meeting/s: March Minutes for the meeting that took place in May 2017 shall be sent when ratified. Committee GB report Template - Engagement Committee May 2017.doc Page 2 of 2 Overall Page 258 of 282

259 QUALITY COMMITTEE (QC) MINUTES Date: Thursday 11 February 2016 Time: 09:30 12:30 Location: Pomona House MR1a Item 1. Welcome and Apologies Apologies and attendance noted [see attendee list at end of minutes]. 2. Declarations of Interest Kevin Muckian declared that his wife, Dr Tricia Allen, sits on SDHFT's Serious Incident Review Panel. 3. Previous minutes and action log It was agreed that the minutes from the meeting held on Thursday 14 January 2016 were a true and accurate record. Outstanding Actions Action 73 on-going action. GG to produce a letter and send to the new commissioner of integrated care as there are on-going problems with waiting times to the lower limb therapy service. Action 87 Discussed at information governance forum. No decision at present for deputies and this will be undertaken end of March/April. On-going action. Action 93 Home oxygen service. ML to send to ST to get an update. The action can be closed if relevant information received. Action On-going action. Update to be received in April Action 102 On-going action. Update to be received in April Action 104 Action closed. Action 105 Action closed. ML to schedule for January 2017 meeting. Action 106 Action closed. ML to schedule for January 2017 meeting. Action 107 Action closed. Action 108 Action closed. Action 109 Action closed. Action 110 Action closed. Action 111 Action closed. Action 112 Action closed. Action 113 Action closed. Action 114 Action closed. Action 115 Action closed. The ICO agreed that community nurses will undertake confirmation of death at nursing homes from May and requested that Devon Doctors out of hours service (Devon Docs) continue with the service until the community nurses take this forward. Training with relevant people will be undertaken. All deaths in a care home must be reported to Devon Docs. 4. Primary Care Quality Report PB gave an update of the report. The practice mergers were noted. Regarding the 12 month requested closed list application from Barton Surgery, NHS England have suggested this is reduced to 9 months. The request for closure for a learning event was declined as this coincided with the junior doctors strike action. There was a discussion regarding GP practices merging and whether this could increase vulnerability and not promote good practice. It was highlighted that GPs not answering their phones had the largest impact on emergency department attendance. It was noted that 3 out of the 4 practices that were merging into the Harbour Medical Group were showing 6 or more outlying data points and this could be a patient safety issue. It was suggested that trajectories for improvement in primary care be produced. Action: PB to send the paper that was distributed to the Joint Committee and the updated heat maps to ML for circulation with the QC minutes. 5. Patient Experience Story AOB read out a patient experience story. The story highlighted that a letter had been incorrectly sent to a patient who had the same name and date of birth as another patient. The story highlighted human error and a question was raised as to why the unique NHS number was not used. A review has been undertaken to alleviate the error occurring in the future. Action GG ML PB Approved Final Minutes.pdf 1 Page 1 of 5 Overall Page 259 of 282

260 Action: SH to contact the Trust to ensure that NHS numbers are used in the future. 6. Patient Experience Report including complaints The patient experience report was noted. There have been several issues relating to gluten free prescribing and recommendations have been provided to OSG which will be confirmed at CFC in the near future. However there will not be a separate paediatric list. SH Regarding the patient leadership network, patient leaders have now been assigned roles within the CCG. The CQC report for Devon Partnership Trust has highlighted that the Trust overall requires improvement There is one outstanding complaint that is with the ombudsman and it is envisaged that this will be returned to the South Devon and Torbay CCG (SD&T CCG) in March. There have been 2 complaints that relate to end of life care which are being discussed. There have been 57 PALS during December and January and one of these relates to the prosthetic service at Royal and Devon Exeter NHS Foundation Trust. Action: AOB to liaise with Tracey Kerslake regarding the prosthetic service. There has been a 125% increase in yellow cards over the year due to promotion of the service and because additional providers are now using it. The highest level of complaints in December and January related to the lower limb therapy service. Action: As agreed under outstanding action 73, GG will produce a letter to send to the new commissioner of integrated care as there are on-going problems with waiting times to the lower limb therapy service. Quality Surveillance Report The report circulated within the board pack was noted. Highlights noted were: Devon Partnership Trust (DPT) There are 7 outstanding incidents over the 60 working day limit for receiving the RCA. A table has been received outlining the proposed date for completion for each incident. The CQC report has highlighted that overall DPT needs improvement but there was a lot of good areas especially secure services. Torbay and South Devon Health Foundation Trust (TSDFT) There are 10 outstanding incidents over the 60 working day limit for receiving the RCA however the situation has improved recently. All prescribing medication yellow cards that are not on the joint formulary will be collated to discuss what further action needs to be undertaken. The A&E friends and family response rate has been recorded as 3.1% with the likely to recommend decreasing to 1%. An action plan has been received. SWAST Only 46% of staff would recommend SWAST and111 as a good place to work. The appraisal rate for staff is being recorded at 51.75% which is low. RD&E There have been 7 serious incidents in December, this may be due to the fact that falls are entered on STEIS and if no reasons are known they are then removed so the level can fluctuate. A CQC report has been undertaken that has shown good results. Plymouth The Trust is recording an 80% appraisal rate. 71% of staff would recommend the Trust as a good place to work. Mount Stuart The figure for the friends and family inpatient rate to be confirmed as this has been recorded at 4%. Action: JM to confirm the friends and family inpatient rate for Mount Stuart AOB GG JM Approved Final Minutes.pdf 2 Page 2 of 5 Overall Page 260 of 282

