NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body Friday 29 September 2017,

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1 NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body Friday 29 September 2017, The Annex, Tomlinson Centre, Queensbridge Road, London, E8 3ND Chair: Dr Clare Highton, CCG Chair AGENDA Please look over the agenda and think about which of these topics might present an area of interest for you. This means an item where a decision or recommendation made may advantage you, your family and/or your workplace. These advantages might be financial or in another form, perhaps the ability to exert unseen influence. Where anything on the agenda has the potential to put you in such a position, or raised in the meeting along the way, you should tell us all about it. This means we can ensure that our decision, recommendations or actions can be guarded from the impact of any possible conflict you or others could have and be seen to be so. If you are unsure it is always best to raise the possibility with the chair before the meeting, or at any point during the meeting if a possible interest strikes you. This openness is important as we can all discuss how to manage decision making in a complex environment and learn together how to manage these issues well. We are agreed that we will all challenge each other on areas of interest or possible conflict as we recognise that sometimes these issues can be overlooked. Agenda Items Led by & Appendix number 1. Welcome, introductions and declarations of interests Clare Highton Verbal Timing (5 mins) 2. CCG Committee business: a. Minutes of the last meeting; b. Action tracker; c. Register of Interests; d. Matters arising. Clare Highton Papers 2a, 2b & 2c Pages (5 mins) 3. Questions from the public Clare Highton Papers 3a, 3b & 3c (5 mins) Pages Board Assurance Framework Sunil Thakker Papers 4a & 4b (10 mins) Pages FOR DECISION Chair: Dr Clare Highton Chief Officer: Paul Haigh

2 5. New Shared Commissioning Arrangements for North East London Clare Highton Papers 5a, 5b, 5c, 5d & 5e Pages (15 mins) 6. CCG Specific Commissioning Intentions 2018/19: Consultation on payment development for the East London Health and Care Partnership. Clare Highton / David Maher / Sunil Thakker Paper 6a Pages (15 mins) /18 Risk Share arrangements Sunil Thakker Papers 7a & 7b (10 mins) Pages CCG Improvement and Assessment Framework update: Integrated Assessment Framework (IAF) Cancer Improvement Plan. Clare Highton / Anna Garner / Siobhan Harper Papers 8a & 8b Pages (15 mins) 9. Prescribing in primary care consultation Haren Patel / Rozalia Enti Paper 9a (10 mins) Pages Payments for 111 Service Appendices available from Richard Quinton / Lee Walker Paper 10a Pages (10 mins) 11. Recommendations from the Contracts Committee Catherine Macadam Paper 11a (5 mins) Pages Chair: Dr Clare Highton Chief Officer: Paul Haigh

3 12. CCG Policies: Conflicts of Interest Policy; Complaints Policy; Joint Working with the Pharmaceutical Industry. Matthew Knell Paper 12a Pages (10 mins) 13. CCG Chair election process and changes to the CCG Constitution Clare Highton Paper 13a Pages (10 mins) FOR DISCUSSION 14. CCG Finance update Sunil Thakker / Philippa Lowe Paper 14a (10 mins) Pages Integrated Commissioning update Paul Haigh Verbal (10 mins) FOR INFORMATION 16. Refresh of CAMHS Local Transformation Plan and KLOEs Clare Highton Paper 16a Pages (5 mins) 17. June 2017 NHS England Assurance Meeting Paul Haigh Paper 17a (5 mins) Pages Chair: Dr Clare Highton Chief Officer: Paul Haigh

4 18. Updates and minutes from other bodies: a. Minutes of the Wednesday 2 August 2017 Hackney Integrated Commissioning Board; b. Minutes of the Wednesday 2 August 2017 Integrated Commissioning Boards; c. Minutes of the Wednesday 2 August 2017 City Integrated Commissioning Board; d. Minutes of the Wednesday 26 July 2017 East London Health and Care Partnership STP Board; e. Minutes of the Wednesday 23 August 2017 East London Health and Care Partnership STP Board. Clare Highton Papers 18a, 18b, 18c, 18d & 18e Pages (5 mins) 19. Updates and minutes from Subcommittees of the Governing Body: a. Update from the Thursday 27 July 2017 Public and Patient Involvement Committee; b. Minutes of the Friday 30 June 2017 Local GP Provider Contracts Committee (Part One); c. Update from the Thursday 13 July 2017 Audit Committee; d. Update from the Wednesday 26 July 2017 and Wednesday 30 August 2017 Finance and Performance Committees; e. Update from the Friday 28 July 2017 Safeguarding Group; f. Update from the Wednesday 13 September 2017 Clinical Executive Committee. Clare Highton Papers 19a, 19b, 19c, 19d, 19e & 19f Pages (5 mins) 20. Friday 27 October 2017 draft CCG Governing Body agenda Clare Highton Paper 20 Pages (5 mins) 21. Any Other Business: Member availability for meeting on Friday 22 December 2017; Moving Friday 30 March 2018 meeting to Friday 23 March 2018 due to bank holiday. Clare Highton Verbal (10 mins) Chair: Dr Clare Highton Chief Officer: Paul Haigh

5 Paper Title CCG Committee business, incorporating: Paper 2a - Minutes of the last meeting; Paper 2b - Action tracker; Paper 2c - Register of Interests. Paper Author Matthew Knell Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) Standing items of the CCG Governing Body, comprising the previous meetings minutes for discussion and approval, the current action tracker for discussion and the latest Register of Interests. Purpose (delete unnecessary) Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) For approval and information The Governing Body is hereby asked to: 1. Discuss and agree any needed changes to the previous meetings minutes, decisions and/or actions; 2. Agree the previous meetings minutes as a true record of the discussions, potentially on the condition that any changes are actioned. 3. Recognise and discuss the current action tracker arising from previous Governing Body meetings; 4. Recognise and raise any issues with the latest Register of Interests. Where else has this paper been discussed? Not applicable What was the outcome of previous discussions? Not applicable Chair: Dr Clare Highton Chief Officer: Paul Haigh

6 DRAFT MINUTES OF THE NHS CITY AND HACKNEY CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING HELD ON FRIDAY 30 JUNE 2017 AT THE ANNEXE, TOMLINSON CENTRE, QUEENSBRIDGE ROAD, LONDON, E8 3ND PRESENT: Dr Clare Highton (CCG Chair) Dr Haren Patel (CCG Clinical Vice Chair) Dr Gary Marlowe (CCG Governing Body GP) Mariette Davis (CCG Lay Member for Governance) Sue Evans (CCG Associate Lay Member for Governance) Dr Christine Blanshard (CCG Governing Body Secondary Care Consultant) Siobhan Clarke (CCG Governing Body Nurse) Paul Haigh (CCG Chief Officer) Sunil Thakker (CCG Joint Chief Financial Officer) IN ATTENDANCE: Penny Bevan (LBH and CoL Director of Public Health) Jon Williams (Hackney HealthWatch) David Maher (CCG Deputy Chief Officer) Matthew Knell (CCG Head of Corporate Services) Richard Bull (CCG ) for agenda item 7 APOLOGIES: Catherine Macadam (CCG Lay Member for Public and Patient Involvement) Honor Rhodes (CCG Lay Member) Gail Beer (City of London HealthWatch) Philippa Lowe (CCG Joint Chief Financial Officer) Agenda Item 1 Welcome, introductions and declarations of Interests Dr Clare Highton (CH), the CCG Chair welcomed members to the July 2017 meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body (GB). Three members of the public were in attendance at the meeting. Apologies were noted and CH confirmed that the GB was quorate for decisions. Paul Haigh (PH) noted that he would cover the agenda items allocated to Honor Rhodes (HR) in her absence. CH acknowledged that the GPs present at the meeting held conflicts of interests as providers of primary care, but that there were no agenda items where discussions would be specifically impacted by this. Chair: Dr Clare Highton Chief Officer: Paul Haigh

7 Agenda Item 2 CCG Committee business Minutes of the last meeting The CCG GB accepted the minutes of the previous meeting as a true record of the meeting. Register of Interest The CCG received the latest register of interests and acknowledged the declarations contained within, plus those highlighted at the start of the meeting. Action Tracker The GB received the action tracker, noting the updates provided and outstanding actions that would continue to be pursued. Matters Arising Sunil Thakker (ST) briefed the GB that the finance team was still looking into what support would be required this year for the East London Health and Care Partnership (ELHCP). CH added that 2 million of the Health Education England (HEE) underspend had been redirected to support ELHCP. No further matters arising were discussed. Agenda Item 3 Questions from the public Michael Vidal (MV), in attendance as a member of the public, drew the GBs attention to the question circulated with papers he had posed: Has NHS England given any indication as to when they will lift the pause on the Integrated Commissioning arrangements as the temporary arrangements are not ideal? CH responded that the CCG was not aware of any impending change to the ongoing pause. Paul Haigh (PH) added that the CCG was still moving forward with its integrated commissioning programme of work and that the Integrated Commissioning Boards (ICBs) were happy with the current arrangements. MV asked if the current arrangements were impacting on the CCGs ability to reach timely decisions, with matters flowing through a number of partners for discussion. CH responded that recommendations from the ICBs were coming to the GB and that any future of pooling finances would happen on an incremental basis with full partner support. Chair: Dr Clare Highton Chief Officer: Paul Haigh

8 Stuart Maxwell (SM), in attendance as a member of the public, asked whether the lack of a legal status for ELHCP was likely to pose issues, especially when working with, for instance, Health and Wellbeing Boards (HWBs), which do have a statutory setup and powers. CH responded that the CCG was not aware of any move to bring Sustainable Transformation Plan (STP) organisations like ELHCP to a statutory footing, and that it was looking likely that this would have little impact on City and Hackney, where we formed our own area under ELHCP and where ICBs covered similar ground. No further questions from the public were received. Agenda Item 4 Board Assurance Framework Summary The GB received the latest summary Board Assurance Framework (BAF), with changes since the last iteration covered in the circulated paper. Mariette Davis (MD) welcomed the very useful summary, highlighting the use of risk tolerances very useful for the GB in particular. CH noted that there was a lot of work underway in the Continuing Healthcare (CHC) area, including a national review and asked whether the GB could programme in time to debate this soon. ACTION: GB discussion of CHC to be placed on the forward plan for a future meeting. Christine Blanshard (CB) noted that risk from the BAF relating to increased numbers of young people self harming and asked how this related to the GB. CH responded that this sad issue was impacting on local services and becoming a real concern for local clinicians and the public. CB responded that this could be clearer in the BAF. GM added that this matter was also manifesting as an increase in accident and emergency (A&E) presentations and use of the local crisis team. CB responded that perhaps the risk could be better framed as insufficient capacity to address this matter, not local patients self harming. GM agreed, adding that the impact on local professionals is worrying as well. PB added that the local authority is also concerned about the impact on local schools as well. CH flagged that the local authority had recently secured a successful bid for 2 million for adolescent mental health support. GM asked when the review of maternal deaths was due. CH responded that a review was currently underway and early results indicated that there was likely to be no avoidable factors to report, but that full external review results would be discussed at a future meeting. CH noted that the area had reported one maternal death in each year for the last two years, with the other maternal deaths being of a historic nature. Siobhan Clarke (SC) asked if there needed to be any risk added to the BAF regarding the implementation of a single Accountable Officer (AO) across ELHCP CCGs. CH responded that perhaps this could be covered in the changes to the commissioning system risk. CH highlighted that there is an emerging risk in relation to the CCGs Looked After Children (LAC) service, with the current team behind on their reviews. The CCG will be taking the Chair: Dr Clare Highton Chief Officer: Paul Haigh

9 Designated Nurse for LAC into the organisation and a further update will be provided to the GB in the future. ACTION: LAC service to be added to the GB forward plan for future discussion. Cynthia White (CW), in attendance as a member of the public, flagged that there might be concern regarding the future of safeguarding in an integrated commissioning environment. CH agreed, noting that this was an area the CCG was already actively exploring. CW asked whether the CCG was monitoring risks around the implementation of the 8 to 8 GP service locally, with the recognised risks of recruiting GPs already present and this addition possibly impacting further. CW flagged that the single City of London GP practice had already lost one GP partner to a career break recently. CH agreed that this was a concern and that more information on the CCGs plans for an 8 to 8 service would be available at a future GB meeting. Agenda Item 5 North East London Sustainability and Transformation Plan PH briefed the GB on the latest progress with ELHCP, noting that NHS England (NHSE) appeared to be pleased with the progress made in the region. CH added that the region wide Clinical Senate meeting had held a very productive session on clinical outcomes and that the co-ordinated work on maternity services across the area was also proving to be very helpful. CH continued that the early work coming from the production of a mental health strategy was also interesting. Jon Williams (JW) flagged that Hackney HealthWatch (HHW) had met with ELHCP regarding their concerns on local communications and engagement. While that meeting had not proven to be very substantive, the STP team seemed to take on-board HHW s feedback. JW continued that, positively, ELHCP were not talking about cuts to services, only efficiency savings and seemed keen on how Homerton University Hospital NHS Foundation Trust (HUHFT) s practices and services could be promoted. JW added that Jane Milligan (JM) will be producing a public note of the meeting and that HealthWatches across the area will be meeting to discuss these issues. JW briefed the GB that a small protest had been held outside the ELHCP launch, which had been invite only and not open to the public. Much of the public feedback to date had been that the public felt talked at and that ELHCP were not prepared for real conversations. CH responded that the role of ELHCP was still developing and that engagement may be best focused on the local level still. JW added that JM was interested in HHW s processes and how they could implemented across other areas. CW drew the GBs attention to paragraph 4.1 on page 43 of the circulated papers, stating that this provided a real example of ELHCP s approach to engagement, with no mention of patients, just key stakeholders invited. MV responded that he had been present at the launch, which had proven to be underwhelming and the audience all made of staff from the involved organisations. Chair: Dr Clare Highton Chief Officer: Paul Haigh

10 GM asked if ELHCP were providing any transparency on their funding, noting that a recent freedom of information request had been required to access information. CH responded that the last information she had seen had indicated a 2.3 million spend on staff. Agenda Item 6 Integrated Commissioning update PH briefed the GB that the ICBs had held their second meetings earlier in the month, with minutes to follow to the next GB meeting, along with the outcomes of the first assurance review. PH continued that the team had learnt from this first review and would be refining their expectations for future reviews. NHSE had confirmed that they were content with the results of their legal review of the CCGs integrated commissioning arrangements, while the results of the NHSE governance review were following shortly. MD asked if the CCG had been offered any draft of the NHSE reviews for comment. PH responded that they had not. Agenda Item 7 Delegated Primary Care Commissioning operating model Richard Bull (RB) joined the GB to present the circulated paper outlining the CCGs plans for the operation of their delegated primary care commissioning responsibilities. RB noted that the CCG was in a solid position, with only one local practice in a requires improvement status. The example quality dashboard in papers had proven to be a helpful tool in monitoring local performance and other organisations were now looking at using it, including HHW for their enter and view visits. MD asked why City and Hackney held a large primary care surplus of 1.3 million versus the overall NEL position of 1.9 million. ST responded that the City and Hackney figures were based on the standard NHSE allocation formula and that the local area was one of the more fortunate areas with headroom available. ST continued that there is risk attached to this however, with Hackney witnessing the largest rent increases in the country and increases in only six property rents would impact heavily on that surplus. ST confirmed that the allocation would decrease over and that the CCG was actively drawing up plans to ensure that it is utilised for the future. CH commented that City and Hackney comes in right on the allocated per patient formula, while Tower Hamlets were allocated higher and Havering lower. MD asked what was present in City and Hackney that drove these differences across areas. RB responded that City and Hackney had significantly fewer Alternative Provider Medical Services (APMS) contracted practices. ST added that the team were actively challenging NHSE on some elements of the allocation as well, and that the CCG were pressing for every benefit locally as they could. Chair: Dr Clare Highton Chief Officer: Paul Haigh

11 HP asked if underperformance of practices was now a CCG responsibility. RB confirmed that this was the case, and that the CCG had issued the notice recently. CH clarified that individual GP performance remained an NHSE issue, while GP practice was with the CCG. GM noted that the two page summary included in papers was very useful and could be shared with local practices as well. MV asked that if any new practices were to open in the local area, would all types of NHS contract be available to them. RB responded that the national position was that only APMS contracts would be entered into at this point. JW highlighted that disability access across practices could benefit from a review, with a couple of practice participation groups (PPGs) expressing concerns on this matter and also the upcoming practice takeovers of APMS contracts. RB responded that there was ongoing discussion regarding the Lawson Practice takeover of the Springfield and Tollgate Practices, with PPG involvement. PH asked if those contracts had been confirmed as awarded in the public Local GP Provider Contracts Committee (LGPPCC). RB confirmed this had been the case. CW noted that the CCG was signed up to the Dignity Code and included it in its core contracts. CW asked if it could also be implemented in primary care contracts. RB confirmed that he would look into this. Agenda Item 8 Recommendations from the June 2017 Local GP Provider Contracts Committee PH drew the GBs attention to the circulated recommendations from the June 2017 LGPPCC, flagging that the meetings minutes needed to be provided to the GB to support their decisions as well. ACTION: LGPPCC meeting minutes to be included in GB papers in full for all future meetings. PH noted that the LGPPCC had made several decisions under its Primary Care Committee (PCC) powers and payments agreed under existing contracts, detailed for the GBs information and that there were four recommendations from the Committee requiring GB approval. The LGPPCC requested that the GB approve entering into contracts with the City and Hackney GP Federation for an Expanded Primary Care Anticoagulation Service, End of Life Care Service and Long Term Conditions Service, with the details summarised in the circulated paper. The Committee also recommended entering into a contract with CHUHSE for a one year extension to the GP Out of Hours Service. DECISION: The GB agreed the Expanded Primary Care Anticoagulation Service, End of Life Care Service and Long Term Conditions Service contracts with the City and Hackney Chair: Dr Clare Highton Chief Officer: Paul Haigh

12 GP Federation and the one year extension to the GP Out of Hours Service with CHUHSE as detailed in circulated papers. Agenda Item 9 Recommendations from the July 2017 Prioritisation and Investment Committee CH noted that the chief recommendation from the July 2017 Prioritisation and Investment Committee (PIC) was to hold fire on any investment of non-recurrent monies until both the funding available was clearer and that the CCG confirm how it wanted to proceed with regards to integration with local authority partners in this area of work. Penny Bevan (PB) noted that the later point was particularly welcome and it was hoped that local authority public health teams and the NHS would be able to benefit from each other s work. CH stated that the only recommendation in need of GB discussion and approval at this point was that regarding the setup of a 250,000 innovation fund, based on the success of previous years funds. MV asked if the CCG expected any issues with the incubator model being proposed this year and potential legal challenge. GM responded that the awards made within the fund were not procurement exercises and within the CCGs legal powers. HP asked if the CCG was considering how to scale up successful innovative projects. GM responded that due to the nature of these projects, this would need to be done on a case by case basis. PH noted that none of the projects were yet final and would need to undergo due diligence to assure the CCG of their stability. CH noted that those relating to outpatient department (OPD) transformation and care at home were likely to impact the most on local performance and patient experience. PH agreed, adding that the Transformation Board (TB) and ICBs would also be debating this work and how the projects could support integrated commissioning and services. DECISION: GB agreed to allocate the CCG Innovation Fund the sum of 250,000 as recommended by the PIC. Agenda Item 10 Emergency Preparedness, Resilience and Response policies and plans Matthew Knell (MK) presented the Emergency Preparedness, Resilience and Response (EPRR) policies and plans, as circulated with meeting papers and made up of the core policy and series of additional documents for the GBs approval. PB highlighted that the section on terrorism in the risk additional document needed to be expanded on in detail, including the coverage of new methods of attack, address impacts on transport for staff, the effects of gridlock and re-visit some of the guidance provided to staff. Chair: Dr Clare Highton Chief Officer: Paul Haigh