261 8 Patient Safety Update The report was noted. There have been 6 serious incidents (SI) relating to lower limb amputations for diabetics. Although these are historic, the cases are being reviewed to review the root cause. All lower limb amputations are now recorded as a SI. No never events have been recorded in Q3. A collaborative network has been set up for improving investigations with relevant providers. 9 Risk Report 1 new risk has been added to the risk register. Risk 167 relates to A&E attendance and the risk this could have to patients. This risk is the most serious risk currently for the Quality Committee. The Quality Committee agreed that the following three risks can be closed Risk 55 As there is a good robust process in place, this risk can be closed. Risk 165 Assurance has been gained that reviews for looked after children are being undertaken. Risk 116 policies have now been aligned. Risk 13 on-going risk. Work is being undertaken regarding C.Diff. Risk 72 on-going risk. Placements are being recorded correctly. Risk 142 on-going risk. Work is being undertaken regarding smart recovery and it is envisaged that the likelihood will decrease. Risk 27 JM to review the risk to confirm if this can be reduced to green/amber as a lot of processes are now in place to reduce the risk of pressure ulcers. Risk 130 on-going risk. It was confirmed that another MRSA bacteremia has been reported by the Trust. Risk 131 on-going risk. Work is on-going but there are problems in some specialty areas regarding RTT. Risk to remain as amber. Risk 85 on-going risk. Risk 109 JT to review the risk as further procedures have been cancelled and therefore the likelihood has increased. Risk 108 ST to provide an update regarding Air Liquide. Risk 30 on-going action. It was envisaged that there would not be widespread disruption as norovirus is being managed more effectively. Risk 41 on-going risk. Risk 31 on-going risk. Risk to remain open currently although there are good processes in place. Risk 157 risk to be reviewed by Mark Procter. Risk 159 on-going risk. JM JT ST MP Action: JM to review risk 27 Action: JT to review risk 109 Action: ST to provide an update on risk 108 Action: MP to review risk 157 It was decided that the risk report to be reviewed at the beginning of the quality committee meeting and an agenda item added at the end of the meeting to record any risks that have been highlighted during the meeting. Action: ML to amend the agenda to reflect above. 10 Clinical Effectiveness Report for noting The report was noted. It was discussed that the ambition is to undertake clinical effectiveness as a whole system approach across the community Patient Group Directions (PGD) Authorisation of Policy The papers presented in the board pack were discussed. The committee agreed that as Northern Eastern and Western Devon (NEW Devon) are the main commissioners and have a robust process in place, SD&T CCG do not need to sign off individual PGDs. Once a PGD is signed off by NEW Devon, SD&T CCG to be informed. The committee approved the policy and agreed to sign the Memorandum of Understanding ML Approved Final Minutes.pdf 3 Page 3 of 5 Overall Page 261 of 282

262 once OR had sought clarification that no further scrutiny of the PGDs were required by the committee Assurance from primary care on quality and safety actions issued by national bodies discussion There was a discussion that no assurance is gained from primary care that they have read and understood the information that is issued by national bodies. Highlights are shared with the committee I the medicines optimisation quarterly report and the annual audit cycle will be included I the next report. Although this is currently NHS England s responsibility it relates to SD&T CCG s patients. It was discussed that once primary care is commissioned via individual CCGs an accountable officer will be appointed. 12. Local Authority and Police CSE Dataset There was a discussion around child sexual exploitation (CSE). NT gave an update on the number of children and young people that have been identified; 47 high; 32 medium and 17 low or standard risk. Those identified as high risk are case managed by a CSE lead. The age range was between 9-17 with the largest number being within the age range. The high risk individuals are mainly being identified as female which may mean that identification of males is not as good. Most children are living within a family setting when they are identified by CSE. 25% of those identified as high risk have mental health capacity. 13. Overview of Research Activity and Support from CLRN JR confirmed that he has been given assurance that the 20,000 that has been given to the local clinical network is being used effectively and they are doing as much as they can with the resources available. 14. Safeguarding Adults KG gave an update on the quarterly report. A request was made that the adults and childrens safeguarding report are amalgamated. The committee agreed to the amalgamation of the two reports to be presented to the Quality Committee on a quarterly basis. KG confirmed that processes are being improved regarding the mental health capacity act especially deprivation of liberty safeguarding. Currently 2 safeguarding investigations are being chaired by the CCG and are part of the local safeguarding adults board. 15. Report on visit to Torbay Hospital s Emergency Department (ED) ND gave an update on the visit to Torbay Hospital s ED following concerns regarding potential risks to patient safety. 4/5 patients who were acutely medically unwell had breached the requirement and were not transferred until they were in a stable condition. The situation is exacerbated due to the hospital not having a high dependency bed unit. It was observed that there are problems in the hospital regarding discharge procedures. An action plan has been produced by the Trust that should address some of the issues raised by both the commissioners and CQC. 16. CAMHS The report produced in the board pack was noted. A young person friendly version of the plan is being worked on. Unfortunately as the money for CAMHS was only received in mid- December limited progress has been made. Providers have agreed to work on eating disorders and out of hours on call psychiatry. Money has also been agreed to support parents of children with autistic spectrum disorder. Any money that is not spent during this financial year will be returned. The crisis service is 3 members down which is having a detrimental effect on the service locally. Ways of commissioning CAMHS differently across all areas is being looked at. Virgin are achieving 87% for seeing children within 6 weeks from referral to treatment and 100% for seeing children within 18 weeks from referral to treatment with the average waiting time of 7 weeks. Currently there are 28 children waiting over 18 weeks and 1 waiting over 60 weeks. This issue will be raised at IPAM as the figures do not correspond. Torbay CAMHS have only achieved 48% for their 1 week target for urgent referrals but has met their 18 week target. 8 children are still waiting for treatment beyond 18 weeks. A different mode of care is required for CAMHS. 17. Minutes for Information 17.1 Clinical Policy Committee Approved Final Minutes.pdf 4 Page 4 of 5 Overall Page 262 of 282

263 NICE Planning, Quality and Assurance Group (NPAG) 17.3 Information Governance Forum The above minutes were noted. Any Other Business Safeguarding Children Investigation KG confirmed that Ofsted have approved that the local nursery be reopened. Criminal proceedings are progressing with the alleged perpetrator. All children concerned have been investigated. There is only one on-going investigation. No new risks were raised during the meeting As apologies for the next meeting on Thursday 10 March were received from Nick D Arcy David Churm and Kevin Muckian. ML to check if the committee is quorate and if not a shortened meeting to be arrange the week beforehand to discuss any issues. Action: ML to check that the next meeting will be quorate Date of next meeting: Thursday 10 March 2016 ML ATTENDEES: Committee Members Initials Title Dr Nick D Arcy (Chair)* ND Clinical Lead for Patient Safety and Quality David Churm* DC Patient Safety Leader Gill Gant* GG Director of Quality Assurance and Improvement Karen Grimshaw* KG Director of Families and Wellbeing Commissioning Janet Honey* Patient Safety Leader Simon Knowles SK Non-Executive Director Secondary Care Kevin Muckian* KM Non-Executive Director, Non-medical Clinical Dr. Jo Roberts* JR Clinical Lead for Innovation and Medicines Optimisation Simon Tapley ST Director of Commissioning and Transformation Diane Thyer DT Practice Manager Representative Nanette Tribble* NT Treatment Effectiveness Manager, Public Health Team Attendees Paul Baker* PB Deputy Director of Primary Care Delia Gilbert* DG Designated Nurse for Safeguarding Adults Jo Hooper* JH Joint Commissioning Manager (Children s) Jennie Mills* JM Quality Assurance Lead Amy O Brien* AOB Quality Assurance Project Manager Oksana Riley* OR Medicines Governance and Community Pharmacy Development Lead Mandy Love (minute taker)* ML PA to Director of Quality Assurance and Improvement Approved Final Minutes.pdf 5 Page 5 of 5 Overall Page 263 of 282

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265 QUALITY COMMITTEE (QC) MINUTES Date: Thursday 9 March 2017 Time: 09:30 12:30 Location: Pomona House MR1a and MR1b Item 1. Welcome and Apologies Apologies and attendance noted [see attendee list at end of minutes]. 2. Declarations of Interest There were no declarations of interest. 3. Previous minutes and action log It was agreed that the minutes from the meeting held on 9 February 2017 were a true and accurate record. Actions Action on-going Action 201 closed. CH is taking this forward. Action 203 closed. Action 204 closed. Action: JPJ to ask CB and the ED matron to come to the committee in either April or May to discuss the various pathways to gain assurance of how patient safety is being monitored. 4. Risk Report Risk 212. On-going risk. The risk score needs to be amended to a higher rating following the GB survey on safeguarding. It was noted that there was a lack of knowledge on safeguarding and training with GB should be undertaken as soon as possible. Risk 205. It was agreed that this risk could be closed as the community hospitals consultation process has been completed. A new risk to be added regarding bed configuration. Risk 185. It was agreed that the risk should remain open as NHS England do not provide regular quality monitoring and assurance information to the PCCG. Risk 207 It was agreed that the risk can be closed as the information is now being obtained by the safeguarding team. The risk report was noted. 5. Quality Assurance Flash Reports Action JPJ Torbay and South Devon NHS Foundation Trust (TSDFT) Referral to Treatment (RTT) incomplete pathways are showing as 87.3% against a target of 92%. Challenges in neurology, cardiology, respiratory, orthopaedics, pain management and endoscopy. There has been an increase in the number of yellow cards and PALS complaints regarding RTT RTT over 52 weeks will now be approached in the same way as a never event. There are 9 outstanding RCAs within the whole of TSDFT. These have built up due to sickness; South Devon and Torbay Clinical Commissioning Group (SD&T CCG) have offered assistance. Action: a full list of RCAs and yellow cards to be presented to the next committee meeting. TSDFT to remain red. Mount Stuart (MS) Turnover is above target at 21.3%. A number of new staff are due to start within the outpatients department. Sickness is above target at 5.41%. Action: As there are concerns regarding the high turnover and sickness rates a more detailed report with a breakdown of figures to be present to the next committee meeting. MS have received a draft copy of the Care Quality Commission (CQC) report that they are reviewing for factual accuracy. JD JD Approved FINAL Minutes.pdf 1 Page 1 of 5 Overall Page 265 of 282