13 ACTION: CCG to revisit the risk register and action cards in the EPRR documentation to expand on coverage of new methods of attack, address impacts on transport for staff, the effects of gridlock and re-visit some of the guidance provided to staff. CH asked whether the CCG now held any responsibility for business continuity in GP practices with their delegated powers. PB responded that each practice should hold a plan that can be implemented but asked if the CCG was assured that these were acceptable. CH responded that the Care Quality Commission (CQC) looked at the documents as part of their review process. PH asked for the CCG to look into how primary care business continuity assurance is carried out and whether the CCG needs to have a role in this work. CH added that even some form of cascading of information to GP practice may help in this area. ACTION: CCG to look into how primary care business continuity assurance is carried out and whether the CCG needs to have a role in this work. DECISION: Core EPRR policy and plans agreed by the GB, with recognition that further changes will need to be actioned to additional documents. ACTION: CCG to work with PB to update risks and actions in additional EPRR documents. Agenda Item /17 Improvement and Assessment Framework CCG annual headline assessments PH drew the GBs attention to the circulated letter from NHSE outlining the CCGs Improvement and Assessment Framework (IAF) assessment for 2016/17. PH noted that it was disappointing that the results had been linked to NHSE s legal and governance review, especially considering the otherwise very positive results. CB noted that the data the IAF was drawing on seemed variable, with a recent analysis from the Health Service Journal (HSJ) not returning sensible results. MV drew the GBs attention to page 152 of circulated papers and the reference to wider NEL and sharing of management structures, noting that he suspected that local patients would disagree with NHSEs views. CH agreed that the CCG and any future Accountable Care System (ACS) needed to be real data based supported by solid transparent evidence and with real clinical outcomes included. Agenda Item 12 CCG Finance update Chair: Dr Clare Highton Chief Officer: Paul Haigh

14 ST briefed the GB on the latest month three financial position, noting that the CCG is currently projecting a break even position at year end, taking into account the current overspends on acute, CHC and funded nursing. ST continued that the CCG had been planning to declare part of the CCGs 1.4 million quality, innovation, productivity and prevention (QIPP) savings in this month, but that NHSE had instructed to move this sum to contingency instead. The GB will be kept updated on any changes coming in this area. ST continued that he had briefed the Audit Committee (AC) and Finance and Performance Committee (FPC) on this NHSE request and that the sum will be included in the CCGs risks and opportunities report. Otherwise the CCG remained on track to meet its control total, with mitigation available to address emerging pressures. ST noted that data quality returns from Trusts had been variable so far this year, while at least some of this was due to the well-publicised issues with cyber attacks, further work was required to reconcile these returns with the CCGs own figures. CH noted that she had been informed that any 2018/19 transformation funding would be reserved for Trusts, similar to how it had been utilised in 2017/18. ST responded that he had not heard of any changes to the approach used this year. ST briefed the GB that NHSE had moved the CCG to an amber status on the operating plan, after the team had confirmed activity plans and the evidence it was based on. Since NHSE analysis of that documentation, the CCG had been moved to assured with enhanced monitoring, which was a positive move. ST continued that NHSE was in the process of moving to SUS+ based activity monitoring, but that most of the CCGs providers were still based on normal SUS reporting, which may result in further triangulation issues and require further assurance. SM asked if there were major differences between the reporting systems. ST responded that the majority of the NHS provider system used to work on SUS and that the CCG hoped to encourage and support providers to move to SUS+, if that was the way reporting was moving at the national level. Agenda Item 13 Healthy London Partnership return on investment update ST drew the GBs attention to the circulated paper from Healthy London Partnership (HLP), noting that they had been funded to the sum of 18.2 million in 2016/17 and 14.5 million in 2017/18. The report covered their deliverables, investments and benefits provided back to the London wide health system, including a sum of 50,000 benefit to City and Hackney. ST stated that this was a high level report and CH added that it also made many assumptions. ST asked for any feedback from the GB which could be passed back to HLP. MD noted that the CCG had little choice on funding the HLP programme of work, considering the London wide nature of the work, but welcomed the report back to the GB. Chair: Dr Clare Highton Chief Officer: Paul Haigh

15 Agenda Item 14 Reports from Subcommittees of the Board The GB received and noted updates from its sub-committees. JW noted that the Public and Patient Involvement Committee (PPIC) had met the previous evening, concentrating on a productive discussion of local patient pathways. Agenda Item 15 Friday 29 September 2017 draft CCG Governing Body agenda The GB received the following meeting s draft agenda, noting that a discussion and probably decision on the move towards a single AO across ELHCP needed to be added to the agenda. Agenda Item 16 Any Other Business MD asked who was leading for the CCG on their work on QIPP and towards a potential future ACS. CH responded that the TB was taking the lead on the latter, although of course the GB would also be involved when there was substantial discussion to be had. No further business was discussed. AGREED BY: AGREED ON: Chair: Dr Clare Highton Chief Officer: Paul Haigh

16 2016/17 NHS City and Hackney CCG Governing Bodies Action Tracker (OPEN) Ref No Action Assigned to Assigned from Assigned date Due date Status Update Update provided by GB0066 GB0068 GB0070 GB0072 AH to double check the data indicated in the re-procurement documentation and split by local residents and commuters, updating CH with the information when ready. ST to look at trends over time on the split of funding across care areas and split out prescription costs from primary care funding and represent this information to the GB at a future meeting. 111 urgent disposition update note received by GB to be sent to Health in Hackney Scrutiny Committee. Matthew Knell to work with CCG Primary Care Quality Team to capture BAF risks relating to primary care commissioning delegation Anna Hanbury Sunil Thakker Anna Hanbury Matthew Knell CCG Governing Body CCG Governing Body CCG Governing Body CCG Governing Body 31/03/ /04/2017 Closed Covered in 111 procurement exercise discussions. AH 31/03/ /10/2017 Open ST pursuing. MK 28/07/ /05/2017 Closed Covered in 111 procurement exercise discussions. MK 26/05/ /09/2017 Closed Included in September 2017 BAF update MK GB0074 Sunil Thakker to investigate 2017/18 STP running costs and update the GB Sunil Thakker CCG Governing Body GB0075 GB0076 Sunil Thakker to discuss PPI funding for working with integrated commissioning workstreams with Catherine Macadam and CCG PPI team Dan Burningham to keep GB updated on progress towards signature of the Access to Mental Health Inpatient Services in London Compact agreement and to investigate whether HLP may be able to support its agreement if needed MK to arrange for re-assessment of risk relating to clinical workforce in the CCGs BAF. GB discussion of CHC to be placed on the forward plan for a future meeting. Sunil Thakker Dan Burningham CCG Governing Body CCG Governing Body GB0077 Matthew Knell CCG Governing Body GB0078 Matthew Knell CCG Governing Body GB0079 LAC service to be added to the GB forward plan for future discussion. Matthew Knell CCG Governing Body GB0080 LGPPCC meeting minutes to be included in GB papers in full for all future Matthew Knell CCG Governing meetings. Body GB0081 CCG to revisit the risk register and action cards in the EPRR documentation Matthew Knell CCG Governing to expand on coverage of new methods of attack, address impacts on Body transport for staff, the effects of gridlock and re-visit some of the guidance provided to staff. GB0082 CCG to look into how primary care business continuity assurance is carried out and whether the CCG needs to have a role in this work. Matthew Knell CCG Governing Body 26/05/ /10/2017 Open No confirmation of the expected contribution to Sustainable Transformation Plan (STP) support had been received yet, but was expected to be in the region of 150,000. MK 26/05/ /06/2017 Closed Resolved by David Maher ST 26/05/ /10/2017 Open CSU reviewing the London Compact agreement with oversight from Consortium. Will return to GB when ready. 30/06/ /09/2017 Closed Included in September 2017 BAF update MK 28/07/ /09/2017 Closed Added to GB forward plan. MK 28/07/ /09/2017 Closed Added to GB forward plan. MK 28/07/ /09/2017 Closed Added to GB standing items on agenda MK 28/07/ /09/2017 Closed Corporate Services team met with Penny Bevan and revised document. MK 28/07/ /09/2017 Open Corporate Services investigating with NHSE & Primary Care team MK GC GB0083 CCG to work with PB to update risks and actions in additional EPRR documents. Matthew Knell CCG Governing Body 28/07/ /09/2017 Closed Corporate Services team met with Penny Bevan and revised document. MK

17 NHS City and Hackney Clinical Commissioning Group NOTE: A new Conflicts of Interest Policy and process was rolled out in November Conflicts declared under the previous policy are included in this Register, but in italic font. Declarations made since the policy change are in a normal font. September 2017 Register of Interests Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Gail Beer 19/11/2016 City of London HealthWatch Representative Guys and St Thomas's NHS Foundation Trust Employed as Interim Director of Operations Non-financial professional interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Penelope Jane Bevan 18/11/2016 Director of Public Health LB Hackney and City of London Corporation Attends Clinical Effectiveness Committee, Prioritisation Committee and Governing Body Advises on clinical and public health issues Signatory to the CCG/Public Health Core Contract Penelope Jane Bevan 18/11/2016 Director of Public Health LB Hackney and City of London Corporation Attends Clinical Effectiveness Committee, Prioritisation Committee and Governing Body Advises on clinical and public health issues Signatory to the CCG/Public Health Core Contract Penelope Jane Bevan 18/11/2016 Director of Public Health LB Hackney and City of London Corporation Attends Clinical Effectiveness Committee, Prioritisation Committee and Governing Body Advises on clinical and public health issues Signatory to the CCG/Public Health Core Contract City of London Corporation Employer Non-financial professional interest Faculty of Public Health Fellow at this Public Health Specialist Body Non-financial professional interest London Borough of Hackney Employer Non-financial professional interest Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Penelope Jane Bevan 18/11/2016 Director of Public Health LB Hackney and City of London Corporation Attends Clinical Effectiveness Committee, Prioritisation Committee and Governing Body Advises on clinical and public health issues Signatory to the CCG/Public Health Core Contract Member of Association of Directors of Public Health London Public Health Specialist Body Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Penelope Jane Bevan 18/11/2016 Director of Public Health LB Hackney and City of London Corporation Attends Clinical Effectiveness Committee, Prioritisation Committee and Governing Body Advises on clinical and public health issues Signatory to the CCG/Public Health Core Contract Member of Association of Directors of Public Health UK Public Health Specialist Body Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Jaime Bishop 20/01/2017 Associate Lay Member and Chair of the Primary Care Committee (Formerly the LGPPCC) Barretts Grove Surgery Registered patient at CHCCG member practice Barretts Grove. Non-financial personal interest Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider.

18 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Jaime Bishop 20/01/2017 Associate Lay Member and Chair of the Primary Care Fleet Architects LTD Financial interest Committee (Formerly the LGPPCC) Director and Shareholder. Fleet is an architecture practice focussing primarily in public sector work including housing, health and education. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Jaime Bishop 20/01/2017 Associate Lay Member and Chair of the Primary Care Committee (Formerly the LGPPCC) Healthports Ltd Director and Shareholder. Dormant property development company. Financial interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Jaime Bishop 20/01/2017 Associate Lay Member and Chair of the Primary Care Committee (Formerly the LGPPCC) Pattern Investments Ltd Director and Shareholder. Property development company co-owned by the directors of Fleet Architects Ltd. Financial interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Christine Blanshard 04/01/2017 CCG Board Consultant Salisbury Hospital NHS Foundation Trust Medical Director at Salisbury Hospital NHS Foundation Trust that does not hold any contracts with the CCG. Non-financial professional interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Siobhan Clarke 24/11/2016 CCG Governing Body Registered Nurse Albion Care Alliance CIC Director Non-financial professional interest Siobhan Clarke 24/11/2016 CCG Governing Body Registered Nurse Albion Healthcare Alliance LTD Director Non-financial professional interest Should this Social Enterprise provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Should this private provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Siobhan Clarke 24/11/2016 CCG Governing Body Registered Nurse Albion Outlook Director Non-financial Should this private provider be specifically discussed in a commissioning

19 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Siobhan Clarke 24/11/2016 CCG Governing Body Registered Nurse Transform Research Alliance CIO Trustee of organisation which facilitates and promotes research and engagement between its constituent organisations Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Siobhan Clarke 24/11/2016 CCG Governing Body Registered Nurse Your Healthcare CIC Managing Director & Shareholder for Provider of Health and Social Care services for the NHS and Local Authority commissioned provider Financial interest Should this Social Enterprise provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Mariette Davis 11/05/2017 CCG Board Governance Lay Member Audit Committee Chair Remuneration Committee Chair Mariette Davis 11/05/2017 CCG Board Governance Lay Member Audit Committee Chair Remuneration Committee Chair Acanthus Capital Limited Consultant Financial interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Tower Hamlets CCG Lay Member for Governance for Tower Hamlets CCG Non-financial professional interest Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Rozalia Enti 14/09/2017 Assistant Director of CCG Medicines Management Declared they have no Interest Declared they have no Interest N/A N/A Sue Evans 19/05/2017 CCG Associate Lay Member for Governance Worshipful Company of Glass Sellers of Company Secretary/Clerk to the Trustees Non-financial Organisation is not a provider of services to CCGs. Should a situation London (City Livery Company) Charitable Fund professional arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Sue Evans 19/05/2017 CCG Associate Lay Member for Governance Loughton Youth Project (registered charity) Trustee and Treasurer Non-financial professional Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Sue Evans 19/05/2017 CCG Associate Lay Member for Governance Barts Health Trust Self and family are potential patients/users of hospital health care services in the local area of the NE London STP. Non-financial personal interest Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider.

20 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Paul Fleming 23/12/2016 Healthwatch Hackney Chair Healthwatch Hackney Chair Non-financial professional interest Should this Public and Patient Involvement partner organisation be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this organisation, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Paul Fleming 23/12/2016 Healthwatch Hackney Chair Shakespeare Schools Foundation Director of Income Generation and Communications at this registered charity that works to improve life skills of young people Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Paul Haigh 17/11/2016 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR and Organisational Development, NHS England (London Region) Anna Hanbury Not yet received Interim Urgent Care Programme Manager Not yet received Not yet received Siobhan Harper 31/01/2017 Director Planned Care Workstream Integrated NHS England Sister is a Criminal Justice Commissioner for London Commissioning Mental Health services with NHSE Indirect interest Indirect interest Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Clare Highton 23/12/2016 CCG Chair Body and Soul Daughter in Law works for this HIV charity. Indirect interest Should this Charity provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Clare Highton 23/12/2016 CCG Chair CHUHSE Sorsby and Lower Clapton Group Practice's are members Financial interest Should this Social Enterprise provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken.

21 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Clare Highton 23/12/2016 CCG Chair GP Confederation Sorsby and Lower Clapton Group Practice's are members and shareholders Financial interest Should this Community Interest Company provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Clare Highton 23/12/2016 CCG Chair Local residents Myself and extended family are Hackney residents and registered at Hackney practices, 2 grandchildren attend a local school. Non-financial personal interest Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Clare Highton 23/12/2016 CCG Chair Lower Clapton Group Practice (CCG Member Practice) Partner at a GMS and an APMS practices which provide a full range of services including all GP Confederation and the CCG's Clinical Commissioning and Engagement contracts, and in addition child health, drug, minor surgery and anticoagulation clinics. We host CAB, Family Action, physiotherapy, counselling, diabetes and other clinics. The buildings are leased from PropCo, and also house community health services. The practices are members of CHUHSE and the GP Confederation. Lower Clapton is a teaching, research and training practice, and I am a GP trainer. I am a member of the BMA and Unite. One partner is a member of the LMC. Financial interest Should this GP provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Clare Highton 23/12/2016 CCG Chair Sorsby Group Practice (CCG Member Practice) Partner at a GMS and an APMS practices which provide a full range of services including all GP Confederation and the CCG's Clinical Commissioning and Engagement contracts, and in addition child health, drug, minor surgery and anticoagulation clinics. We host CAB, Family Action, physiotherapy, counselling, diabetes and other clinics. The buildings are leased from PropCo, and also house community health services. The practices are members of CHUHSE and the GP Confederation. Lower Clapton is a teaching, research and training practice, and I am a GP trainer. I am a member of the BMA and Unite. One partner is a member of the LMC. Financial interest Should this GP provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Clare Highton 23/12/2016 CCG Chair Tavistock and Portman NHS Trust Husband is Medical Director of Tavistock and Portman NHS FT which is commissioned for some mental health services for C&H CCG. Non-financial personal interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken.

22 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Clare Highton 23/12/2016 CCG Chair Daughter is a trainee Psychiatrist, not within the City and Hackney area. Non-financial personal interest Should this provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Dr Prakash Kakoty Not yet received City of London HealthWatch Representative City of London HealthWatch Not yet received Not yet received Not yet received Matthew Knell 01/02/2017 CCG Head of Corporate Services Somerford Grove Practice (CCG Member Practice) Patient at Somerford Grove Practice, a CCG member practice. Non-financial personal interest Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Glyn Kyle 05/01/2017 City of London HealthWatch Chair Age UK East London Trustee Non-financial professional interest Glyn Kyle 05/01/2017 City of London HealthWatch Chair GLA Strategic Asset Panel Chair Non-financial professional interest Glyn Kyle 05/01/2017 City of London HealthWatch Chair Heart of England Housing Association Independent Board Member Non-financial professional interest Glyn Kyle 05/01/2017 City of London HealthWatch Chair Orbit South Housing Association Independent Board Member Non-financial professional interest Glyn Kyle 05/01/2017 City of London HealthWatch Chair Swan Housing Association Independent Committee Member Non-financial professional interest Should this Charity provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation.

23 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Philippa Lowe 22/12/2016 CCG Joint Chief Financial Officer GreenSquare Group Board Member, Group Audit Chair and Finance Committee member for GreenSquare Group, a group of housing associations. Greensquare comprises a number of charitable and commercial companies which run with co-terminus Board. Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Philippa Lowe 22/12/2016 CCG Joint Chief Financial Officer NHS Oxford Radcliffe Hospital Member of this Foundation Trust Non-financial personal interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Philippa Lowe 22/12/2016 CCG Joint Chief Financial Officer PIQAS Ltd Director at PIQAS Ltd, dormant company. Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation. Catherine Macadam 10/05/2017 Lay Member of Governing Body with responsibility for Patient and Public Involvement Ann Sanders Consultancy Services Ann Sanders, close friend, owner of Ann Sanders Consultancy Services which does business with health or social care organisations Indirect interest Should this private provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Catherine Macadam 10/05/2017 Lay Member of Governing Body with responsibility for Patient and Public Involvement Catherine Macadam, Coaching/Mentoring and OD Consulting Owner/Sole Trader; occasional contracts with health and social care organisations Financial interest Should this private provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Catherine Macadam 10/05/2017 Lay Member of Governing Body with responsibility for Patient and Public Involvement City and Hackney Carers Centre Volunteer and occasional sessional worker at City and Non-financial Hackney Carers Centre; carers champion within CCG (as professional interest part of PPI role) Should this provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Catherine Macadam 10/05/2017 Lay Member of Governing Body with responsibility for Patient and Public Involvement People Opportunities Ltd Associate for People Opportunities Ltd (POL); Deborah West, close friend, part owner of POL; POL regularly does business with health and social care organisations Financial interest Should this private provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken.

24 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Catherine Macadam 10/05/2017 Lay Member of Governing Body with responsibility for Patient and Public Involvement Volunteer Centre Hackney Contractor for Volunteer Centre Hackney Non-financial professional interest Should this provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. David Maher 13/09/2017 Deputy Chief Officer Cross sector Social Value Steering Group Convenor of Cabinet Office, DH, NHSE, PHE, RSA and others - supporting Michael Marmot and the SDU reduce improve life chances by supporting policy development which reduces health inequalities. Non-financial professional interest Organisation is a public sector partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. David Maher 13/09/2017 Deputy Chief Officer Global Action Plan Board member: supporting environmental and social sustainability. David Maher 13/09/2017 Deputy Chief Officer NHS England, Sustainable Development Unit Social Value and Commissioning Ambassador: supporting the development of sustainable commissioning models across NHSE and PHE which promote the opportunities for increased social value David Maher 13/09/2017 Deputy Chief Officer Social Value UK Council member supporting the promotion of social value best practice and policy development Gary Marlowe 17/01/2017 Planned care clinical lead, joint chair SW consortium, member of Governing Body Non-financial professional interest Non-financial personal interest Non-financial professional interest British Medical Association (BMA) Chair of London Regional Council Non-financial professional interest Company is not active in the CCG area or provider of health services and highly unlikely to provide services to CCG patients. Should a situation arise where the provider is being discussed in a commissioning capacity by the CCG, the individual will be asked to leave the room when the relevant matter is being discussed and when any decisions are being taken. Company is not active in the CCG area or provider of health services and highly unlikely to provide services to CCG patients. Should a situation arise where the provider is being discussed in a commissioning capacity by the CCG, the individual will be asked to leave the room when the relevant matter is being discussed and when any decisions are being taken. Company is not active in the CCG area or provider of health services and highly unlikely to provide services to CCG patients. Should a situation arise where the provider is being discussed in a commissioning capacity by the CCG, the individual will be asked to leave the room when the relevant matter is being discussed and when any decisions are being taken. Should this NHS related organisation be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Gary Marlowe 17/01/2017 Planned care clinical lead, joint chair SW consortium, member of Governing Body C&H GP Confederation Member, provider local NHS contracts Financial interest Should this Community Interest Company provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken.

25 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Gary Marlowe 17/01/2017 Planned care clinical lead, joint chair SW consortium, member of Governing Body De Beauvoir Surgery GP partner/provider GMS contract Financial interest Should this GP provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Gary Marlowe 17/01/2017 Planned care clinical lead, joint chair SW consortium, member of Governing Body Homerton Hospital/ Local GP practice Used by members of my family, including current ongoing care Non-financial personal interest Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Gary Marlowe 17/01/2017 Planned care clinical lead, joint chair SW consortium, member of Governing Body Labour party NHS campaigner Non-financial personal interest Jonathan McShane 08/12/2014 London Borough of Hackney Councillor Health, Social Care and Culture, Cabinet Member Hackney Health and Well Being Board None applicable Jonathan McShane 08/12/2014 London Borough of Hackney Councillor LBH, Hackney Health and Wellbeing Chair Board Jonathan McShane 08/12/2014 London Borough of Hackney Councillor Shoreditch Town Hall Trust Director Deputy Joyce Nash 03/01/2017 Chairman of City of London Health and Wellbeing Board City of London Corporation Declared they have no Interest N/A N/A Haren Patel 14/09/2017 Chair of CCG Clinical Executive Committee GP Board Member of City & Hackney CCG Prescribing Lead for City & Hackney CCG Klear Consortia Lead of City & Hackney CCG GP member of Integrated Commissioning Board GP Member of NHS England Regional Medicine Optimization Committee Acorn Lodge Nursing Home NHS Service Provider for Acorn Lodge Nursing Home Financial interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Haren Patel 14/09/2017 Chair of CCG Clinical Executive Committee GP Board Member of City & Hackney CCG Prescribing Lead for City & Hackney CCG Klear Consortia Lead of City & Hackney CCG GP member of Integrated Commissioning Board GP Member of NHS England Regional Medicine Optimization Committee Haren Patel 14/09/2017 Chair of CCG Clinical Executive Committee GP Board Member of City & Hackney CCG Prescribing Lead for City & Hackney CCG Klear Consortia Lead of City & Hackney CCG GP member of Integrated Commissioning Board GP Member of NHS England Regional Medicine Optimization Committee City & Hackney GP Confederation One of the paying members of the confederation Financial interest Should this Community Interest Company provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. City & Hackney Local Medical Committee GP Member of LMC paying subscription Non-financial professional interest Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Should this NHS related organisation be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion.

26 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Haren Patel 14/09/2017 Chair of CCG Clinical Executive Committee GP Board Member of City & Hackney CCG Prescribing Lead for City & Hackney CCG Klear Consortia Lead of City & Hackney CCG GP member of Integrated Commissioning Board GP Member of NHS England Regional Medicine Optimization Committee Latimer PMS Plus Practice (CCG Member Practice) Senior GP at this practice Financial interest Should this GP provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Haren Patel 14/09/2017 Chair of CCG Clinical Executive Committee GP Board Member of City & Hackney CCG Prescribing Lead for City & Hackney CCG Klear Consortia Lead of City & Hackney CCG GP member of Integrated Commissioning Board GP Member of NHS England Regional Medicine Optimization Committee Newcare Pharmacy in Brent Joint Director with 4 other family members Financial interest Should this private provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Honor Rhodes 10/01/2017 CCG Lay Member Barton House Practice I, partner and one child are patients at Barton House Practice (CCG Member Practice) Non-financial personal interest Should a situation arise where the GP provider is being specifically discussed in a commissioning capacity by the CCG, the individual will be asked to not take part in discussions, leave the room when the relevant matter is being discussed and/or when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Honor Rhodes 10/01/2017 CCG Lay Member Early Intervention Foundation Trustee and Company Secretary of Early Intervention Foundation Non-financial professional interest Should this Charity provider be specifically discussed in a commissioning capacity, the individual will be asked to not take part in discussions or to leave the room when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Honor Rhodes 10/01/2017 CCG Lay Member Oxleas CAMHS Partner is Consultant Family Therapist at Oxleas CAMHS Non-financial personal interest Should this NHS provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Honor Rhodes 10/01/2017 CCG Lay Member Tavistock Relationships Employed as Director at Tavistock Centre for Couple Relationships Non-financial professional interest Should this Charity provider be specifically discussed in a commissioning capacity, the individual will be asked to not take part in discussions or to leave the room when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Honor Rhodes 10/01/2017 CCG Lay Member The School & Family Works Special advisor (paid) to this charity Non-financial professional interest Should this Charity provider be specifically discussed in a commissioning capacity, the individual will be asked to not take part in discussions or to leave the room when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the GP provider. Geoffrey Rivett 20/11/2016 City of London HealthWatch Representative Declared they have no interest Retired; no financial or other conflicts of interest N/A N/A Fiona Sanders 19/01/2017 LMC Chair GP Partner Arsenal Football Club Contractor Non-financial professional interest Organisation is not a provider of services to CCGs. Should a situation arise where the organisation is being discussed in a commissioning capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the organisation.

27 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Type of interest Actions taken to mitigate risk Fiona Sanders 19/01/2017 LMC Chair GP Partner Heron Practice GP partner Financial Interest Should this GP provider be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this provider, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken. Fiona Sanders 19/01/2017 LMC Chair GP Partner NHS England GP appraiser Non-financial professional interest Organisation is a commissioning partner of the CCG. Should a situation arise where the organisation is being discussed in a commissioning (or joint management of commissioning) capacity, the individual will be able to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting, or not take part where decisions are being taken. The action taken should depend on the involvement of the partner in the matter under discussion. Sunil Thakker 10/05/2017 CCG Joint Chief Financial Officer Declared they have no Interest Declared they have no Interest N/A N/A Jonathan Gruffydh Williams 27/02/2017 Director, Healthwatch Hackney, engaged with following CCG meetings: CCG Governing Body, Patient and Public Involvement Committee, Mental Health Programme Board and Local GP Provider Contracts Committee Healthwatch Hackney Director of Healthwatch Hackney (public voice organisation for Hackney residents on issues of health and social care), lead organisation, responsible for strategy and operational management and fundraising Non-financial professional interest Should this Public and Patient Involvement partner organisation be specifically discussed in a commissioning capacity, the individual will be asked to leave the room or not take part in the meeting when the matter is being discussed and when any decisions are being taken. The action taken should depend on the involvement of the provider in the matter under discussion. Should broader commissioning matters be discussed that might be attractive to this organisation, the individual will be allowed to participate in some or all of the discussion when the matter is being discussed but asked to leave the meeting or not take part when decisions are being taken.

28 Paper Title Questions from the public Paper Author Matthew Knell Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) Two questions from a member of the public have been received in advance of the Governing Body, accompanied with two supporting papers. Other members of the public are welcome to pose other questions under this agenda item, or at the end of other agenda items, as time allows. Purpose (delete unnecessary) For discussion Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Discuss the questions received from the public in advance of the meeting and any that arise in the course of the meeting, as time allows. Where else has this paper been discussed? Not applicable What was the outcome of previous discussions? Not applicable Chair: Dr Clare Highton Chief Officer: Paul Haigh

29 Questions from the public 1. In regard to the letter from the Inner North East London Joint Health Overview and Scrutiny Commission following the discussion of this matter at its meeting on 6 September. Can the Board confirm that the reasons it gave for not endorsing these proposals do not give rise to any issues which the Board feels need further consideration? 2. Is the Board happy that the concerns raised in the two submissions (see following documents) to the Overview and Scrutiny Commission, on the legality of these proposals are not well founded so as to give rise any concern by the Board on the legality of the proposals?

30 SUBMISSION To From Subject Inner North East London Joint Health Overview and Scrutiny Commission Michael Vidal Member of the Public in receipt of services from NHS City and Hackney CCG Proposal to have a Single Accountable Officer for all North East London CCGs The Proposal 1. INTRODUCTION 1.1 While I graduated with a second class honours Degree in Law from the University of Teesside in 1996 I have never gone on to take my professional exams. Accordingly, any views I express on the law in this submission are my personal views and not meant as legal advice. The Commission should take such advice on what I say as they feel appropriate. 1.2 These submissions are provided to give the Commission a view from the perspective of the patient. I am a former member of the Board of Healthwatch Hackney. I am also a member of the Patient Participation Group at Brooke Road Surgery. 1.3 Of necessity these submissions have been written without having had sight of the proposal. My knowledge of the proposal has been based on what it has been able to be gleaned from discussions where the proposal has been discussed but not in any detail. 2. FUNCTION OF A CCG 2.1 To put the proposal in context I would argue that we need to understand what the function of a CCG is. Clinical Commissioning Groups were created by S.1I of the National Health Service Act 2006 The 2006 Act. (As inserted by S.10 of the Health and Social Care Act 2012 The 2012 Act ). This provides as follows 1IClinical commissioning groups and their general functions (1) There are to be bodies corporate known as clinical commissioning groups established in accordance with Chapter A2 of Part 2. (2) Each clinical commissioning group has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act. 2.2 A clinical commissioning group s function is that given by the Act. It follows that the only statutory function it has is that defined in the Act. This becomes important when it comes to deciding what responsibility, if any; a CCG has beyond its own area. 2.3 The duties of a CCG are found in S.3 of the 2006 Act as amended by S.13 of the 2012 Act. This as far as it is relevant says

31 13 Duties of clinical commissioning groups as to commissioning certain health services (1)Section 3 of the National Health Service Act 2006 is amended as follows. (2)In subsection (1) (a)for the words from the beginning to reasonable requirements substitute A clinical commissioning group must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility, and (b)in each of paragraphs (d) and (e) for the words as he considers substitute as the group considers. (3) After that subsection insert (1A) For the purposes of this section, a clinical commissioning group has responsibility for (a) persons who are provided with primary medical services by a member of the group, and (b) persons who usually reside in the group's area and are not provided with primary medical services by a member of any clinical commissioning group. (1B)Regulations may provide that for the purposes of this section a clinical commissioning group also has responsibility (whether generally or in relation to a prescribed service or facility) for persons who (a) were provided with primary medical services by a person who is or was a member of the group, or (b) have a prescribed connection with the group's area. (1C)The power conferred by subsection (1B)(b) must be exercised so as to provide that, in relation to the provision of services or facilities for emergency care, a clinical commissioning group has responsibility for every person present in its area. (1D)Regulations may provide that subsection (1A) does not apply (a) in relation to persons of a prescribed description (which may include a description framed by reference to the primary medical services with which the persons are provided); (b) in prescribed circumstances. (1E)The duty in subsection (1) does not apply in relation to a service or facility if the Board has a duty to arrange for its provision.

32 (4)After subsection (1E) insert (1F) In exercising its functions under this section and section 3A, a clinical commissioning group must act consistently with (a) the discharge by the Secretary of State and the Board of their duty under section 1(1) (duty to promote a comprehensive health service), and (b) the objectives and requirements for the time being specified in the mandate published under section 13A. 2.4 As will be seen the area of responsibility of a CCG is prescribed by S.3(1A) (1C). There is nothing in this wording I would submit that gives rise to a statutory responsibility for a wider group of people. 3 NEED FOR THE PROPOSAL 3.1 The question arises is there a need for the proposal. S.3(1F)(b) of the 2006 Act (as inserted by S.13(4) of the 2012 Act) does require the CCG to discharge its functions consistently with the requirements and objectives of the Mandate to NHS England. Paragraph 1.11 of the Mandate states We expect the NHS to deliver the Five Year Forward View and close the gaps in the quality of health, care and NHS finances through Sustainability and Transformation Plans (STPs). For the first time local service leaders in every part of England, both on the commissioner and provider side, have come together to develop these plans, with the aim of transforming health and care in the communities they serve. A number of metrics will be used to measure progress across STP footprints in delivering the Five Year Forward View, linking performance of the NHS at a local level more explicitly to national accountability. The objectives in the Mandate are at paragraph 2 of the Mandate. The Mandate is attached to these submissions. 3.2 It is my argument that there is no need consistent with the wording of paragraph 1.11 of the Mandate or any of the objectives in paragraph 2 of the Mandate for there to be a single accountable officer for the seven CCGs in North East London. This is especially true when you recall that the North East London Sustainability and Transformation Plan contains three sub plans. Each of the sub plans can be delivered as efficiently with a separate Accountable Officer for each CCG as one for all seven CCGs. In fact the argument can be made that as the current accountable officers have already started on delivering the sub plans you may cause disruption to the plans by making significant management changes. 3.3 A further argument against the proposal goes back to the point about the function of a CCG that I alluded to before. Under S.3(1A) of the 2006 Act as amended the statutory responsibility of a CCG is only to the people in its area. A CCG has no statutory responsibility for any wider area. Therefore in discharging its statutory duty under S.3(1F)(b) of the 2006 Act it does not have, in my submission, any wider responsibility as neither the

33 Mandate or Sustainability and Transformation Plans can amend in any way a statutory duty. Accordingly, a CCG s duty remains as in the Act to the people in its area. 3.4 It follows from what I said in paragraph 3.3 above that if a CCG has any wider responsibility to people in the STP area that responsibility is subject to the statutory duty to the residents in its area. A non statutory responsibility cannot fetter the exercise of a statutory responsibility. Accordingly in as far as the proposal is needed to further the aims of the STP it can only be done in as far as it does not interfere in the exercise by a CCG of its statutory responsibility. 4 IS THE PROPOSAL LEGAL 4.1 It is accepted that under paragraph 12(3) of Schedule 1A to the 2006 Act as inserted by Schedule 2 to the 2012 Act that The Board may appoint a person to be the accountable officer for more than one clinical commissioning group. Accordingly the Accountable Officer is an NHS England appointee. However, paragraph 12 contains no provision for the removal by NHS England of the Accountable Officer. The only provision for terminating the appointment of the Accountable Officer that I am aware of is in S.14Z21(4) of the 2006 Act (as inserted by s.26 of the 2012 Act.) This provision comes in the intervention powers of NHS England. However, these powers can only be used where a CCG fails or is failing to perform a function. It follows that absent a merger of CCGs there is no power to remove an Accountable Officer so as to replace him with a joint appointment. I would accept that if the Accountable Officer was to resign or retire then he could be replaced by a joint appointment. However, I doubt that it would be permissible to bring in a new management structure across CCGs on the basis that a number of Accountable Officers will retire at the same time. 4.2 In as far as it is sought to argue that the proposal is in the interest of the health service it is noted that while the definition of failing to perform a function in relation to a CCG includes a failure to discharge it consistently with what the Board considers to be the interests of the health service. 1 This only relates to the performance of a function of a CCG and commissioning services on a regional basis is not a function of a CCG. As under s.3 of the 2006 Act (as amended) a CCG s responsibility is only for people in its area and nothing more. 4.3 It has been stated publicly that the STP is not a new body it is a forum for discussing how to do things that need to be done once across a wider area. However, there have been other comments which cast doubt on this public statement. 2 It would seem from the way that the STP has developed and the responsibilities given to it 3 that it is a de facto regional health authority. 4.4 In as far as the STP is a regional body this would be contrary to the intent of Parliament in passing the 2012 Act. Therefore, in as far as the proposal is designed to further 1 See s.14z21(14)(b) of the 2006 Act as inserted by s.26 of the 2012 Act 2 For example in a letter to NHS City and Hackney CCG dated 18 June 2017 it states In such circumstances we would wish to review the governance and financial arrangements in advance of any future change so that we are assured that such arrangements are consistent with the strategic commissioning plans of the STP and that all relevant parties have been consulted. The existence of a strategic commissioning plan of the STP is inconsistent with it being merely a forum 3 By way of example the STP has to assure all applications for transformation funds. It decided which applications for funding from the ETTF were submitted.