266 Agreed to keep as red until the outcome of the CQC report is known. Virgin Care Limited (VCL) No updated data available since the last meeting as Northern, Eastern and Western Devon CCG (NEW Devon CCG) receives data on a bi-monthly basis. Action: GG to discuss ongoing quality assurance mechanisms with LCB. It was agreed to change the status to red due to lack of data provided as this did not give assurance. Royal Devon and Exeter (RD&E) 5 of the 9 cancer standards are unlikely to meet the required targets. A decision has been taken to close the breast care unit due to backlog. A&E 4 hour standard for January is 91% which is below the required 95% target. DPT is looking at capacity regarding waits for the psychiatric liaison service. 18 week RTT is below target. 2 consultant cardiologists have been employed which will improve capacity. Agreed to remain as amber. Action: More detailed information and evidence to be reported at next month s meeting. Integrated Urgent Care Service (IUCS) An average of 90% of calls are answered within 60 seconds. There are still issues with weekend calls due to unpredictable demand. However as modelling will be in-house from 1 April it is hoped that this will improve. A CQC inspection has been undertaken and it is thought that this went well. Agreed to remain as green. South Western Ambulance Service NHS Foundation Trust (SWASFT) There are real quality issues that are affecting ambulance delays and there have been a number of incidents across the SWASFT footprint which has resulted in patients death. This significant risk has been escalated to the Quality Surveillance Group (QSG). There have been significant handover delays from health care providers and these have been escalated to the March QSG meeting. Retention of paramedics in border areas are causing problems. There has been negative feedback regarding working patterns across all areas although there has been an increase in staff morale. Agreed that the RAG rating to change from amber to red. Action: An update to be provided at the next meeting regarding QSG feedback and what remedial actions have been put in place in relation to the concerns raised. Devon Partnership Trust (DPT) Concerns raised regarding the increase in the number of assaults and suicides. DPT are now an outlier regarding suicides within their area. A letter will be sent to DPT to gain assurance. A quality summit has been arranged for 15 March to discuss the CQC inspection report. Concerns raised that as some funding will stop in March this may have an impact on the internal investigations team handling complaints in a timely manner. As this will be a shared contract from April with NEW Devon, shared intelligence will provide better assurance as currently SD&T CCG only have access to their own data. Agreed to remain as red. Action: SH to report CQC findings at the next committee meeting. Plymouth Hospitals NHS Trust (PHT) The new Integrated Performance and Assurance Meeting (IPAM) has begun which will mean that SD&T CCG will be better sighted on any issues. The IPAM meeting has not occurred since November. Action: GG to discuss ongoing quality assurance mechanisms with LCB. There is a good level of performance in respect of staff morale and patient feedback. GG SH SH SH GG Approved FINAL Minutes.pdf 2 Page 2 of 5 Overall Page 266 of 282

267 There are pressures with RTT performance The flash reports were noted. 6. Patient Experience Report There has been a decrease in formal complaints. The target of case duration is 45 days with the current average being 46 days. There have been no complaints to the ombudsman either this or the previous period. There has been 2 formal complaints for TSDFT and 1 for the Devon Referral Support Services (DRSS). Identified learning from complaints is that communication has been poor therefore a master class has been arranged to include customer service skills. All providers will be invited to attend. The number of informal enquiries has decreased over the period. There has been an increase in the number of formal enquiries for NHS England s (NHSE) services especially dental services. There has been an increase in communication regarding the way in which the CCG communicated its plans for self-care and repeat medication. There have been 118 yellow cards which is a huge increase from previously. The end of life experience survey will remain open until the end of April. There is variable experience regarding end of life care with key themes identified as lack of communication and involvement in decision making. The report was noted. 7. Safeguarding Children Quarterly Report CH presented the safeguarding quarterly report. There were no questions. The report was noted. 8 Feedback from the Governing Body (GB) Survey regarding Safeguarding 9 out of a possible 16 responses received. The results did not give assurance regarding the level of knowledge of board level safeguarding responsibilities and general safeguarding knowledge by GB members. It was agreed that this needs to be highlighted to GB and training arranged as soon as possible. 9. Safeguarding Children Policy The policy has been updated to include a section on disabilities following the Section 11 Report. There is now a link regarding safeguarding risks around social media and reference to looked after children has now been removed as safeguarding children have their own policy. The revised policy was approved. 10. Safeguarding Children Training Needs Analysis It was confirmed that the embedded link would be added to the report once the report was approved. The report to be amended to confirm that GB needs to undertake level 1 training. The report was approved with the caveat that the link is embedded. 11. Information Governance KK presented the following reports for approval. All the reports contained minor amendments. (a) Confidentiality and Data Protection Policy (b) Corporate Governance and Freedom of Information Policy (c) Information Governance (IG) Strategy Policy (d) Information Governance Management Framework Policy (e) Information Lifecycle Management Policy (f) Information Governance Workplan (g) N Drive Risk Assessment 2016 Policy (h) Risk Review Report for Information Assets February 2017 Report ND The confidential and data protection policy will be undergoing a major review in May. It was discussed that the CCG will not be able to charge for a general access request in the future unless they can establish that it would take a reasonable time to comply. Information governance compliance is currently recorded as 85% against a target of 95%. The above policies were approved. It was agreed that all changes need to be highlighted or the report to have a front page Approved FINAL Minutes.pdf 3 Page 3 of 5 Overall Page 267 of 282