34 this it is tainted by illegality. In that NHS England is acting ultra vires in setting up a body contrary to the intent of Parliament. 5 CONCLUSION 5.1 In conclusion it is my submission that the proposal is unnecessary and has the potential of hindering transformation work already underway in Inner North East London. This transformation work is in accordance with the statutory duties and responsibilities of the CCGs in Inner North East London. I would respectfully ask that the Inner North East London Joint Health and Overview Scrutiny Commission declines to endorse the proposal. Michael Vidal August 2017

35 SUBMISSION To From Subject Inner North East London Joint Health Overview and Scrutiny Commission Michael Vidal Member of the Public in receipt of services from NHS City and Hackney CCG Proposal to have a Single Accountable Officer for all North East London CCGs The Proposal 1. INTRODUCTION 1.1 These submissions are supplementary to the submissions dated August 2017 and deals with issues arising from the details of the Proposal which were disclosed on 1 September Due to the brevity of the details of the Proposal that have been given there is a risk that what follows might be based on a misconception of what is proposed. 1.2 Statutory references in this submission have the same meaning as in the submission dated August CONFLICTING DUTIES AND POWERS 2.1As I understand the Proposal certain functions are to be delegated to a Joint Committee of CCGs (the Committee). This is to be done under the power in S.14Z3 of the 2006 Act (as amended by S.26 of the 2012 Act.) when read with the Legislative Reform Order made in Accordingly, subject to what is said below there is statutory power to create the Committee. 2.2 However, while there is a statutory power to create the Committee it is a permissive power which may be used to further the functions of the Clinical Commissioning Group. This discretionary power is to be contrasted with the mandatory duty under S.14Z1 to promote integration. It is my argument that if there is a conflict between the two then the duty under S.14Z1 takes precedence. 2.3 I would submit that there is a potential conflict between the two duties. This arises because if you delegate powers to the Committee then you cannot then delegate those powers in order to integrate health and social care. It would therefore seem that the Proposal has the potential to fetter the way that the Clinical Commissioning Groups discharge a mandatory statutory duty. 3 LEGALITY OF THE PROPOSAL 3.1 I would repeat what I said in paragraph 4.1 of the submission of August Moreover, it is submitted that there is no power to create the single management team across the seven Clinical Commissioning Groups in North East London. As I said in paragraph 2.1 there is power to establish the Committee, however, it is my argument that in this case the use of the power would be an abuse of power as its use would go against the intent of Parliament as I stated in paragraph 4.4 of the submission of August 2017.

36 3.2 Section 33 of the 2012 Act states 33 Abolition of Strategic Health Authorities (1) The Strategic Health Authorities continued in existence or established under section 13 of the National Health Service Act 2006 are abolished. (2) Chapter 1 of Part 2 of that Act (Strategic Health Authorities) is repealed. Unlike with PCTs no replacement body was created this indicates that it was the intent of Parliament that there should not be any strategic health commissioning bodies. Accordingly, it is my submission that the power under S.14Z3 cannot be used to do what Parliament did not legislate for. 3.3 Further while S.14Z3(1) states (1) Any two or more clinical commissioning groups may make arrangements under this section. It is my submission that arrangements under the section do not include the power to create a single management structure. This argument is reinforced by the fact that the section as originally enacted did not include a power to create Joint Committees and a Legislative Reform Order was needed to give this power. Accordingly, absent a specific provision in S.14Z3 there is no power under that section to create a single management structure. I am not aware of any provision in the 2012 Act that allows such a structure to be created. 3.4 As both NHS England and Clinical Commissioning Groups are creatures of statute they only have the powers given to them under the statute that created them. It follows that unless there is specific statutory authority, and I have not been able to find any, there is no power to create the single management structure that is proposed. 4 CONCLUSION 4.1 For the reasons given above and in my submission of August 2017 I would invite the Joint Health Overview and Scrutiny Commission to make a referral to the Secretary of State of the Proposal. Michael Vidal September 2017

37 Paper Title Full Board Assurance Framework (BAF) and CCG Risk Management Paper Author Olivia Katis Lead Presenter Sunil Thakker Paper Summary (3 bullet points of relevant background to the paper) Following on from the July 2017 Audit Committee review of the BAF and review by all teams in the CCG, the current BAF in its full, detailed format is provided to the Governing Body for discussion. Purpose (delete unnecessary) For information and discussion Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: Acknowledge the highlights for consideration in the summary paper; Consider and discuss the BAF itself and the impact any of the indicated risks may have on the Governing Bodies discussions; Make any requests or recommendations on further work to be undertaken or refinement of the BAF. Where else has this paper been discussed? In previous versions, at preceding Governing Bodies and the Thursday 13 July 2017 Audit Committee. What was the outcome of previous discussions? The BAF is a living document and receives input from the across the CCG, Audit Committee and Governing Body. Specific changes to the BAF are recorded in Audit Committee and Governing Body minutes. Chair: Dr Clare Highton Chief Officer: Paul Haigh

38 Full Board Assurance Framework and CCG Risk Management Report to the 29 th September 2017 CCG Governing Body The BAF was last discussed by the CCG Governing Body on 28 th July 2017.

39 Highlights for Consideration: - At the CCG Audit Committee 13 July 2017, the Committee requested that the following risk was removed from the BAF. Please see a summary below, and the rationale: - IC03 [Devolution Pilot failing to progress as proposed, leading to unplanned system changes] the Devolution pilot has been subsumed by wider system changes (of which the CCG is part), and there is not a requirement for this risk to be recorded on the BAF.

40 Highlights for Consideration: This month one residual risk score has increased on the BAF. - Prescribing risk re Impact of less robust Repeat prescribing / Prescription reordering processes at Practice and Community pharmacy settings on budgets and patient safety (IH03): residual score has increased from 4 to 6 due to challenge engaging all community pharmacies. No residual scores have decreased on the BAF. No new risks have been included in the BAF. It has been requested that one risk is removed from the BAF [IC03 relating to the Devolution Pilot], please see the previous slide.

41 Residual Risk Score 2016/17 Residual Risk Score 2017/18 Monthly progress on action plan (March) Risk movement Description Inherent risk score Risk tolerance Q4 Q1 Q2 Q3 Q4 Objective 1 Improve the health of our patients IH01 Maternal deaths. There were 5 maternal deaths in a 2 year timeframe at HuH which was unusual and concerning. There was a heightened risk of further deaths which needed to be mitigated and there was also a possible impact on women's perception of safety at the Homerton. There was the risk that greater and continued scrutiny unearthed further quality, clinical, safety, staffing and other issues that required swift resolution. The CCG's reputation could also be impacted on negatively. A significant amount of work was undertaken by HuH to strengthen their delivery of quality and safe services with a focus on embedding best practice clinical processes. Staffing and leadership has also been scrutinised with changes to made to improve patient experience and outcomes, but a staffing review is outstanding. The combined action plan contained 53 items and 5 items remain open: 2 items relate to the staffing review, 1 item to the Tavistock leadership programme, 1 item to the maternity vision and strategy and 1 to an outstanding audit (named professional for every woman). There have been 2 further maternal deaths, in July 2016, and in January 2017 taking the total to 7 over a 3 year period. The maternal death in July 2016 was formally reviewed, including external input. The review found that HUH acted appropriately and HUH was praised for the level of consultant involvement in the care of the woman. The main recommendation related to amending admission criteria for early pregnancy unit. We are awaiting the report for the maternal death in January It was proposed to the Maternity Programme Board that the residual risk score could be reduced if the 7th maternal death review does not identify any concerns relating to care provided by the HUH, and once all items on the combined action plan are completed. This proposal was accepted by the Board on Actions progressed: 11/09/2017: We have received the Maternity Strategy which will be taken to the Mat Programme Board on 15 September Risks to delivery of actions: 11/09/2017: Waiting for final three actions to be completed [HUHFT Maternal Deaths Action Plan]. This includes: Birth Rate Plus Midwifery Staffing Audit, Obsteric Workforce and update on Tavistock Programme team development. As a result of increased pressure on the services in acute trusts there is a risk that people will not be seen and/or treated in a timely manner (Constitution rights - 18 weeks RTT, 62 Day Cancer waits) and may therefore experience a less than optimal outcome and/or poor patient experience Actions progressed: N/A IH Risks to delivery of actions: N/A

42 IH03 Impact of less robust Repeat prescribing / Prescription reordering processes at Practice and Community pharmacy settings on Budgetary control of Primary Care Prescribing Budget & Potential Patient Safety Actions progressed: April 2017: Repeat prescribing training sessions delivered from September 2016 to January Session has been delivered to 100 practice staff from 42 practices-these staff are involved in practice s repeat prescribing function(s). One of the practice did not attend as practice staff are not involved in the practice repeat prescribing functions. Feedback from the Sep 16-Dec 16, shows that 94% of attendees felt that the session enhanced their understanding of the issues discussed around repeat prescribing (79 attendees from 28 GP practices). Update at Sep2017: PPB agreement for 2018/19 W/plan, joint work with community pharmacies looking at patterns of repeat prescription ordering, joint meetings with communuty pharmacies Risks to delivery of actions: Engagement from all community pharmacies remains an ongoing challenge IH04 In order to ensure continued provision of the anticoagulation service for established patients whilst a new tendering exercise is being considered for the future service the existing Primary Care Anticoagulation Contract was reviewed and updated to reflect National Guidance only with no material change. This Contract has been issued to GP Practices in the Standard NHS Contract form. As this is a continuation of an established contract and a full comprehensive review of the current service has not been undertaken there may be a risk to the quality and safety of the service being provided Actions progressed: xxx Risks to actions: xxx IH05 There have been two child suicides at one of our Hackney Schools. The children were in the same year group. The impact on the school is significant and this is causing a significant increase in demand in to all our CAMHS. We are currently implementing a temporary enhanced offer for CAMHS to be in the school every day until august. This will also generate increase demand for CAMHS Actions progressed: xxx Risks to delivery of actions: xxx IH06 If systems are not in place to enable the early detection of serious problems with the quality of care patients receive this could lead to inequalities in care, delivery of poor clinical outcomes, poor patient experience and a lower standard of care Actions progressed: Planned Care and PPI presented at March 2017 Programme Board, Q3 2016/17 Quality report discussed at June 2017 Programme Board, M1 2016/17 Performance Report discussed at June 2017 Programme Board, Homerton SI Panel held Risks to delivery of actions: xxx IH07 Increasing pressure on GPs could mean an increase in rates of referrals to secondary services. This would lead to an increase in costs resulting in a possible adverse effect on the financial position of the CCG Actions progressed: MECS Spec and MECS Overview Spec approved at Planned Care Programme Board, Planned Care to submit proposals following engagement with clinical leads/consortia/gps Risks to delivery of actions: xxx IH08 Controlled Drugs (CDs) - assurance of appropriate prescribing & access Actions progressed: From Q3 2017/18- data analysis to provide quartely CD prescribing by practice. By April 2018, establish quarterly reviews at PPB of outliers in CD prescriptions/ Other CD reviews

43 IH09 HUHFT has experienced significant increases in CYP Crisis attendance at A&E, a large proportion of these cases relate to self harm : Oct = 7; Nov=10; Dec = 9; Jan =17; Feb=21; Mar=20. Over half of those who die by suicide have a history of self harm; this increase in CYP who are presenting for self harm significantly increases City and Hackney's risk of high suicide levels in our young people later in their childhood / adolescence, or in adulthood. This increase demand is also impacting on the A&E 4 hour target n/a n/a 10 NEW Objective 2 Commissioning System Development No risks to report at present

44 Objective 3 Integrated Commissioning IC1 Insufficiently robust framework of assurance provided by the ICBs to statutory bodies delegating authority whilst retaining responsibility could result in them not delivering their legal duties. 15 tbc Actions progressed: xxx Risks to delivery of actions: xxx Devolution Actions progressed: xxx IC3 Risks to delivery of actions: xxx IC2 A lack of robust joint commissioning arrangements may lead to the CCG committing by default to resource/support provision which has not met the governance requirements of the CCG or is contrary to CCG values/commissioning intentions Actions progressed: xxx Risks to delivery of actions: xxx Objective 4 CCG Governance If the Board is not sufficiently developed the CCG would not be able to implement and manage its business and would not be meeting its statutory requirements Actions progressed: xxx GV Risks to delivery of actions: xxx A possible over-performance on acute contracts could lead to a financial overspend potentially impacting on the CCG financial position. Actions progressed: New governance structure, involving HUHFT in acute contract management via the Joing Transformation Board (JTB) and Integrated Commissioning Board (ICB). GV Risks to delivery of actions: The score has increased to reflect the liklihood of acute contract overspend. GV03 As a result of increasing population numbers, people living longer, new drug therapies, there is a risk that the prescribing budget could overspend possibly causing an adverse impact on the financial position of the CCG Actions progressed: 13/04/2017- Practices informed of prescribing work plan for 17/18 which details various QIPP work streams (including QIPP indicators). 26/05/2017- Allocated prescribing budgets sent to practices individually. This will monitored monthly and uploaded to intranet for practices to access. Update at Sep2017:- all practices have received (as of Jul2017) prescribing allocations for 2017/18; budgets monitored monthly as practice level; Practices and their practice pharmacists have online access to their forecast outturns. PSP work continues with 437K savings made by PSP work in year to date. Significant overachievement on QiPP for primary care prescribing Risks to delivery of actions: Risks to delivery of actions: Pricing policies by Pharma companies, adoption of new highly priced drugs, NICE Tas, Hospitals non adherence to their agreed formularies GV04 Increased rental charges due to retrospective rent revaluation by lanlords could erode available headroom and possibly cause a financial deficit situation Objective 5) Primary Care

45 No risks to report at present

46 Objective 6) Productive Health Economy PHE03 Ongoing difficulties in recruiting staff within OOH, A&E and Primary Care will lead to - difficulties in covering rotas (OOH) - increases in waiting time (A&E) - inability to deliver enhanced services (Primary Care) This impact on primary care capacity will place further strain on A&E through increased attendance Actions progressed: xxx Risks to delivery of actions:xxx CHUHSE OOH contract expires end of November Risk of gap in out of hour service provision. Actions progressed: xxx PHE04 20 tbc Risks to delivery of actions: xxx Risk: Integrated Urgent Care (111) re-procurement risk of negative impact on quality of service provided and risk of both cost and activity increases across the urgent care system. Actions progressed: xxx PHE05 25 tbc Risks to delivery of actions:xxx DTOC levels have significantly improved, however still remain an issue for the system. Risk that improvement will not be maintained. PHE06 20 tbc Actions progressed: xxx As a result of cuts to local authority statutory services there is the potential for demand on Continuing Healthcare to increase placing a significant strain on CCG finances. Risks to delivery of actions:xxx Actions progressed: CHC review is underway. Review into Broadcare and Rio computer systems is planned PHE Risks to delivery of actions: None specific. The residual score of this risk has been increased to reflect the increased liklihood of CHC impacting CCG finance. It is understaood that the score should reduce once the CHC review has been carried out. If Primary care services are not sufficiently developed and are not established as a first point of call for patients this could lead to an increase in the number of inappropriate attendances at A&E and unplanned admissions to hospital. Actions progressed: None to report this month PHE Risks to delivery of actions: None to report this month Risk that Homerton A&E will not maintain delivery against four hour standard PH0E8 for 16/17 and 17/

47 Objective 1 Risk Ref: IH01 Date Risk Added: 01/01/2015 Improve the health of our patients Maternal deaths. Risk Owner Chief Officer There were 5 maternal deaths in a 2 year timeframe at HuH which was unusual and concerning. There was a heightened risk of further deaths which needed to be mitigated and there was also a possible impact on women's perception of safety at the Homerton. There was the risk that greater and continued scrutiny unearthed further quality, clinical, safety, staffing and other issues that required swift resolution. The CCG's reputation could also be Review Committee Maternity Programme Board impacted on negatively. A significant amount of work was undertaken by HuH to strengthen their delivery of quality and safe services with a focus on embedding best practice clinical processes. Staffing and leadership has also been scrutinised with changes to made to improve patient experience and outcomes, but a staffing review is outstanding. The combined action plan contained 53 items and 5 items remain open: 2 items relate to the staffing review, 1 item to the Tavistock leadership programme, 1 item to the maternity vision and strategy and 1 to an outstanding audit (named professional for every woman). There have been 2 further maternal deaths, in July 2016, and in January 2017 taking the total to 7 over a 3 year period. The maternal death in July 2016 was formally reviewed, including external input. The review found that HUH acted appropriately and HUH was praised for the level of consultant involvement in the care of the woman. The main recommendation related to amending admission criteria for early pregnancy unit. We are awaiting the report for the maternal death in January It was proposed to the Maternity Programme Board that the residual risk score could be reduced if the 7th maternal death review does not identify any concerns relating to care provided by the HUH, and once all items on the combined action plan are completed. This proposal was accepted by the Board on Inherent Risk Score (pre-mitigation) Impact Likelihood Total Impact Likelihood Total Residual Risk Score (post-mitigation) OBJECTIVE 1 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Safe and high performing Maternity Services Target Score Impact The impact of a maternal death will always he high [4-Major] 4 Likelihood A maternal death is a rare occurrence [1] 1 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Improve / increased scrutiny of HUHFT Maternity unit performance through an ongoing programme of meetings and reviews MITIGATION ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Maternity Review (Jan 15), Gateway Review (Jan 15), Minutes to MPB, Maternity summit meeting minutes x 4, 5th maternal death report, CQC investigation report x 2, NHSE Risk summit minutes, Combined action plan (now V16), 6th maternal death report. Copies of minutes and notes from meetings. Total 4 Create combined Action Plan to support scrutiny of performance Carry out HUHFT Maternity Staffing Review Regularly updated, currently on version 16 (March 2017), copy of action plan showing progress Support HUHFT in carrying out this review and escalate if no progress, copy of review ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Delivery Date Action Owner GAPS Meetings to enhance scrutiny of performance (quality and risk summits) Develop combined action plan to support scrutiny of performance Completed Completed CCG Maternity programme Director As above Report on combined action plan - 5 out of 53 items remaining Work with HUHFT to commission / carry out a maternity staffing review Review of Serious Incident report for 7th maternal death Review Committee Chair Feedback: Maternity Programme Board Aim to close plan once all items completed - Oct 17 Midwifery - June 17 Obstetrics - Oct 17 Jul-17 CCG Maternity programme Director CCG Maternity programme Director CCG Maternity programme Director Copy of SI report Date Risk Conclusion OBJECTIVE 1 Objective 1 Risk Ref: IH02 Date Risk Added: 12/08/2014 Improve the health of our patients As a result of increased pressure on the services in acute trusts there is a risk that people will not be seen and/or treated in a timely manner (Constitution rights - 18 weeks RTT, 62 Day Cancer waits) and may therefore experience a less than optimal outcome and/or poor patient experience Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of individuals being seen later than 18 weeks / 62 days is considered [Major, 4] 5 Likelihood It is considered unlikely that individuals will seen later than 18 weeks / 62 days [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Reduce patient waiting time through increase monitoring of performance ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Support Homerton's implementation of Cancer 62 day recovery plan Work with NEL CCB to address Bart's Performance issues Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Planned Care PB Action Update Delivery Date Action Owner 30/09/2017 SH 31/03/2017 SH ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Discuss performance at PB meeting bi-monthly, minutes and papers Discuss monthly at FPC meetings, FPC Minutes and papers, F&A Report Produced Monthly PD review provider performance targets on a monthly basis, F&A Report Attend NEL CCB - Minutes Contracts Team meet monthly with Providers to discuss performance, and NEL Teleconference - Minutes of these meetings GAPS Total 10 Review Committee Chair Feedback: Programme Board Date Risk Conclusion

48 Objective 1 Risk Ref: IH03 Date Risk Added: 01/06/2016 Improve the health of our patients Impact of less robust Repeat prescribing / Prescription reordering processes at Practice and Community pharmacy settings on Budgetary control of Primary Care Prescribing Budget & Potential Patient Safety Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Head of Medicines Management Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact Financial impact on CCG and Impact on patient safety is considered [Moderate, 3] 3 Likelihood Financial overspend and risk to patient safety are considered [Possible, 3] 3 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Ensure GP practices and pharmacies have adequate systems for ordering medicines on behalf of training Training for staff and practices developed and delivered Increase communication & support from the CCG Medicines Management Team (MMT) to Practices through assigning Practice Support Pharmacists (PSPs) to each practice ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Community Pharmacies policy [developed with PPB, endorsed Local Pharmaceutical Committee Practices attend Repeat Prescribing Training, Practice administrative staff attend training developed by MMT re generating repeat prescriptions, Satisfaction surveys [practices conveying satisfaction] archive of queries demonstrating ongoing communication between CCG MMT and practices. Total 9 OBJECTIVE 1 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Deliver Repeat Prescribing Training & training for Practice admin staff Action update Action Owner Delivery Date Training sessions carried out in Sept, Oct, Nov and Dec for practice admin staff involved in generating repeat prescriptions. There are plans to raise awareness of the practice medicines coordinator training materials which have been developed by Prescqipp. This training material also features training on the repeat prescribing process. A further session will be carried out in January By Jan 2017, 32 practices would have completed the training. In order to accommodate the remaining 11 practices that could get a place on the training, a final session will be held in March. A total of 98 staff would have completed the training by Jan out of 43 practices have attended Repeat Prescribing training. This is equivalent to approx. 100 staff. Final training session to be held on 6th March. April 2017 Feedback from the Sep 16-Dec 16, shows that 94% of attendees felt that the session enhanced their understanding of the issues discussed around repeat prescribing (79 attendees from 28 GP practices). GAPS Link each Practice with a PSP & monitor ongoing communications Explore all channels for patients to order repeat prescriptions - some CCG areas / practices have or looking to restrict repeat ordering to single access through extended practice LPC and NELCSU IT to write protocol for ERD- particularly re cancellations; including version for GP practices Share outcomes of the repeat prescribing training report to PPB and practices Surveys are sent in which practices convey their satisfaction. Queries often received by the PSPs and forwarded to the MMT. Work submitted by the PSPs are often discussed at the Prescribing Programme Board tbc tbc tbc tbc Outcomes of the repeat prescribing training report shared with PPB at the June Meeting (12/06/17) and will be uploaded to the GP intranet for practices to review. Review Committee Chair Feedback: Programme Board Prescribing Programme Board Risk Conclusion Date

49 Objective 1 Risk Ref: IH04 Date Risk Added: 14/07/2014 Improve the health of our patients In order to ensure continued provision of the anticoagulation service for established patients whilst a new tendering exercise is being considered for the future service the existing Primary Care Anticoagulation Contract was reviewed and updated to reflect National Guidance only with no material change. This Contract has been issued to GP Practices in the Standard NHS Contract form. As this is a continuation of an established contract and a full comprehensive review of the current service has not been undertaken there may be a risk to the quality and safety of the service being provided. Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total Review Committee Prescribing PB RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of a poorly functioning service is considered high for the CCG and patients [Major, 4] 4 Likelihood This risk is considered [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Monitor practice activity data, including: the number of patients treated by practices and the number of home visits carried out & a point prevalence report for the quarter [the Develop and implement an Audit of anticoagulation primary care services for practices to complete Visit practices to support anticoagulation service Work with the GP Confed to deliver anticoagulation training for practices ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Ongoing reporting cycle: Reports received every x2 months from WEQAS, INR Star reports received at the end of every quarter from Practices Practices are followed up with to ensure audit has been completed / any additional input from CCG is given. Results / summary report of the audit Arrange standardised clinical governance / performance management visits from clinician, follow up with practices requiring additional input Training sessions The Thrombosis Centre, Kings College Hospital. Training covers: Anticoagulation for new, existing and senior staff, and Action update Action Owner Delivery Date GAPS Total 8 OBJECTIVE 1 Monitor practice activity data [NPT, number of patients treated by practices / home visits, point prevalence reports] Audit of anticoagulation primary care service Latest reports: Q2 2016/17 recommendations of payments to Practices providing the service presented to PPB on 14th Nov 2016 and the Contracts Committee on 25th Nov Audit completed October 2016, 19 practices completed. Results analysed by interim pharmacist CCG anticoagulation lead and GP clinical lead. Letters sent to 3 practices w main concerns, s to 2 practices re training. Further follow up is to be done with the 3 practices of concern in January 2017 as no responses received as of 19th Dec Full summary of audit results will be included in the Q3 anticoagulation report planned for presentation to the PPB on Feb 13th 2017 and the Mar contracts committee Visit practices to support anticoagulation service Work with the GP Confed to deliver anticoagulation training for practices GP confederation provided confirmation that 16 out of the 19 practices currently providing the service had sent staff to at least one of the anticoagulation training sessions. Data to be presented, 13th Feb 2017, Contracts Committee March 2017 Review Committee Chair Feedback: Programme Board Date OBJECTIVE 1 Risk Conclusion Improvements to the controls in place around this risk since Q2 have resulted in a reduction of the impact score (from 5 to 4). At the same time, it is recognised that the original target of reducing impact to 2 is not realistic. Consequently the risk tolerance score has been amended from 4 to 6. Objective 1 Risk Ref: IH05 Date Risk Added: 07/02/2017 Improve the health of our patients There have been two child suicides at one of our Hackney Schools. The children were in the same year group. The impact on the school is significant and this is causing a significant increase in demand in to all our CAMHS. We are currently implementing a temporary enhanced offer for CAMHS to be in the school every day until august. This will also generate increase demand for CAMHS Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact 2 Likelihood 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Provide a temporary enhanced CAMHS in the school every morning until august Monitor any increases in demand for the CAMHS service ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Mental Health PB ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Action Update Delivery Date Action Owner GAPS Total 4 Review Committee Chair Feedback: Programme Board Date Risk Conclusion OBJECTIVE 1 Objective 1 Risk Ref: IH06 Date Risk Added: 01/01/2015 Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of poor performance on patients and the CCG is considered [Moderate, 3] 3 Likelihood It is considered unlikely that a lack of robust systems would lead to poor performance [Unlikely, 3] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Monitor provider quality on an on-going basis CQRMs with HUH, ELFT [Monthly] Tavi and St Josephs [bi-monthly]. Quarterly Combined action plan, and minutes from all meetings. Work to improve capacity and outcomes for City and Hackney's hospital services, report to Programme Boards and CCG GB Include in PB commissioning intentions and clinical ambitions, review on a quarterly Minutes of FPC and CEC Report Duty of Candour issues from practices to HUHFT & discuss at CEC and PBs Communicated via Quarterly CCG Board Report on quality Minutes / s / discussions Report on Serious Incidents (SIs) Bi-monthly panels to review all SIs reported by main providers (HUH, ELFT). Incident Report & CEC minutes ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Attend / facilitate ongoing CQRMs Monitor Quality through quarterly Quality Report Improve the Health of our patients If systems are not in place to enable the early detection of serious problems with the quality of care patients receive this could lead to inequalities in care, delivery of poor clinical outcomes, poor patient experience and a lower standard of care Monitor Quality through quarterly Performance Report Review PB commissioning intentions and clinical ambitions quarterly Attend / facilitate / take heed of feedback from Bi-monthly panels to review all main provider SIs Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Planned Care PB Action Update Delivery Date Action Owner GAPS Planned Care and PPI presented at March 2017 Programme Board Ongoing SH Q3 2016/17 Quality report discussed at June 2017 Programme Board Ongoing JS M1 2016/17 Performance Report discussed at June 2017 Programme Board Ongoing RC Homerton SI Panel held Ongoing JS 2 8 Total 6 Review Committee Chair Feedback: Programme Board Date Risk Conclusion

50 Objective 1 Risk Ref: IH07 Date Risk Added: Improve the health of our patients Increasing pressure on GP resources could mean an increase in rates of referrals to secondary services. This would lead to an increase in costs resulting in a possible adverse effect on the financial position of the CCG Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total Review Committee Planned Care PB OBJECTIVE 1 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The financial impact for the CCG of an increase in secondary referrals is considered [Major, 4] 4 Likelihood This is considered an unlikely occurrence [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Strengthen secondary care providers through identifying Clinical Leads across different specialities Develop and carry out audits on out-patient activity Develop work plan to strengthen pathways of care Review Secondary Care service opportunities working with the Consortia ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Outpatient refferal audits have been undertaken in 2017/18 Clinical Leadership programme underway with HUH. Rheumatology and Urology priority areas for planned care. Work continuing on community services : CHS reviews - developing Gynaecology and Dermatology service. Active promotion of services such as ENT and Minor surgery. Virtual fracture clinics in development. Teledermatology pilot commenced, MECS in final development and to be implemented by Q1 2017/18 Review Committee Chair Feedback: e Programme Board Planned Care Programme Board Risk Conclusion ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Annual appraisal: Undertaken 21st April 2017; supporting paperwork Audit developed and carried out: Audit reports and minutes of PCPB Work plan agreed and review and development of pathways of care underway, work plan updated on an ongoing basis Consortia review / proposals and updates presented at PB. Minutes / review documentation Action Update Delivery Date Action Owner GAPS Planned Care to submit proposals following engagement with clinical leads/consortia/gps 31/03/2017 PC PD 4 meetings held in for Rheumatology, 2 for Urology 31/03/2017 PC PD MECS Spec and MECS Overview Spec approved at Planned Care Programme Board Ongoing PC PD Total 8 Date 20/02/2017 Objective 1 Risk Ref: IH08 Date Risk Added: Improve the health of our patients Controlled Drugs (CDs) - assurance of appropriate prescribing & access Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total Review Committee Prescribing Programme Board OBJECTIVE 1 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of inappropriate prescribing and access of CDs is considered [Major, 4] 4 Likelihood Inappropriate prescribing and access to CDs is an unlikely occurance [Unlikely, 1] 1 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Proactive & regular data analysis of prescribing activity relating to Controlled Drugs to feed into PPB / London CDAO ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Quarterly CD prescribing reports to be downloaded from epact.net. Review Committee Chair Feedback: Programme Board ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Regular & planned review of CD prescribing patterns not in place currently Actions Update Action Owner Delivery Date GAPS Have started to review epact data- have volume of CDs prescribed available on epact but not daily Programme Director defined dose Prescribing/ Prescribing Programme Board Date Total 4 Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Objective 1 Risk Ref: IH09 Improve the health of our patients HUHFT has experienced significant increases in CYP Crisis attendance at A&E, a large proportion of these cases relate to self harm : Oct = 7; Nov=10; Date Risk Added:10/07/17 Dec = 9; Jan =17; Feb=21; Mar=20. Over half of those who die by suicide have a history of self harm; this increase in CYP who are presenting for self harm significantly increases City and Hackney's risk of high suicide levels in our young people later in their childhood / adolescence, or in adulthood. This increase demand is also impacting on the A&E 4 hour target. Risk Owner : Mental Health Programme Board Director Review Committee: Mental Health Programme Board Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total OBJECTIVE 1 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of a child suicide is always going to be high and we cannot expect to reduce this. 5 Likelihood A multi-agency response [working with our partners] is required to reduce likelihood of increase suicide rates in City and Hackney. Ideal score of [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Crisis workstream - CAMHS Alliance (Improving the crisis pathway) which links with some of the MHPB's work with schools Self harm reduction rates evidenced by Audit data 24/7 all age crisis resolution / increase capacity in CYP Psych Liaison at HUH Improved management of self-harm and reduced re-attendance/ reduction in repeat acts of self harm / reduction in A&E breaches Total 10 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Actions Update Action Owner Delivery Date GAPS CAMHS Alliance Workstream deliverable - prevention through to Crisis Pathway redesign Greg Condon Apr-18 Main gaps are 1) timescales in completing the work, 2) Increase investment in to Psych liaison service - funding not yet confirmed Greg Condon TBC multisystem solution (just doesn't sit with CAMHS Alliance) Review Committee Chair Feedback: Planned Care Programme Board Date Risk Conclusion

51 Objective 2 Commissioning System Development No risks to report at present

52 Objective 3 Risk Ref: IC2 Date Risk Added: Integrated Commissioning A lack of robust joint commissioning arrangements may lead to the CCG committing by default to resource/support provision which has not met the governance requirements of the CCG or is contrary to CCG values/commissioning intentions Risk Owner Prog Director Prescribing Review Committee Prescribing Programme Board Inherent Risk Score (pre-mitigation) Residual Risk Score (post-mitigation) Impact Likelihood Total Impact Likelihood Total OBJECTIVE 3 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact 4 Likelihood 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Establish integrated commissioning governance structure with LBH [SEND Partnership Governance structure] Ensure that resources cannot be committed without the approval of the CCG for the largest cohort of children moving forward: through ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Hackney SEND Partnership Governance structure established (includes integrated commissioning group). Records of joint commissioning takes group meetings EHCP in place, held by the Learning Trust. Copies of EHCP held by the Homerton Hospital FT & Hackney Learning Trust Total 8 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Review Committee Chair Feedback: Programme Board Actions Update Action Owner Delivery Date GAPS There is not yet a clear policy in place to manage the process of reaching agreements regarding EHCPs. Once agreements are made there may be some cost pressure on the CCG, but this will be subject to negotiation and CCG approval. Date Risk Conclusion OBJECTIVE 3 Objective 3 Risk Ref: IC3 Date Risk Added: Integrated Commissioning The Devolution pilot fails to progress as proposed which may lead to funding being redistributed elsewhere as part of a bigger system and may include the local Trust services being reconfigured as part of that system. Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Impact (pre-mitigation) Likelihood Total Impact (post-mitigation) Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact CCG business & finances would be moderately impacted by changes to the scope / delivery of the Devo Programme, Moderate [3] 3 Likelihood It is unlikely that the Devo Programme will not deliver as specified, Unlikely [2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Transformation Board & Members engage effectively with partners (NHSE/PHE/Treasury) to ensure close coordination and managed Review Committee CCG Board / Transformation Board / Integrated Commissioning Board s and updates ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Total 6 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Actions Update Action Owner Delivery Date GAPS No Transformational Director currently in post Devolution plans not yet in place. Review Committee Chair Feedback: Programme Board Date Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

53 OBJECTIVE 3 Objective 3 Risk Ref: IC1 Integrated Commissioning RISK TOLERANCE (The CCG's objective in relation to managing this risk) Impact Likelihood PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Ensure governance arrangements are watertight Risk Owner Chief Officer Insufficiently robust framework of assurance provided by the ICBs to statutory bodies delegating authority Date Risk Added: whilst retaining responsibility could result in them not delivering their legal duties. Review Committee CCG Board / Transformation Board / Integrated Commissioning Board Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION Inherent Risk Score Residual Risk Score Impact (pre-mitigation) Likelihood Total Impact (post-mitigation) Likelihood Total Target Score tbc tbc ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Governance reviewed by legal advisors and Auditors and Terms of Reference for the Transformation Board and ICBs have been prepared for approval by statutory Total tbc ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Review Committee Chair Feedback: Programme Board Action Update Delivery Date Action Owner GAPS Design and implement clear reporting and assurance frameworks / dashboards to ensure that statutory bodies retain oversight and control over delivery of services under s75 agreements Date Risk Conclusion

54 OBJECTIVE 4 Objective 4 Risk Ref: GV01 Date Risk Added: 01/01/2015 CCG Governance If the Board is not sufficiently developed the CCG would not be able to implement and manage its business and would not be meeting its statutory requirements Inherent Risk Score Residual Risk Score Impact (pre-mitigation) Likelihood Total Impact (post-mitigation) Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact Given that CCG GB is supported by other staff within the organisation - there would be support available should the CCG GB underperform, Minor [2] 2 Likelihood It is unlikely that the CCG GB would under-perform [2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Through the CCG appraisal process, ensure individual Members of the CCG Governing Body (GB) are effectively engaged and developed Ensure the whole CCG GB is effectively engaged and developed through a Board wide appraisal and training Engage with practices and other stakeholders [360 Survey] Recruit an additional Lay Member to build capacity across the CCG GB and other Committees ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Engage with practices and other stakeholders Build capacity across the CCG GB and other Committees Ensure individual Members of the CCG Governing Body (GB) are effectively engaged and developed Review Committee Chair Feedback: Programme Board Risk Owner Chief Officer Review Committee CCG Board ASSURANCES & EVIDENCE - how will you know that your mitigations are working? All GB Members have PDPs, Annual individual Board Member appraisal process, review induction programme for CCG GB Members. Records of PDPs completed and Whole CCG GB annual appraisal process, programme of learning By Doing workshops held across the year as required. Board effectiveness development session held, CCG 360 Survey to be carried out, feedback to be used to aid organisational development. 360 report and accompanying data analysis Additional Lay Member with financial expertise recruited as part of succession planning for Audi Chair role. Interview schedule, advert & appointment. Actions Update Action Owner Delivery Date Outcomes of the 360 survey to be assessed in July 2017 Paul Haigh 31/07/2017 to aid organisational development Assess whether Audi Committee needs additional Lay Member support Clare Highton 31/07/2017 Finalise new induction packs for GB Members and Clinical Matthew Knell 31/07/2017 Leads GAPS Date Total 4 Risk Conclusion Objective 4 Risk Ref: GV02 Date Risk Added: CCG Governance A possible over-performance on acute contracts could lead to a financial overspend Risk Owner Chief Finance Officer Review Committee CCG Board Inherent Risk Score Residual Risk Score Impact (pre-mitigation) Likelihood Total Impact (post-mitigation) Likelihood Total OBJECTIVE 4 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact Financial overspend is considered [Moderate, 3] 3 Likelihood This is considered [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Formalise provider contracts, ensure a robust mechanism for monitoring and reviewing provider contracts is in place Review finance performance data Acute risk reserve and contingency held ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Business as usual activities as detailed above New governance structure, involving HUHFT in acute contract management via the Joing Transformation Board (JTB) and Integrated ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Contracts held for each provider organisation, regular performance review meetings held, regular SPRG meetings held. CCG Contracts Office hold a copy of the acute Q&A Finance Data is presented to the FPC at each meeting, the full F&A report is scrutinised by the FPC on a quarterly basis. Minutes & reports. Finance reports the risk reserve position to GB, CEC and FPC. Minutes & reports Actions Update Action Owner Delivery Date Onging CFO Onging Discussed at FPC meeting on 22 May GAPS Total 6 Review Committee Chair Feedback: Programme Board Date Risk Conclusion