268 drawing attention to the changes. 12. Equality & Diversity including Quality & Equality Impact Assessments (QEIA) update MC gave an update. Time has been spent on establishing the QIEA tool at sustainability and transformation plan (STP) project workstream level. Decisions are being made as to whether to adopt the QEIA tool across the STP. Work is being undertaken with TSDFT to confirm adoption of the wider process. Work is continuing with the equality co-operative that includes equality and diversity leads from TSDFT, DPT and NEW Devon working together to support diversity strategies to ensure that statutory responsibilities are being met. The equalities co-operative is an informal committee that drives forward the equality agenda. Recent successes included being part of the Be Active Be Safe (BASH) awards. The annual blue light day which hosts a day of activities and is linked with training for local primary schools to be active, safe and healthy will be undertaken. This event is funded by Devon and Cornwall Police who have put 5000 towards it. Contact has been established with Exeter mosque to undertake multi-faith work. Work is being undertaken with Torbay deaf club regarding access to primary and secondary care. The verbal report was noted. 13. New NICE guidance re end of life care for the dying child SCu presented the report regarding commissioning of services for children who are at the end of their life. The report noted the new National Institute for Health and Care Excellence (NICE) guidance regarding end of life care for the dying child. The NICE report recommends that there should be a specialist palliative care consultant locally as well as a named specialist nurse for paediatric palliative care. However there is a lack of specialist palliative care consultants in the South West Peninsula and only around five level 4 specialists across the whole country. Torbay does not have a named specialist nurse for paediatric palliative care although all nurses are trained to provide it. Torbay does have a paediatric pharmacist who has experience of end of life care. The NICE report recommends that access to nursing care should be available 24/7 however the service in Torbay runs from 09:00 17:00 Monday to Friday. It was noted that most children who have a life limiting or life threatening condition are referred to the Children s Hospice South West (CHSW). CHSW are looking to recruit a Level 4 palliative care consultant. The report was noted. 14. Transforming care for people with Learning Disabilities SCh provided an update on the placed people deep dive that had been undertaken. The deep dive was undertaken to identify good and poor practice; to consider whether an admission could have been avoided; to consider whether a package of care could have been less expensive and to test the thoroughness of existing panel arrangements. 3 deep dives were undertaken with patients with different care needs. The findings from the investigations have led to changes in care packages and services and an action plan. The action plan is reviewed monthly with the Place Peoples Governance Group (PPGG). Further six monthly deep dives will be undertaken. The report was noted. 15. Minutes for Information (I) NICE Planning Advisory Group (NPAG) It was noted that neither TSDFT nor Northern Devon Healthcare NHS Trust (NDHT) has provided a response to motor neurone disease NICE recommendations Approved FINAL Minutes.pdf 4 Page 4 of 5 Overall Page 268 of 282

269 The minutes were noted. 16. Agreed Risks to be escalated to Governing Body DPT s and SWAST s quality surveillance RAG ratings have now been changed to red. Most provider s quality surveillance RAG ratings are now being recorded as red. Following the GB survey on safeguarding, it was noted that there is a lack of knowledge at GB of safeguarding and the recommendation is that training should be undertaken as soon as possible. 17. Any Other Business (I) There was no other business. Date of next meeting: Thursday 13 April 2017 ATTENDEES: Committee Members Initials Title Dr Nick D Arcy (Chair)* ND Clinical Lead for Patient Safety and Quality Cathy Bessent A CB Deputy Director of Nursing, TSDFT Felix Burden* FB Non-Executive Director David Churm* DC Patient Safety Leader Gill Gant A GG Director of Quality Assurance and Improvement Kevin Muckian* KM Non-Executive Director, Non-medical Clinical Pam Prior A PP Trustee Healthwatch Torbay Dr Jo Roberts* JR Clinical Lead for Innovation and Medicines Optimisation Simon Tapley A ST Director of Commissioning and Transformation Nanette Tribble* NT Treatment Effectiveness Manager, Public Health Team Attendees Shona Charlton* SCh Senior Commissioning Manager, Joint Commissioning Marisa Cockfield* MC Equality & Diversity Lead Scarlett Curtis* SCu Commissioning Support Officer for Joint Commissioning Sam Holden* SH Quality Assurance & Patient Experience Lead Cathy Hooper* CH Designated Nurse Safeguarding Children Kenny Kennington* KK IT Operations Manager JoAnne Panitzke-Jones* JPJ Head of Quality, Safety & Experience Ellie Rowe* ER Clinical Lead for Commissioning Lorraine Webber* LW Deputy Director of Quality Assurance and Improvement (Lead Nurse) Mandy Love (minute taker)* ML PA to Director of Quality Assurance and Improvement Approved FINAL Minutes.pdf 5 Page 5 of 5 Overall Page 269 of 282