55 OBJECTIVE 4 Objective 4 Risk Ref: GV03 Date Risk Added: 01/01/2015 CCG Governance Inherent Risk Score Residual Risk Score Impact (pre-mitigation) Likelihood Total Impact (post-mitigation) Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact The impact of financial overspend is considered [Major,4] 4 Likelihood Financial overspend considered an unlikely occurrence [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Monthly updates on Prescribing Budget to Prescribing Programme Board (PPB) and prescribinig budget data to be uploaded onto GP intranet Working with the Pharma industry' policy As a result of increasing population numbers, people living longer, new drug therapies, NICE Technology Appraisals, Pharmaceutical Industry pricing strategies, there is a risk that the prescribing budget could overspend possibly causing an adverse impact on the financial position of the CCG PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Frequent updates to Prescribers with recommendations on quality, safety as well as cost effectiveness of prescribing PSPs utilised in the following ways: Assigned QIPP areas, report regularly on qualitative as well as quantitative interventions (such as Monthly Primary Care Budget monitoring - by practice & identification of areas of financial pressure Dedicated Joint Formulary Pharmacist supporting JPG agenda setting & decision making Development of appropriate policies & DOI register held Risk Owner Prog Director Prescribing Review Committee Prescribing Programme Board ASSURANCES & EVIDENCE - how will you know that your mitigations are working? This includes via: minimum 4 face to face practice level meetings, GP Education events, minimum 10 Newsletters per annum. Minutes of meetings;' Education / Forum Fortnightly & monthly reports produced by PSPs, Monthly QiPP dashboard, London Procurement Partnership Dashboards, Regular feedback from practices on Budget statements produced for monthly Prescribing Board mtg and FPC based on NHSBSA forecasts of spend. Dashboard reports to PPB & archived on Intranet Updated ebnf available to all Practices (& HUHFT) in City & Hackney Fraud, Bribery and Corruption covered in the CoIs policy & stand alone policy, working with the Pharma industry' policy, Declarations of interest requested from Actions Update Action Owner Delivery Date Budget update provided to PPB at June meeting (12/6/17). Practices have also received an update with regards to progress on their 16/17 prescribing budget allocations at their annual prescribing visit. Awaiting final approval Programme Director Prescribing/ Medicines Management Team Prescribing Programme Board GAPS Total 8 Review Committee Chair Feedback: Programme Board Date Risk Conclusion OBJECTIVE 4 Objective 4 Risk Ref: GV04 CCG Governance Risk Owner Chief Financial Officer Inherent Risk Score (pre-mitigation) Residual Risk Score (post-mitigation) Increased rental charges due to retrospective rent revaluation by lanlords could erode available headroom and Impact Likelihood Total Impact Likelihood Total possibly cause a financial deficit situation Review Committee Finance / Primary Care Committee [s] Date Risk Added: part of the aligned budget portfolio RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact 4 Likelihood Describe the likelihood of the risk happening 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Working with NHS property services and using their expertise in re-negotiating the value and terms and conditions of leases current and retrospective to mitigate the liability to GPs and the CCG ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Ensuring that the vale of the rent increase propsed has been professionally assessed by an independent party [property assessor] - to ensure rent is in line market value / value trends Total 6 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Monthly meeitngs with NHS Property Services Scrutiny of the lease renegotiation process for Hackney practices impacted Actions Update Action Owner Delivery Date GAPS Review Committee Chair Feedback: Programme Board Date Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

56 Objective 5 Primary Care No risks to report at present

57 Objective 6 Risk Ref: PHE02 Date Risk Added: 10/05/2015 Productive Health Economy If Primary care and Community Services are not sufficiently developed and are not established as a first point of call for patients this could lead to an increase in the number of inappropriate attendances at A&E and unplanned admissions to hospital. Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Urgent Care PD Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact Impact of on A&E [increased attendances] and hospitals [unplanned admissions] is considered [Moderate, 3] 3 Likelihood The impact on increased attendances is considered [Unlikley,2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. Total 6 OBJECTIVE6 PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Increase the resilience of Hackney nursing homes through enhancing GP provision to the nursing homes contract Increase support to frail housebound patients at risk of admission through the Frail Home Visiting Service (FHV) Provide C&H patients with alternative methods of accessing Primary Care Services [not just A&E] through the Duty Doc Service Reduce the number of inappropriate attendances at A&E and unplanned admissions to hospital through Paradoc and SPOC services Mitigate growth in LAS Conveyances Develop and implement a new model of Quadrant for working [objective] ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Quarterly reports from the GP provider presented at Urgent Care Prog Board & CCG Contract Committee Monthly dashboard presented at Urgent Care Prog Board, CCG Contract Committee Ongoing discussions at Urgent Care Prog Board, CCG Contract Committee CHUHSE Quality and Performance Meeting and UCPB Functioning SPOC services, Unplanned Care Board Unplanned Care Board [more detail?] Action Update Delivery Date Action Owner GAPS Review Committee Chair Feedback: Programme Board Date Risk Conclusion OBJECTIVE 6 Objective 6 Risk Ref: PH0E8 Date Risk Added: 14/07/2014 Productive Health Economy Risk that Homerton A&E will not maintain delivery against four hour standard for 16/17 and 17/18. Impact Likelihood Total Impact Likelihood Total RISK TOLERANCE (The CCG's objective in relation to managing this risk) What does success look like? Target Score Impact Failure to 4hr target will have a high impact on patients and providers [Major,4] 4 Likelihood The likelihood of A&E services missing the 4 hour target is [Unlikely, 2] 2 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Increase system resilience through delivering an investment and transformation plan which includes: 1.Additional Clinical Capacity Performance Dashboard presented at UCPB and FPC Divert ambulance activity Maintain and further integrate ParaDoc model CHUHSe quality and performance meeting Deliver a programme of targeted support to A&E A&E Delivery Plan: this covers 5 mandated initiatives including streaming UCPB ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Urgent Care PD Action Update Delivery Date Action Owner GAPS 3 12 Total 8 Review Committee Chair Feedback:Programme Board Date Risk Conclusion

58 Objective 6 Risk Ref: PHE03 Date Risk Added: 06/05/2016 Productive Health Economy Ongoing difficulties in recruiting staff within OOH, A&E and Primary Care will lead to : - difficulties in covering rotas (OOH) - increases in waiting time (A&E) - inability to deliver enhanced services (Primary Care) This impact on primary care capacity will place further strain on A&E through increased attendance. Risk Owner Chief Officer Review Committee Urgent Care PD Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total OBJECTIVE 6 RISK TOLERANCE (The CCG's objective in relation to managing this risk) What does success look like? Target Score Impact The impact of a consistent lack of staff will have a moderate impact on patients and primary care services [Moderate, 3] 3 Likelihood Staffing numbers negatively impacting on primary care services and patients is considered [Possible, 3] 3 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Address provider workforce development Section 256 agreement Copy of signed contract [by C&H CCG and LBH Social Services] Address workforce development issues in Primacy and Community Services Develop and deliver a funded programme [ 700k] of activity to a-piloting Proposal taken to CEC May action plan? Strengthen back office functions of partner organisations Feasibility study and options appraisal to be carried out [maximum 150k LGPPCC Papers April 2016 Total 9 ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Action Update Delivery Date Action Owner GAPS Review Committee Chair Feedback:Programme Board Date Risk Conclusion OBJECTIVE 6 Objective 6 Risk Ref: PHE04 Date Risk Added: 13/02/17 Productive Health Economy CHUHSE OOH contract expires end of November Risk of gap in out of hour service provision. RISK TOLERANCE (The CCG's objective in relation to managing this risk) What does success look like? Impact Likelihood Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Contract extension negotiation taking place between CCG and CHUHSE ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Urgent Care PD Action Update Impact Likelihood Total Impact Likelihood Total ASSURANCES & EVIDENCE - how will you know that your mitigations are working? CHUHSE seeking approval for extension from CHUSHE board 22nd February Minutes of the meting Delivery Date Action Owner GAPS 2 10 Target Score tbc tbc Total tbc Review Committee Chair Feedback: Programme Board Date Risk Conclusion

59 OBJECTIVE 6 Objective 6 Risk Ref: PHE05 Date Risk Added: 16/02/2017 Productive Health Economy Integrated Urgent Care (111) re-procurement risk of negative impact on quality of service provided and risk of both cost and activity increases across the urgent care system. RISK TOLERANCE (The CCG's objective in relation to managing this risk) What does success look like? Impact Likelihood Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Carry out modelling work with stakeholders (patients, clinicians, commissioners) to ensure Clinical Model and Specification are developed with appropriate partners Re-procurement of service to be overseen by appropriate CCG Committees [Audit and CCG GB] Seek to reduce patient attendances at A&E through promotion of alternative services [Duty Doc, digital offer including online access to health information and e- Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Urgent Care PD Impact Likelihood Total Impact Likelihood Total ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Work reporting into the following organisations CEC, CCF, PPI/PUEG/OPRG, UCPB Invitation to tender documentation reviewed by CCG Governing Body. Audit Committee & Governing Body mins Promotional materials produced, work reporting into UCPB 3 12 Target Score Tbc Tbc Total Tbc ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Action Update Delivery Date Action Owner GAPS Review Committee Chair Feedback: Programme Board Date Risk Conclusion OBJECTIVE 6 Objective 6 Risk Ref: PHE06 Date Risk Added: 13/02/2017 Productive Health Economy Delayed Transfer of Care (DTOC) levels have significantly improved, however still remain an issue for the system. Risk that improvement will not be maintained. RISK TOLERANCE (The CCG's objective in relation to managing this risk) What does success look like? Impact Likelihood Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Develop discharge to assess [?] Work with HUHFT and LBH to establish a regular DTOC group to develop effective joint arrangements around discharge Scrutiny of discharge actions through A&E Delivery Plan Risk Owner Chief Officer Inherent Risk Score Residual Risk Score Review Committee Urgent Care PD Impact Likelihood Total Impact Likelihood Total ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Working group established to develop proposals, reporting into UCPB Reporting into UCPB Monitored by the UCPB Target Score Tbc Tbc Total Tbc ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Action Update Delivery Date Action Owner GAPS Review Committee Chair Feedback: Programme Board Date Risk Conclusion Objective 6 Risk Ref: PHE07 Date Risk Added: Productive Health Economy As a result of cuts to local authority statutory services patients could be re-assessed into the healthcare (NHS) remit there is the potential for demand on Continuing Healthcare to increase placing a significant strain on CCG finances. Risk Owner Chief Finance Officer Review Committee Finance Performance Committee / CCG Board Inherent Risk Score Residual Risk Score Impact Likelihood Total Impact Likelihood Total OBJECTIVE 6 RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Impact CCG Business and finance would be moderately impacted by this occurrence [Moderate, 3] 3 Likelihood It is considered possible that CCG finances will be impacted by CHC demand [Possible, 3] 3 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] Report on CHC finance activity - review situation and risk attached Introduce Multidisciplinary Team as a mechanism in place to review CHC care packages & forecast future activity Contain and manage CHC costs and managing quality of service through increased scrutiny of CHC information and commissioning an independent review of the CHC ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Mechanism in place to review CHC care packages & forecast future activity. Best practice would involve regular package reviews. Updates to Broadcare and Rio systems [Dilani] Carry our an independent review of the CHC service to better understand ways which costs can be contained and a quality service delivered. Implement recommendations via an action pla. ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Finance reports now include a section on CHC activity [produced monthly], summary of the current CHC position is reported to FPC each Multidisciplinary Team in places to review and provide trend analysis & review forecasting. Minutes and reports Increased scrutiny of CHC information provide by NELCSU : Regular meetings with CUS CHC manager 7 feedback to FPC, meetings to Actions Update Action Owner Delivery Date Forecast Planning has improved with a more refined process in place. There has been a slight financial impact on the Finance and CCG as a result of the Integrated refined forecasting but Care the process is now more Programme accurate. Manager Independent review of CHC underway Workstream Director Planned Care [Q2] Due to be presented at July 2017's FPC GAPS Total 9 Review Committee Chair Feedback: Programme Board Date Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

60 RISKS REMOVED OR CLOSED FROM THE BAF [old format] Date Risk Added: BAF Ref: MH16 Risk: Psychiatric Liaison (RAID) Service - There may be failure to find a sustainable financial model that supports a core 24 compliant service, therefore impacting on clinical provision, staff morale and CCG reputation in achieving NHSE monitored service compliance and KPIs. No risks have been removed from the BAF since the previous Audit Committee meeting in March Risk Owner Chief Officer Risk Lead Programme Director Inherent risk score before we consider any mitigation Residual Risk score Risk after consideration of controls Risk Tolerance The level of risk the CCG will tolerate in line with the Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total Strength Strength Controls 1=red Assurances Evidence 1=red Control Specific tasks and measure implemented to mitigate the effect of the pricipal 2=amber Reports/information received that confirms controls listed are working effectively what was received and where 2=amber Internal / risks. Ref: 3=green was it presented Date 3=green External Negotiations now complete for a re-designed urgent response Clinical Working Groups and Financial Working Groups have been Working group papers and C1 3 3 Internal Underspend pathway with in efficiency the urgent savings care pathway through is a used Clinical to create Working a established minutes C2 2 As above As above 2 Internal further year s top up funding to bridge any shortfall. Cross Ref: C1 C2 Actions actions taken to directly improve the effectiveness of controls or assurances Action 3 Sign off the implementation plan (mid March) Action 4 Sign off service specifications and KPIs in HOT (end March) Actions completed. Type Control Control Delivery Date Owner Ref: Prog Dir Mental Health Prog Dir Mental Health Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Date Risk Added: Risk 29/5/15 Ref: UC11 Review Committee Mental Health Programme Board Date 20-Jun-16 Committee Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Risk: Non-recurrent funding for primary care initiatives may not be approved beyond 16/17 This will have an impact on Urgent Care systems, potentially increasing A&E attendances & admissions. Risk Owner Chief Risk Officer Lead Urgent Care Programme Risk Tolerance Inherent risk score Residual Risk score The level of risk the CCG will tolerate in line with the before we consider any mitigation Risk after consideration of controls Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total Strength Strength Controls 1=red Assurances Evidence 1=red Control Specific tasks and measure implemented to mitigate the effect of the pricipal 2=amber Reports/information received that confirms controls listed are working effectively what was received and where 2=amber Internal / risks. Ref: 3=green was it presented Date 3=green External Proposal to be developed for crisis and out of hospital services C1 2 two workshops planned 2 Internal Revised for 2017/18 service specifications for include more robust C2 2 performance data presented to UCPB UCPB Minutes 2 Internal performance Non-recurrent indictaors service specifications to better evidence include the review value dates of the for C3 2 Review of service to be presented at UCPB UCPB Minutes 2 Internal overall evaluation of non-recurrent investment. Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Urgent Care Programme Board Date 30-Sep-16 Committee Feedback Risk Conclusion Non-recurrent funding of projects in 2016/17 became recurrent for those projects continuing into 2017/18 in September 2016 following the agreement of the CCG Prioritisation and Investment Committee and the Local GP Provider Contracts Committee.

61 Date Risk Added: 4/10/2016 BAF Ref: CH16 Risk: Unavailability of designated doctor for safeguarding leading to lack of available supervision and clinical advice to medical safeguarding leads. This could lead to wrong decisions and lack of safeguarding actions, with risk of harm, lack of confidence and reputational Risk Owner Chief Officer Risk Lead Carol McLoughlin - Inherent risk score before we consider any mitigation Residual Risk score Risk after consideration of controls Risk Tolerance The level of risk the CCG will tolerate in line with the Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total TBD TBD TBD Control Ref: Strength Strength Controls 1=red Assurances Evidence 1=red Specific tasks and measure implemented to mitigate the effect of the pricipal 2=amber Reports/information received that confirms controls listed are working effectively what was received and where 2=amber Internal / risks. 3=green was it presented Date 3=green External C1 1. NHSE Informed of the situation and ongoing liaison with Written correspondance 2 Tavistock Institute requesting provision of service locally. n/a n/a 1 Internal 2. Liaison with London network to enquire if any other C2 Designated Doctors may be able to fill the position as interim 2 6 September Internal Local Health Safeguarding Forum set up for support - latest message sent out on 6 September 2016 This arrangement is in place, but update is poor, owing to the City & Hackney CCG have agreed to fund supervision through C3 1 distance to the Tavistock. n/a n/a 1 Internal the Tavistock in lieu of a Designated Doctor appointment The Designated Nurse - Safeguarding Children and Young C4 2 n/a n/a 1 Internal People conducts 3-monthly peer reviews with clinicians Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances C1 CCG Chair in discussion with NHSE regarding the management of risk. Control Type Delivery Date Owner Ref: PC Programme Director Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Children's Programme Board Date 16-Sep-16 Committee Chair Feedback Risk Closed as of January 2017 as the deisgnated post-holder has returned to work. Risk Conclusion

62 Date Risk Added: BAF Ref: CH10 Risk: A lack of robust joint commissioning arrangements may lead to the CCG committing by default to resource/support provision which has not met the governance requirements of the CCG or is contrary to CCG values/commissioning intentions Risk Owner Chief Officer Risk Lead Children's Programme Inherent risk score before we consider any mitigation Residual Risk score Risk after consideration of controls Risk Tolerance The level of risk the CCG will tolerate in line with the Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total Control Ref: Controls Specific tasks and measure implemented to mitigate the effect of the pricipal risks. Strength 1=red 2=amber 3=green Assurances Reports/information received that confirms controls listed are working effectively Evidence what was received and where was it presented Date Strength 1=red 2=amber 3=green Internal / External Minutes from joint Hackney SEND Partnership Governance structure C3 2 commissioning task groups 2 Internal established which includes integrated commissioning group (1) Records of joint commissioning taks group meetings demonstrate C5 2.Education Healthcare Plans (EHCPs) are now in place, which 3 robustness of process This means that resources cannot be committed without the EHCPs held by the Learning approval of the CCG for the largest cohort of children moving Trust with copies held by 3 Internal Cross Ref: C1 Actions actions taken to directly improve the effectiveness of controls or assurances All arrangements to be approved via Children's Programme Board Type Assurance Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance reaching agreements regarding EHCPs. Once agreements are made Review Committee Children's Programme Board Date 15-Dec-16 Committee Chair Feedback Risk Conclusion The risk is being managed within defined appetite levels. Date Risk Added: 1/11/15 BAF Ref: M04 Control Ref: Strength Strength Controls 1=red Assurances Evidence 1=red Specific tasks and measure implemented to mitigate the effect of the pricipal 2=amber Reports/information received that confirms controls listed are working effectively what was received and where 2=amber Internal / risks. 3=green was it presented Date 3=green External Maternity programme board have submitted proposals for new Funding or arrangements to progress 6 initiatives in place for Funding agreementsfrom C6 1 Dec-17 3 Internal short The programme term funding board and had extensions discussion to funding with HUH for about these their at risk support Assurance for has socially been vulnerable received through women. examination This element of of HUH the plans: risk has finance. HuH plans to address C7 3 Jan-16 3 Internal plans 7 community to address midwfiery funding teams cuts to operating specialist with midwifery the team services. leader HUH An updated on the community Maternity Programme midwifery team Board restructure in January 2016 provided of possible cuts C8 3 PB minutes Jan-16 3 Internal holding the former public health midwife role. at the Programme Board in July Cross Ref: Risk: Vulnerable women's pathway. This item was added to the maternity risk register and the BAF as cuts to LA funded services meant limited support available for vulnerable women locally. In addition the London review of maternal deaths 2015 has highlighted that Actions actions taken to directly improve the effectiveness of controls or assurances The Programme Board has successfully identfied funding, or other support, to enable projects supporting vulnerable women to continue or commence. Risk Owner Clinical Lead Planned Care Risk Lead Maternity Programme Type Control Inherent risk score before we consider any mitigation n/a Delivery Date Owner Ref: 2016/17 Programme Director Maternity Residual Risk score Risk after consideration of controls Risk Tolerance The level of risk the CCG will tolerate in line with the risk appetite Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Funding for beyond 2018 is not secured but work can be undertaken to further manage this in the intervening time. Review Committee Maternity Programme Board Date 19-Dec-17 Committee Chair / Clinical Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

63 OBJECTIVE 5 Objective 5 Risk Ref: MH17 Date Risk Added: 01/01/2015 RISKS REMOVED OR CLOSED FROM THE BAF [new format] To Address Mental Health Needs Risk Owner Chief Officer Inherent Risk Score Residual Risk Score The IAPT waiting list run by Homerton Hospital and has a waiting list of c1,200. There is a risk that this will not be sufficiently reduced in a Impact Likelihood Total Impact Likelihood Total timely manner leading to a breakdown in referrals to the service and continued failure to meet waiting list targets. Review Committee Mental Health PB RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Total Impact Describe what the impact would be 3 9 Likelihood Describe the likelihood of the risk happening 3 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? Invest c 582,660 of funding to IAPT [used to fund agency staff] Monthly meetings with HUH and the CCG to review progress. Minutes of meetings, The 1300 has now been reduced to c57and the service is on track to fully reduce Triage of some C&HCCG patients to other mental health services Psychological therapies alliance have started triaging patients and referring them on to other services ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Actions Update Action Owner Delivery Date GAPS Action plan developed which includes the following: 1 Review waiting list by telephoning patients Mental Health PD Action 2 - Improved Triaging to correct balance between High Intensity and Low Intensity to 50/50 Action 3 Increase group work Action 4 Increase trainees [agency staff?] Triage of some C&HCCG patients to other mental health services Action 1: Alliance organisations asked to produce Mental Health PD initiatives to reduce the waiting list. Some alliance contingency funding could be made available for this. Action 2: Monitor cross referrals from HUH to Alliance members through the Alliance. Review Committee Chair Feedback: Programme Board Date Risk Conclusion OBJECTIVE 5 Objective 5 To Address Mental Health Needs Risk Ref: MH19 Due to work beginning in November 2016 to clear the IAPT backlog, the IAPT Recovery Rate is predicted to temporarily drop below the 50% Risk Owner Chief Officer Inherent Risk Score Residual Risk Score national target. The IAPT backlog represents 1300 patients that have been waiting for treatment longer than 6 months. Now that they are Impact Likelihood Total Impact Likelihood Total Date Risk Added: being seen their potential for recovery is likely to be lower than a patient seen immediately. This is likely to negatively impact the CCG's Review Committee Programme Director Mental Health /01/2015 nationally published IAPT recovery rate for the next six months while the backlog clearance programme is running. RISK TOLERANCE (The CCG's objective in relation to managing this risk) Target Score Total Impact Describe what the impact would be 3 9 Likelihood Describe the likelihood of the risk happening 3 Is the risk tolerance higher than the residual risk score? Yes / No [if yes, please devise specific actions to reduce this risk & include in controls]. MITIGATION PROPOSED MITIGATIONS - what are you doing to address this risk? [Control] ASSURANCES & EVIDENCE - how will you know that your mitigations are working? We have in place a recovery rate improvement plan to help mitigate the impact. We are in close discussions with our NHSE Assurance team in detailing the current Monthly SPRs with the IAPT service. Recovery rate improvement plan in place and monitored, Provider meeting minutes and papers ACTIONS - How are you planning on achieving proposed mitigations? Actions required to reduce likelihood of risk: Update with between 2-3 actions to describe current activities which would impact the movement of this risk here Action Update Delivery Date Action Owner GAPS Review Committee Chair Feedback: Programme Board Date Risk Conclusion

64 Paper Title New Shared Commissioning Arrangements for North East London Paper Author(s) This paper is the product of joint working across 7 CCGs, directed by CCG chairs and through external support from Simon Standish and Paul Haigh, Chief Officer, City & Hackney CCG in the role of Workstream Lead of the People Management Workstream of the North East London Commissioning Arrangements Programme. Lead Presenter Dr Clare Highton, Chair, NHS City and Hackney CCG Paper Summary (3 bullet points of relevant background to the paper) The report asks the NHS City and Hackney CCG Governing Body to approve recommendations for new commissioning arrangements across North East London, delivered through the appointment of a single accountable officer and supporting governance arrangements, along with a range of people management processes in relation to the single accountable officer role across North East London. These arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. The proposals are seen as a starting point that may evolve over time to reflect progress with the development and implementation of the local accountable care systems. Purpose (delete unnecessary) For discussion and approval Chair: Dr Clare Highton Chief Officer: Paul Haigh

65 Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Approve the recommendation to appoint of a single accountable officer for the CCGs in North East London; 2. Approve the recommendation that the single accountable officer will also act as the STP lead; 3. Approve the recommendation to establish the governance arrangements, including the joint committee and committees in common at system level, to provide clear direction and support for the single accountable officer, including delegated functions. 4. Approve the recommended scheme of delegation and job description. 5. Agree the recruitment & selection process and timeline of the single Accountable Officer role 6. Review and provide comments on the job description for the single Accountable Officer role and provide CCG Chairs with delegated responsibility for final approval. 7. Agree CCG Remuneration Committee in Common arrangements and remit of decision making with respect to the Accountable Officer 8. Agree the host employer and funding for the single Accountable Officer 9. Agree executive support package for the current Chief Officers 10. Note the arrangements for discussing the implications with the current CCG COs Where else has this paper been discussed? There has been no presentation of this paper at any previous meeting for City and Hackney CCG. However there have been discussions relating to commissioning arrangements across North East London in Board Development sessions including one on 5th July This board paper was presented to the NHS Newham CCG Governing Body on 13th September and will have been presented to all 7 NEL CCGs by the end of September. What was the outcome of previous discussions? The discussion at the Newham CCG Governing Body was deferred until 28th September. Chair: Dr Clare Highton Chief Officer: Paul Haigh

66 New Shared Commissioning Arrangements for North East London Introduction and Purpose 1. The purpose of this paper is to recommend to the 7 CCG Governing Boards in North East London, new shared commissioning arrangements in the form of a shared Accountable Officer and supporting governance arrangements. These arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. The proposals are seen as a starting point that may evolve over time to reflect progress with implementation of the local accountable care systems. 2. This paper is the product of joint working across the 7 CCGs directed by CCG Chairs, meeting together as a Steering Group. The recommendations have been agreed by us and we believe that they will offer benefits in terms of a stronger focus for collaborative work and efficiencies of commissioning process that will both underpin the development of local accountable care systems and secure in year delivery of priorities set out in the Five Year Forward View. 3. This paper begins with some important context, talks about the direction of travel for local accountable care systems, before then setting out the proposals for a shared Accountable Officer and supporting governance arrangements. Context 4. Public services have been through a decade of austerity with consequences for service users and citizens. 5. There is consensus that the public sector should work to integrate services and emphasise collaboration rather than competition, and to mitigate the effects of austerity as far as they can. The 2012 Health and Social Care Act is still the legal framework, and any changes must be compatible with statutory duties of a CCG as laid out in the Act. 6. The NHS 5 year Forward View and more recent guidance sets out the expectation of moving towards Accountable Care Systems (ACSs). The NHS Five Year Forward View said: The traditional divide between primary care, community services, and hospitals largely unaltered since the birth of the NHS is increasingly a barrier to the personalised and coordinated health services patients need. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term Chair: Dr Clare Highton Chief Officer: Paul Haigh

67 rather than providing single, unconnected episodes of care. Increasingly we need to manage systems networks of care not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does. And services need to be integrated around the patient. 7. The East London Health and Care Partnership (ELHCP) Sustainability and Transformation Plan (STP) gives the overall strategic direction of shifting towards self-care, prevention, and care closer to home, trying to address the health and social inequalities that are marked across NEL, using Marmot principles in relation to the wider determinants of health. It attempts to show ways to improve outcomes while striving for financial balance, in the context of a large financial gap and population growth. 8. This broader approach requires strong partnership working between the NHS and others, with Local Authorities being very key partners. Local authorities are keen to be involved and boroughs provide the main sense of place to most people. Local accountability is important to service users and citizens. 9. It is anticipated that ACS s will evolve into entities which will hold a capitated budget, and are accountable to their local population and the commissioners for health and social care outcomes. 10. Across the STP there are many examples of strong clinical leadership, for example building local professional relationships around specific co-designed patient pathways to improve patient experience and ensure care is cost effective. 11. At the same time there is recognition of the need to enable working at scale where appropriate, with some positive early work around areas like informatics or medicines optimisation, recognising the need to standardise interface functions and some ways of working. CCGs collectively will need to operate with consistency when it comes to commissioning the local ACSs; that includes defining outcomes, framing the budgets, contracting with hospital providers, reviewing performance and evaluating the outcomes. Accountable Care Systems 12. All areas in North East London have made substantial progress in developing Accountable Care Systems, and are clear this is the future direction. 13. All are working to develop integrated commissioning with their local authorities with pooled budgets under section 75 arrangements and the Better Care Fund, and with aligned decision making in other areas. Indeed there is a requirement to have local plans to integrate health and social care budgets by In Barking, Havering and Redbridge (BHR) there is a tri-borough Integrated Commissioning Board, which has a provider and commissioner Board reporting to it. There are 10 localities working to integrate health and social care. The 3 CCGs have Chair: Dr Clare Highton Chief Officer: Paul Haigh

68 had a single accountable officer since their inception, and much of their governance operates in common to enable decisions to be taken that are relevant to all 3 CCGs and on a borough basis when required. 15. In City & Hackney (C&H) there is a history of strong system collaboration and there are now 2 integrated commissioning Boards (ICBs) which meet in common, with 6 voting members, 3 drawn from the Local Authority members and 3 from the CCG s governing body. The Transformation Board is drawn from all local providers and commissioners in health and social care, including the voluntary sector, Healthwatch and the PPI lay CCG member; this board makes recommendations to the ICBs. There are 4 system wide work-streams with aligned LA and CCG budgets covering all health and social care and these, working with the Transformation Board, are the building blocks for the local ACS and for taking forward local transformation work. There are 4 localities for the delivery of community based services. 16. In Waltham Forest and East London (WEL), the three CCGs (Waltham Forest, Newham and Tower Hamlets) work both at borough level and collaborate across the WEL system. There is a long history of such collaboration with a joint clinical strategy group and development of the Transforming Services Together programme, as well as established joint arrangements to commission services from Barts Health. Recent work across WEL has acknowledged the need to align the ACS developmental work in each of the 3 Boroughs more closely with Barts Health s future strategic direction and to develop a single operating framework to ensure consistency of hospital service support to the borough based ACS s. 17. In Waltham Forest, outcome based contracts for community services have been developed. The CCG has been working with the local authority and provider partners to develop a robust approach to a locally owned and responsive Accountable Care System. The ACS is being developed in an incremental way by piloting the approach across four key areas (Community Care (Planned), Integrated Urgent Care, Leaving Hospital Pathways and End of Life Care). The work to create these 4 systems will be managed through the Better Care Together Programme Board which has representatives from WFCCG, NELFT, LA and Barts Health. 18. In Newham, the CCG has developed a very close working relationship with its partners locally and in particular with the London Borough of Newham in pooling some of its resources. The CCG and the Borough have established joint posts in commissioning and are jointly commissioning child health services, mental health using the opportunities of the Better Care Fund to have a transparent approach to the funding of these services. The CCG has redesigned and worked collaboratively with providers to develop an MSK service which is integrated and outcome-based within a fixed budget with robust risk sharing agreements. This has provided valuable learning for the development of an ACS. Chair: Dr Clare Highton Chief Officer: Paul Haigh

69 19. The CCG has also made significant progress working with local partners in developing an ACS which will be primary care-led. The ACS will be commissioned in partnership with LBN and will involve Newham Health Collaborative, Barts Health and ELFT as core partners in the collaboration. The Building Healthy Communities programme and Primary Care Home pilot are key enablers for this. The CCG is establishing the necessary governance in place and working with providers to develop the provider partnership required for these services to go live in Progress towards accountable care in Tower Hamlets has been given considerable impetus through the national Vanguard programme as one of the multi-specialist community provider sites. The vanguard, Tower Hamlets Together, has developed into a strong provider partnership with commissioners which will form the bedrock for Accountable Care System development. From September 2017 the THT Board have been delegated the CCGs commissioning intentions and QIPP monitoring functions, reporting into its Governing Body. The Tower Hamlets Health and Wellbeing Board, whose members include local providers and the voluntary sector, has taken on the overall leadership and governance for Tower Hamlets Together. New joint commissioning arrangements between LBTH and the CCG will report in through this Board. The CCG and Borough are currently out to recruitment for a Joint Director of Integrated Commissioning to lead a new joint team of THT commissioners. THT has also been at the forefront of work on population health, including capitation funding models and locally there are three key population health programme boards, children and young people, complex adults and mainly healthy adults that undertake much of the planning and development work underpinning the local ACS. Evolution of the Commissioning System 21. It is anticipated that the commissioning system will change as ACSs become established. A substantial part of the current CCG s work, in particular, the service development and pathways work, will move into the ACS. Some CCGs already work in a wider system arrangement while others do not. In the transitional period CCGs will continue to need borough/system-based commissioning teams with senior management to ensure the development and delivery of these ACSs using local integrated commissioning levers with Local Authority partners. This will require senior management working with the CCG governing body/bodies and local partners to deliver the new system. 22. CCGs need to nurture the development of ACSs against strong and clear desired health and well-being benefits. CCG members are playing a key role within the emerging ACS s as they develop networks of services on the ground. Many CCG members are focussing now on the delivery of new models along with local partners. Chair: Dr Clare Highton Chief Officer: Paul Haigh

70 23. The development of ACS s will take time and there is an important transition management role for CCGs. CCGs continue as statutory organisations through this period and retain both responsibility and accountability for achieving performance locally and living within allocations. A key goal for all CCGs is to secure an effective local ACS capable of delivering improved service performance, improved population outcomes and long term sustainability. The AO will develop links with national work on ACS development so that learning can be shared across NEL. 24. At a NEL level, commissioning needs to evolve into commissioning the mature ACSs. Time and resource can be unlocked through being more efficient and in practice this means undertaking certain functions once across the 7 CCGs. This includes how CCGs account for performance upwards to the NHSE on critical change and transformation issues, including the delivery of the FYFV priorities. 25. Additional resources can become available to NE London if CCGs can take on, together, the commissioning of specialised services valued currently at around 630m per year (indicative 7 borough based allocations) in association with NHSE. By working effectively together, having one Accountable Officer (AO) and a robust governance structure, CCGs can also access funds for transformation; our share of the Strategic Transformation Fund (STF) rises annually to 136m by It is clear that having one AO, combined with their role as STP lead, is a precondition for transfer and then application of these funds locally. Finally, NEL CCGs would like to negotiate direct access to Health Education England funding for decision making locally on key areas of workforce development that fit with priorities for ACS development and service change. 26. One of the key relationships is with our hospital and mental health providers since they will be integral to delivering services as part of the local ACSs. Much of the commissioning of hospital services will be part of the local ACS to ensure that local partners work effectively together to re-shape and then integrate services. The planning and delivery of this need to be locally determined. 27. However, there are some big order issues for hospital providers that require collective attention and action. CCGs are committed to ensuring the longer term viability of Barts Health, BHRUT and the Homerton but can only do this by working together to agree the overall shape of services, develop an aligned commissioning strategy for each of the large provider Trusts which supports the delivery of the ACSs and most importantly how to move to new payment arrangements away from payment by results (PBR) in order to ensure that hospital partners can play their full part within the local ACSs. Failure to address these issues collectively will lead to instability of services locally with the risk of inequity across the NE London system. Chair: Dr Clare Highton Chief Officer: Paul Haigh

71 The current arrangements do not effectively secure focus, attention and follow through on those things which are better done together. The appointment of one Accountable Officer will provide leadership and focus on those things which are done collaboratively and in ensuring that the big changes required to support local ACS effectiveness are delivered. Some of the strategic issues for acute services need to be addressed by the 7 CCGs together whilst others will be more appropriately progressed at a system (BHR, WEL and City and Hackney) or at Borough level. Role of the East London Health Care Partnership (ELHCP) 28. The partnership is established to develop and implement a collective strategic plan (the STP) to address the quality performance and financial challenges that are unique to the population in NEL and take forward the Five Year Forward View priorities. It involves local authorities, providers, commissioners and other third parties under an independent chair. Touch points, where collaborative action across North East London (NEL) is beneficial, have been set up. It is likely that debate about population outcomes, benchmarking of data and action to share best practice and improve quality will be an ELHCP function. The ELHCP does not have a legal status, but is the place for debate and making collective recommendations to the commissioning system. It is proposed that the single Accountable Officer (AO) is also the lead for the ELHCP and will responsible for ensuring that ideas can be brought to fruition through the ACSs when changes are agreed by commissioners. The proposed New Commissioning Arrangements 29. We are proposing a change in the commissioning arrangements for NE London with two key propositions: a. The appointment of a shared Accountable Officer who will also take the STP lead role b. The establishment of new shared governance arrangements to support commissioning at NEL, system and individual borough levels 30. The Accountable Officer will be appointed by the 7 CCG governing bodies to be the AO for each of the CCGs but in particular to lead strengthened collaborative functions and work across the 7 CCGs. 31. The functions work stream has undertaken some initial work on functionality at the 7 CCG level. On the basis of their work, they propose that the following are delivered collectively through a Joint Committee: the commissioning of specialist services the strategic development of primary care Chair: Dr Clare Highton Chief Officer: Paul Haigh

72 the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs the agreement of acute services strategy including the approaches to payment workforce development development of the framework for commissioning of local ACSs first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 32. All other areas will be undertaken at a system level or individual borough level using governance structures such as Committees in Common and / or Section 75 Agreements where needed. These will include for example: a. Mental health and community services commissioning b. Quality and safety c. Integrated commissioning d. Implementation of some decisions taken at a NEL level i.e. implementing and utilising the ACS commissioning framework 33. The administration of the Strategic Transformation Fund would be led by the AO although decision making on disbursement is a function of the 7CCGs working with partners as part of the STP process. 34. CCGs have agreed financial risk sharing in order to ensure the achievement of overall financial performance for the 7 CCGs. An updated agreed process for how this would work is still in progress but we anticipate that the agreed process would be managed by the AO working as part of a new delegated governance process. 35. It is important for NHSE to have a clear and easy communication with the sector when it comes to performance, FYFV priorities and change issues. The AO will be responsible for assuring NHSE and other partners that these issues are being gripped and that action follows with robust delivery arrangements in each system. 36. Clearly this would be a very big job. In practice this option assumes the continuing presence of strong system or borough based leadership and designated staff that will continue to be responsible for ensuring and reporting on local day to day performance, ensuring the delivery of the plans within the local system, local finances and the engagement of local partners in developing the ACSs. Each system where collaborative commissioning already exists, or borough where it does not, would have their own Senior Manager and a team focussed on local delivery. Whilst the local Manager would be accountable to the AO they would be responsible for local delivery in conjunction with the CCG GB(s) and CCG Chair(s) with jointly Chair: Dr Clare Highton Chief Officer: Paul Haigh