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271 QUALITY COMMITTEE (QC) MINUTES Date: Thursday 13 April 2017 Time: 09:30 12:30 Location: Pomona House MR1a and MR1b Item 1. Welcome and Apologies Apologies and attendance noted [see attendee list at end of minutes]. 2. Declarations of Interest There were no declarations of interest. 3. Previous minutes and action log It was agreed that the minutes from the meeting held on 9 March 2017 were a true and accurate record. Action 4. Actions Action 212 NEW Devon had stood down the IPAM meetings as they have embedded staff within the provider to gain assurance. GG and LCB are working together to write a new strategy. Action closed. Risk Report 2 new risks have been added to the register and there are 18 risks that report to the Quality Committee Risk There is a risk that patients attending A&E during time of high activity and poor 4 hour wait performance may have comprised quality of care and safety. Currently A&E performance has much improved and there is less of a risk to the quality of patient care and safety. It was agreed that the likelihood can be reduced due to better performance. Risk 214 There is a risk that the deteriorating financial position within Torbay and South Devon NHS Foundation Trust (TSDFT) will have an adverse effect on patient safety and quality of care provided within the integrated care organisation. After discussion it was agreed that as this risk does not just relate to TSDFT and the risk to be reworded to read There is a risk that the deteriorating financial position within the health community whole system will have an adverse effect on patient safety and the quality of care provided. Action: GG to request SD changes the wording. Risk 184 Primary care quality and safety of services. It was agreed that the adequacy score could be reduced as work is being undertaken to produce a primary care quality monitoring tool. Risk 201 Mount Stuart CQC rating. A meeting has been undertaken to look at the action plan regarding CQC recommendations. Action: JD to confirm that the adequacy score is recorded correctly. Risk 164 Increase in spam being received that contains malware. As it was indicated that a new contract would be in place from April that would alleviate this position, KK to be invited to the next quality committee to give an update. Action: ML to invite KK to next quality committee to provide an update on malware. Quality Assurance Flash Reports Torbay and South Devon NHS Foundation Trust (TSDFT) A&E performance for February was recorded as 89.2% which is an increase on the January position. Indications are that the A&E performance for early April was 95%. There is a potential for growth in patients who are reported as waiting over 52 weeks as the foot and ankle surgeon has resigned. Agreed to rate the Trust as green as there is no impact or concerns around quality although the Trust are not hitting their required targets. The CCG have been invited to be part of the 52 week root cause analysis (RCA) reviews. It was requested that the next monthly report includes the stillbirth cluster as there GG JD ML Approved FINAL Minutes.pdf 1 Page 1 of 6 Overall Page 271 of 282

272 have been 5 during the first 2 months of this year and a further 2 since this date. An independent investigator has been appointed to undertake a review of all stillbirths. Action: JD to add stillbirths data to the next monthly report. Mount Stuart (MS) The CQC re-inspection visit that was held at the end of March has rated MS as inadequate overall. The following was reported: - Safe requires improvement - Effective requires improvement - Caring Good - Responsive Good - Well-led inadequate A meeting has been undertaken with the matron and general manager and an action plan in response to the CQC report has been produced. Monthly meetings will continue to look at the action plan to ensure that the actions are embedded. The action plan covers all areas and MS have appointed a quality improvement coordinator. A CQC inspection was also undertaken in March 2016 and the latest CQC report has highlighted that some of the actions had not been embedded as well as they thought they should be. The committee raised concerns regarding the improvement that is required in surgery and that MS is not well-led. There was a discussion around consultants not following protocol for patients that have been commissioned via NHS services. A check is required against the consultants national results as this need to be cross-referenced to their performance at MS. A check also needs to be undertaken that consultants are signed up to their disciplines at the Royal College of Surgeons Action: JD to gain further information regarding the evidence against these actions. It was requested that peer review information be included as part of their audit plan as currently this is not happening and would provide further evidence. Action: JD to get a copy of the audit. Mount Stuart has been rated as amber. Mount Stuart Workforce Metrics Exception Report JD presented the paper as turnover and sickness at MS was high for a period of time. Turnover is gradually decreasing over time as this was due to natural wastage and staff retiring. In January there were a number of new starters and a recruitment drive undertaken. There have been a number of long term sicknesses however this is consistently reducing. A trajectory plan for each of these metrics has been produced and will be monitored. Virgin Care Limited (VCL) CAMHS RTT is being recorded as 94.2% for Devon which is an improvement across Devon as a whole. An ombudsman complaint has been upheld in regards to the assessment process for autism. A deep dive will be undertaken. As there were concerns from VCL regarding the governance arrangements, SD&T CCG have agreed to take on the running of the quality sub-group. VCL have been rated as green. Royal Devon and Exeter (RD&E) Of the 9 cancer standards, 5 will not be met as a result of the breast care unit being closed temporarily. 4 hour performance has improved from last month but is recorded as 91.89% against a target of 95%. As SD&T CCG are associate commissioners for this contract and NEW Devon lead on it, formal communication is undertaken regarding any problems arising to gain assurance. RD&E have been rated as green. Integrated Urgent Care Service (IUCS) Performance remains good with 92% of calls being answered within 60 seconds against JD JD JD Approved FINAL Minutes.pdf 2 Page 2 of 6 Overall Page 272 of 282

273 a target of 85%. The number of ambulance dispatches has reduced. There has been no negative input experienced from a reduction of treatment centre locations. There has been negative feedback that a 111 call handler gave inappropriate advice which led to a patient s health deteriorating. Recruitment is being undertaken for clinical leads in commissioning. IUCS have been rated as green South Western Ambulance Service NHS Foundation Trust (SWASFT) SWASFT have been rated as green. There have been some significant ambulance attendance delays some of which have resulted in the death of patients. This has been escalated to QSG. Ambulance delays are a national issue. Meetings have been undertaken between Gloucester and Dorset CCGs to discuss commissioning of SWASFT. Data has been provided to mitigate some of the issues. Devon Partnership Trust (DPT) DPT have been rated as amber overall DPT received an overall rating of good in the CQC re-inspection. A deep dive has been undertaken regarding the increased incidents of suicides by patients either within the DPT service or awaiting referrals, this has given a level of assurance. The CQC re-inspection focused on acute wards for adults of working age and psychiatric intensive care units (PICUs); wards for people with learning disabilities or autism; wards for older people with mental health problems; community based mental health services for older people and mental health crisis services and health-based placed of safety. DPT was assessed on whether each service was safe, effective, caring, responsive and well led. Overall 1 area requires improvement, 1 area was outstanding and the rest of the areas were rated as good. Plymouth Hospitals NHS Trust (PHT) PHT have been rated as green. There has been a decrease in the number of A&E attendances. PHT ran a successful perfect week in February which highlighted a lot of silo working within departments. However the learning has been embedded within PHT s workplan. PHT continue to see a sharp increase in delayed transfers of care. PHT are not on track with its CQC action plan following the refocused re-inspection in late As PHT has misinterpreted national guidance regarding transfers of care, SH to gain assurance that this has not happened in other areas and will report back to the next quality committee meeting. The flash reports were noted. 6. New joint Devon policy for persistent and unreasonable communication It was agreed not to adopt this policy but to merge the current policy that SD&T CCG uses. The title of the current policy to be amended to read persistent and unreasonable rather than vexatious and to be made a stand-alone policy. The amended policy to be used by both SD&T and NEW Devon CCGs. Action: SH to amend the policy and share with NEW Devon. 7. Primary care quality monitoring SH shared the tool that NHS England has developed that shows primary care quality and what should be monitored. The tool does not include patient experience and feedback although complaints are included. This will be a good intelligence tool and is presented to the primary care quality and sustainability hub. It was agreed to continue to develop the tool and for it to be presented to the quality committee periodically. 8 CQUIN update JD gave an update on Q3 CQUIN achievement for TSDFT and DPT. SH Approved FINAL Minutes.pdf 3 Page 3 of 6 Overall Page 273 of 282

274 TSDFT TSDFT did not achieve antimicrobial resistance and antibiotic stewardship but this will be continued next year. TSDFT did not achieve in-patient sepsis, 1 hour antibiotic and screening of patients although TSDFT are working towards a new sepsis bundle. TSDFT missed the uptake of flu vaccinations by 3%. It was agreed that sepsis to be part of the quality committee flash report next month if they fail to hit targets. Action: LW to look into sepsis bundle and the findings to be reflected in August s report for paeds and adults. LW to become a member of the sepsis review group. The appropriateness of antibiotic prescribing discussed and it was agreed that meds optimisation to present a report to quality committee in June. Action: OR and LS to bring back a plan on how both TSDFT and primary care are tackling the antibiotic prescribing issue and how this will improve in the future. DPT DPT met all their targets for Q3. LW OR/LS The reports were noted. 9. Caldicott Guardian report GG gave an update and confirmed that there has been a new set of guidance. A log of Caldicott activity is recorded on IKnow. No Level 2 incidents have been reported by the CCG and there has been no security breaches regarding patient identification. The report was noted. 10. Looked after children (LAC) report LV presented the three reports. Looked after children is now reported separately, there is a looked after children policy as well as a training needs analysis skills and competencies. The training for looked after children will be delivered alongside the training for safeguarding children. The lack of data from South Devon has been escalated to Devon County Council. There is also a risk that LV cannot provide assurance that the governing body is compliant with their competencies for looked after children and therefore a training pack will be undertaken with governing body. The report outlines workstreams that are currently being undertaken. Tier 4 CAMHS provision discussed. Watcombe Hall was adult provision but then morphed into providing tier 4 in-patient provision for children and young people. LV has been providing support and has identified that some of their safeguarding processes were not robust. Another 10 bedded provision will be opened in Chudleigh on 1 May, this will have 8 general and 2 HDU beds and the learning from Watcombe Hall will be embedded and all functions will be in place. Chudleigh will open with 2 beds and increase provision over a period of time. The Huntercombe group has invested in their quality assurance processes and has employed a new director of nursing; a director of quality and some regional quality leads. There will be 2 level 4 named safeguarding nurses on each site. Unaccompanied asylum seeking children national transfer scheme is still being undertaken and Devon will be receiving children. The reports were noted Looked After Children Policy The policy was approved. 11. Meds Optimisation report There has been 1 patient safety alert regarding the use of Valproate in girls and women of child bearing age.. The surgeries have received the initial CAS alert and there is a plan of how to implement the actions that have been suggested. This alert will be formally presented in the next report to the quality committee. A reminder will be put in the GP newsletter. TSDFT have reported that they are experiencing a decline in the reporting of incidents but Approved FINAL Minutes.pdf 4 Page 4 of 6 Overall Page 274 of 282

275 an action plan is in place to find out why this is happening. Rowcroft and Mount Stuart medication incidents are currently reported on a quarterly basis however as there are so few incidents it was suggested that this should be reported annually. It was agreed that if it was a serious incident it would need to be reported within the quarterly timeframe however if it was trend analysis or lower level incidents these could be reported annually. It was agreed that Meds Optimisation should attend the quality risk surveillance group. Action: Maia Chammings to invite OR to the quality surveillance group. MC The report was noted. 12. Influenza update LW gave an update. The over 65 uptake was down although the at risk and pregnant women categories were slightly up. Overall the results were not has good as hoped for but were as expected. In Somerset where there had been a large increase in uptake ie pregnant women, there had been a mandate that all women attending antenatal clinics should be offered the vaccine. There has been a request from TSDFT to allow respiratory consultants to undertake vaccination of at risk patients. To move this forward and to increase update next year, a meeting has been set up between NHSE, the consultants and the ADM for obstetrics and gynaecology. It was confirmed that most vaccines were delivered in either primary care or at the pharmacy. There will be changed for the 17/18 programme and the morbidly obese or those that have a BMI of 40 or above will become part of the at risk group. Reception year children aged 4-5 will be offered flu vaccinations in class rather than general practice. School year 4 children, aged 8-9, as part of the phased roll-out of the children s programme will also be offered the vaccination. It was suggested that there are gaps in care home staff and nurses taking up the flu vaccination. LW to take forward the system wide approach to flu vaccinations to protect both patients and staff. As the initiative of one care home one practice relationship is now being undertaken it was suggested that general practices should be alerted to the issue of non-uptake of care home workers vaccinations. Action: LW to discuss with Caroline Dimond and Virginia Pearson that as part of the winter planning whether the voucher scheme for care home and front-line health and social care workers will be reintroduced. 13. Primary care quality dashboard The report was noted. 14. Equality Cooperative update The report was noted. 15. Minutes for Information (I) NICE Planning Advisory Group (NPAG) The minutes were noted. 16. Agreed Risks to be escalated to Governing Body TSDFT failed their CQUIN for antimicrobial resistance and antimicrobial stewardship and their antibiotic screening and administration of sepsis inpatients. The number of stillbirths in maternity. Action: GG to discuss with NT whether Public Health England is looking at high risk births and the link to obesity. 17. Any Other Business (I) There was no other business. LW GG Date of next meeting: Thursday 11 May Approved FINAL Minutes.pdf 5 Page 5 of 6 Overall Page 275 of 282

276 ATTENDEES: Committee Members Initials Title Dr Nick D Arcy (Chair)* ND Clinical Lead for Patient Safety and Quality Cathy Bessent A CB Deputy Director of Nursing, TSDFT Felix Burden* FB Non-Executive Director David Churm A DC Patient Safety Leader Gill Gant* GG Director of Quality Assurance and Improvement Kevin Muckian* KM Non-Executive Director, Non-medical Clinical Pam Prior* PP Trustee Healthwatch Torbay Dr Jo Roberts* JR Clinical Lead for Innovation and Medicines Optimisation Simon Tapley A ST Director of Commissioning and Transformation Nanette Tribble A NT Treatment Effectiveness Manager, Public Health Team Attendees Jennie Dodge* JD Quality Assurance & Patient Safety Lead Demelza Grimes* DG Medicines Optimisation Pharmacist Sam Holden* SH Quality Assurance & Patient Experience Lead Oksana Riley* OR Medicines Governance & Community Pharmacy Development Lead Linda Village* LV Designated Nurse Looked After Children Lorraine Webber* LW Deputy Director of Quality Assurance and Improvement (Lead Nurse) Mandy Love (minute taker)* ML PA to Director of Quality Assurance and Improvement Approved FINAL Minutes.pdf 6 Page 6 of 6 Overall Page 276 of 282