73 agreed objectives. The single AO will be responsible for the alignment of the CCG plans and for the big system changes. 37. The AO will also be supported by a small corporate team focussed on the functions undertaken at scale and for the collaborative process on the big issues. The AO will lead a team comprised of the Borough/System leaders and Corporate Directors, including a lead Chief Finance Officer, acting together to provide executive lead for the NEL commissioning system. It is proposed that work should be undertaken to define the borough and shared teams over the next few weeks with a further paper presented to November Governing Body meetings. 38. It is important for us to emphasise that the AO is an Accountable Officer for each CCG separately. They will be members of each CCG governing body and act with each to take local responsibility for local performance. The current AOs responsibilities are formally set out in the CCGs Schemes of Delegation and a revised set of Schemes of Delegation will need to be produced to take account of the NEL AO role. This is a mechanism both for clarifying the roles and responsibilities of the AO but also for ensuring that the accountability of the AO to the CCGs governing body is clear. The AO is unable to exceed the powers delegated to them in these Schemes of Delegation which can provide CCG governing bodies with some additional assurance that the single AO will still need to work with and for CCG governing Bodies to agree strategies and priorities and implement them. 39. For those areas of collaborative work and functionality across the 7 CCGs, the AO will need a new and different kind of collective governance drawn from each CCG. This is to ensure effective decision making and oversight for those aspects of policy, change and commissioning which CCGs have delegated upwards. We wish to emphasise that joint decision making is the product of the CCG governing bodies acting together and not the responsibility of an AO and their team working in isolation as an Executive. 40. The Governance work stream has considered the options for how to achieve effective governance at this level and they suggested a joint committee. This joint committee would be responsible for the strategic functions that need to be done at NEL level as set out in point 31 of this paper. The document on Scheme of Delegation defines areas of responsibility at GB level, Committee in common, Joint Committee and ELHCP Board. 41. However, given the importance of preserving local accountability, sovereignty and the concept of subsidiarity, which are key aims for local people and local authorities, appropriate governance arrangements are required at a more local level. These will Chair: Dr Clare Highton Chief Officer: Paul Haigh

74 include the use of Committees in Common for functions where CCGs wish to collaborate at a system level (including the option of Governing Bodies choosing to meeting in Common ) and Joint Committees with Local Authorities to oversee Section 75 Agreements and other agreements relating to ACS development and management. The recommended composition and terms of reference are set out in a separate working paper. 42. The AO will be a key member of the Joint Committee whose additional membership is recommended to include the 7 CCG Chairs, 7 CCG Lay members and two other clinical members (Nurse and Secondary Care Clinician). This Committee would agree the objectives and work programme for NEL collaborative work encompassed by the delegated functions. Members of the Committee are then jointly accountable for achievement of the objectives and work programme with the AO taking the lead role in securing delivery. 43. The AO will also be a key member of any committees in common that may be established by Governing Bodies to support collaborative working at a system level. A separate proposal setting out how the NEL Chairs and Governing Bodies will work together to appoint the AO has been developed for consideration by Chairs and Governing Bodies. 44. The AO will be line managed for administrative and HR issues by the Chair of the CCG that employs the AO, which will be different from the NEL CC Chair s CCG. There will be a MOU between the 7 CCGs to describe how the management of the AO will be exercised and the roles of the individual CCGs and the Chairs. Attached at appendix one is a job description. 45. Figure one illustrates the assumptions made about functionality and governance with the following key assumptions: a. Agreed delegated financial responsibility for specialist commissioning and STF monies and this might be added to by further access to HEE spend and the risk pool. b. Continuing local CCG financial responsibility for hospital, mental health, and community and primary care budgets. c. Continuing local CCG and Local Authority responsibility for agreed integrated commissioning of health and social care. Chair: Dr Clare Highton Chief Officer: Paul Haigh

75 Figure one 46. These governance arrangements will need to connect effectively with joint arrangements to support decision making as part of the STP and those critical local governance arrangements, the local Health and Well- Being Boards, which oversee integrated health and social care. 47. In parallel to the appointment, further work would be undertaken to confirm the areas of delegation and the precise form of governance required for collective decision making. There is likely to be need for consultation with CCG members on delegation of powers. 48. It is proposed that work should commence now through the auspices of the existing Commissioning Arrangements Steering Group to further define any new corporate Chair: Dr Clare Highton Chief Officer: Paul Haigh

76 positions and the local leadership arrangements. These proposals should be presented to the October 2017 Governing Bodies for consideration. 49. Subject to the approval by the 7 CCG governing bodies we wish to ensure that the AO is in place along with the new governance arrangements no later than January 1 st 2018 and earlier if possible. In order to achieve this the following actions will be required: a. Confirm agreement to the STP part of the job description with NHSE/I and with local providers b. Advertise and select the AO; noting the interview panel needs majority CCG Chair representation given their relationship with AO is critical c. Confirm the areas for delegation and the precise form of the new Joint Committee and any system level Committees in Common d. Consult CCG members on any changes required to constitutions to enable the delegation of functions to the Joint Committee or any system level Committees in Common Financial cost of proposed changes 50. It is not possible to cost the proposed changes until further work is completed on the local borough and shared teams however; there is an expectation that the proposed changes will be cost neutral. Costs will be set out in the October 2017 Governing Body paper noted above. Summary of Benefits 51. We are asking the 7 CCG governing bodies to approve the appointment of a shared Accountable Officer who will also lead the STP. We are also asking for the approval in principle of new governance arrangements, including the Joint Committee and the Committees in Common at a system level, to provide clear direction and support for that role with delegated functions. We believe that these two proposals will provide the following benefits: a. A clear focus on those critical aspects of strategic collaboration which will support the local development and operation of the emerging accountable care systems at the system and borough levels b. Strengthened collaborative arrangements to enable access to greater commissioning resources c. Efficiencies of commissioning process that will free up local time to build on the progress already made locally on integrated health and social care d. Continued local management presence at the system and borough level to ensure local development and continued local accountability Chair: Dr Clare Highton Chief Officer: Paul Haigh

77 e. Clearer lines of communication with regulators on performance and with partners for system transformation and sustainability The Governing Body is asked to approve the proposals set out in this paper. Appendix 3 FURTHER GOVERNANCE ADVICE IN RESPECT OF JOINT COMMISSIONING ARRANGEMENTS BETWEEN THE NORTH EAST LONDON CCGs Background The 7 CCGs in North East London wish to adopt new shared commissioning arrangements in the form of a shared Accountable Officer and supporting governance arrangements. Advice has been requested on the specific constitutional steps that each CCG will need to take in order to establish a joint committee, Governing Bodies meeting in common and committees in common in order to give effect to the proposed governance arrangements. Establishing a Joint Committee City and Hackney CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. Chair: Dr Clare Highton Chief Officer: Paul Haigh

78 The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution. Changes to the Scheme should therefore ideally be subject to the agreement of the Members Committee by Special Resolution. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV Governing Bodies meeting in common Arranging for Governing Bodies to meet at the same time, in the same location, and with a common agenda does not require specific constitutional changes. Each CCG must ensure that it complies with the requirements of its standing orders in respect of calling meetings; giving notice to members and advertising to the public. Each CCG will need to issue its own agenda and set of papers for the meeting, albeit that there may be content in common. Establishing Committees in Common ( CiC ) It appears from the governance proposals that have been tabled that the CCGs may wish to form more than one committee in common, and that not all CCGs will necessarily join each such committee. The overall approach to the formation of committees in common is as set out in our previous advice. Generally, the approach will be as follows: The CiC will be a committee of the Governing Body, and therefore the Governing Body will need to approve the terms of reference and membership, and agree to the delegation of relevant functions to the CiC. The CCG's Scheme of Delegation will need to be amended to reflect the delegation of functions to the CiC. Amendments to the Scheme of delegation must be agreed by a special resolution of the Members' Committee of the CCG. Chair: Dr Clare Highton Chief Officer: Paul Haigh

79 It is also recommended that the amendments to the scheme of delegation are approved by NHS England as amendments to the Constitution. Capsticks Solicitors LLP 7 th September 2017 Chair: Dr Clare Highton Chief Officer: Paul Haigh

80 AccountaOfficer N o r t h E a s t L o n d o n C l i n i c a l C o m m i s s i o n i n g G r o u p s Accountable Officer North East London Clinical Commissioning Groups Grade: Reports To: Accountable To: Very Senior Manager (VSM) Chair of NEL CCGs Commissioning Committee Chairs of the Governing Bodies for the CCGs within the collaboration Base: Hours: To be agreed but with a requirement to be regularly present at CCG sites within the collaboration Full time Context North East London CCGs have been successful in delivering strong clinical commissioning in collaboration with our patients and in developing strong relationships with providers and partner local authorities to jointly plan services which deliver improvements for our diverse and growing populations. We have recognised that there are a number of areas where strong leadership is needed to coordinate our collective work to achieve our ambitions as quickly as possible but in a way that adds value to the efforts at a local level to support the move to Accountable Care Systems. The NEL CCGs are therefore looking to appoint a single Accountable Officer to support the work of the 7 statutory bodies and also act as convener for the NEL Sustainability and Transformation Partnership. The successful candidate will be the Accountable Officer for all seven CCGs supporting them to discharge their statutory responsibilities at the same time as working at scale, to ensure that outcomes are improved, the FYFV is delivered and that NEL moves rapidly towards Accountable Care Systems. The following local organisations within North East London are working together as the East London Health and Care Partnership to deliver the North East London STP s plan Clinical Commissioning Groups: Barking & Dagenham; City & Hackney; Havering; Newham; Redbridge; Tower Hamlets and Waltham Forest Local Authorities: Providers: Barking & Dagenham; Corporation of the City of London; Hackney; Havering; Newham; Redbridge; Tower Hamlets and Waltham Forest Barking, Havering and Redbridge University Hospitals Trust; Barts Health NHS Trust; East London NHS Foundation Trust; Homerton University Hospitals NHS Foundation Trust; NELFT NHS Foundation Trust NHS England, Health Education England and UCL Partners are also supporting the NEL partnership. The role The job description is split into 3 elements

81 The statutory role of CCG Accountable Officer (section 1) The role as convenor of the NEL STP (section 2) The local operating model across the NEL CCGs (section 3) The attributes and skills for each element of the role are outlined in the person specification MAIN DUTIES AND RESPONSIBILITIES SECTION 1 - ACCOUNTABLE OFFICER TO EACH CCG The Accountable Officer is responsible for ensuring that each CCG complies with its obligations under section 14Q of the NHS Act 2006 (duty on CCGs to exercise their functions effectively, efficiently and economically); its obligations under section 14R of the NHS Act 2006 (duty as to improvement in quality of services); its financial duties under sections 223H 223J of the NHS Act 2006; its duties in relation to accounts and audit, the provision of financial information to NHSE and the provision of information required by the Secretary of State under paragraphs of Schedule 1A of the NHS Act 2006; and any other provisions of the NHS Act 2006 as specified in guidance published by the NHSE. The Accountable Officer is responsible for ensuring that the CCG fulfils its duties to exercise its functions effectively, efficiently and economically thus ensuring improvement in the quality of services and the health of the local population whilst maintaining value for money. The Accountable Officer will, at all times, ensure that the regularity and propriety of expenditure is discharged, and that arrangements are put in place to ensure that good practice (as identified through such agencies as the Audit Commission and the National Audit Office) is embodied and that safeguarding of funds is ensured through effective financial and management systems. The Accountable Officer, working closely with the Chair of each of the Governing Bodies, will ensure that proper constitutional, governance and development arrangements are put in place to assure the members (through the Governing Body) of the organisation s ongoing capability and capacity to meet its duties and responsibilities. This will include arrangements for the ongoing development of its members and staff The Accountable Officer is also responsible for ensuring that each CCG exercises its functions in a way which provides good value for money It is for the Chief Executive of NHS England, as the Accounting Officer for that organisation, to confirm the appointment to the role of CCG Accountable Officer. This does not create an employment relationship between the AO and NHS England. NHS England will have a role in the performance management of the AO and have the authority to remove AO status in the event of significant concerns. The individual who undertakes the AO role is required to be a member of the CCG s Governing Bodies and therefore needs to meet the core requirements for Governing Body members and work within the constitution for each CCG. Regulations also provide that some individuals are not eligible to be appointed to CCG Governing Bodies. These are summarised on the final page. Full details are detailed in schedules four (which deals with lay membership) and five of The National Health Service (Clinical commissioning groups) Regulations The effect of the provisions of Schedule Five is that MPs, Local Authority Councillors and employees or members of organisations that support the CCG in delivery of services are amongst those precluded from being members of the governing body. This includes any NHS England employee as well as Commissioning Support Unit (CSUs) employees. As the AO must be a member of the CCG s governing body none of the individuals listed above can therefore be the AO. The AO may not also hold the position of Chair of the Governing Body, nor be the CFO AO appointments must also take account of the Professional Standards Authority standards for members of NHS boards and CCG Governing Bodies in England. SECTION 2 - CONVENOR OF THE STP From 1 April 2017, all NHS organisations are expected formally to be part of a Sustainability and Transformation Partnership (STP). These partnerships lead the development of the initial proposals developed in October 2016 into

82 agreed plans for improving urgent and emergency care, cancer, mental health and cancer services whilst managing within a shared financial control total. These plans must now be updated in light of the two year operational plans that have now been agreed, as well as local engagement with NHS staff, patients and communities. They should also reflect key national milestones set out in Next Steps on the NHS Five Year Forward View published in March STP leaders will be at the heart of the NHS transition towards a system based on collaboration, with commissioners, providers and local government working together to improve services. STP leaders will be responsible for convening these systems, developing the governance required to make effective decisions, directing STP resources and most importantly driving the rapid implementation of key service improvements. The key responsibilities are Convening a Sustainability and Transformation Partnership composed of local NHS organisations, including primary care, local government and other public services. STP leaders will normally chair the STP except where an independent chair is in place with an STP board from constituent organisations and including appropriate nonexecutive partnership. An early task will be to improve collective governance, ensuring that decision-making is effective and responsive enough whilst remaining consistent with the individual statutory accountabilities of their constituent bodies. In some cases, this may include working with accountable care systems operating as part of a wider STP. These systems will be directly accountable to their populations and to the national bodies for improving services within their share of the NHS resources, but they will also be expected to play a part in the STP in order to collaborate on issues that cross boundaries. Overseeing improvements in priority services as set out in Next Steps on the NHS FYFV with a focus on: Improving A&E performance and upgrading the wider urgent and emergency care system so as to manage demand growth and improve patient flow in partnership with local authority social care services. Strengthening access to high quality GP services and primary care, which are the largest point of interaction that patients have with the NHS each year. Improvements in cancer and mental health - common conditions which between them will affect most people over the course of their lives. STPs are vehicles for collaborating across traditional divides to improve these and other services. Managing within the funding available for their populations as defined by shared system control totals across commissioners and NHS providers, together with relevant local government budgets for the wider health and care system. Although this does not in any way supplant the financial accountabilities of constituent organisations, a successful STP must facilitate financial sustainability and enable organisations to achieve greater efficiencies together than they could separately. Leading conversations with patients, staff and local communities and involving them in STP plans. STP leaders will need to engage a very diverse set of stakeholders from service users, to staff, the voluntary sector, local government, elected members and MPs, and others. Providing overall strategic leadership for the STP charting a locally specific course for ameliorating health, improving care and managing the available share of the NHS budget. This includes updating the initial STP proposals put forward in October 2016 in light of the 2017/ /19 contracting and operational planning round and translating these plans into local implementation plans with clear accountabilities for delivering local goals and the key national milestones set out in Next Steps on the NHS Five Year Forward View. This strategic leadership role may also include developing the STP towards an accountable care system systems in which NHS organisations (commissioners and providers), in partnership with local authorities, choose to take on collective responsibility for resources and population health. Managing and engaging the network of wider organisations that contribute to the delivery of NHS services, including the academic sector, voluntary/charitable/social enterprise sector, and independent sector. Ensure the STP has necessary programme management and implementation capability. Most of this capability will be drawn from constituent organisations. However, NHS England will also deploy its own local staff under the direction of the STP where appropriate. This may also include aligning CCG management teams or governing bodies with the STP. Working with the national leadership bodies. At the same time as convening local action, STP leads will be the key point of contact for the national bodies, particularly NHS Improvement and NHS England, which will exercise their powers in consultation with STP leads where this will facilitate improvement. The national bodies will also regularly work with STP leaders on how to evolve the national architecture to better support local progress, for example, by simplifying regulatory relationships. SECTION 3 - LOCAL OPERATING MODEL ACROSS THE NEL CCGs The NEL AO will take responsibility for supporting the delivery of the following areas as it is agreed that these need strategic leadership across the NEL footprint given:-

83 o o o o The ambition to create ACSs which will require coordination of a significant change programme. The ambitions outlined in our STP to improve services and improve patient outcomes. The financial challenges in NEL The need for scale to better deliver our plans through the commissioning system. To provide leadership for reaching collective agreement on how to transform the health and care system across North East London as SRO for the STP and to ensure the execution of these plans through the commissioning system To support the development and implementation of an aligned NEL wide commissioning strategy which reduces system costs and implements new models of care in conjunction with the clinicians and patients in each local system To ensure there are robust local commissioning plans across the CCGs and in each system which will ensure the delivery of the FYFV priorities (mental health, urgent care, cancer, primary care) across the NEL footprint and that NEL can provide a single line of reporting against these to NHSE and other partners. To ensure that there is a commissioning strategy in place within each system to reduce unwarranted variations between the providers and CCGs who make up the NEL footprint and ensure that the individual commissioning plans of the systems don t lead to inequalities across the NEL footprint (this is of particular importance given the patient flows into NEL providers). To ensure the effective management of the delegated commissioning functions from NHS England relating to Primary Care, ensuring effective systems are in place within each system to manage the delegation and ensure objectives are met. To establish arrangements for and lead the implementation of an operating model for the commissioning of specialised services for NEL as NHS England develops delegated and/or joint arrangements. To ensure that the work on provider collaboration and productivity is implemented through commissioning arrangements across NEL To provide leadership to the agreed NEL STP touchpoints, (beyond the FYFV priorities) of workforce, prevention, maternity, medicines optimisation, learning disabilities, ensuring that there are system wide plans to address these underpinned by robust commissioning arrangements in each of the systems. To support the coordinated introduction of payment reform across NEL in conjunction with local systems To ensure that robust plans are developed for any new monies available to NEL, that the plans have partner support and will achieve improved outcomes and STP ambitions and that there are commissioning arrangements in place to ensure the outcomes are achieved. To ensure that there is transparency and openness across the CCGs in how all funds are deployed recognising that the CCGs remain the statutory organisations. As CCGs remain statutory bodies with a financial allocation to be used for the benefit of their resident populations, the only way that money can be "moved" across the system is if CCGs agree that this would deliver benefit for their patients and is transacted via a collective risk share agreement. Therefore to be responsible for the development agreement and operation of the agreed risk share so as to ensure good governance and strategic benefit by developing and presenting proposals, ensuring there is agreement on what any funding from the risk share is used to commission, ensuring the plan is transacted via contractual arrangements, ensuring delivery and system impact is achieved and that performance is regularly monitored and reported back to the CCGs. To support the CCGs and local teams in the transition to the end state of ACSs which are each responsible for delivering the outcomes and improvements agreed by the constituent CCGs and local authorities to achieve the STP. The work to put this in place rests firmly with the leaders in each ACS but as the ACSs develop there will be a particular key leadership role for the NEL AO to develop and implement a coordinated plan and change programme across NEL focusing on the functions which will need to be done once in an aligned way including the strategic commissioning of the ACS s and to link with national ACS development work to bring learning back to NEL To establish the performance management system for NEL and ensuring local commissioning plans are in place to deliver national and local performance targets, that appropriate remedial action is taken as required and taking responsibility for assurance and performance management to NHS England on behalf of NEL To ensure that the strategic direction and vision for the CCGs agreed by the Governing Bodies is kept under regular review and support them and the local teams to ensure that their agreed plans are effectively delivered.

84 To work with the CCG chairs to ensure that the CCGs fulfill their statutory obligations whilst working on a larger footprint and ensure that the CCGs exercise their functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCGs constitutions as agreed by their members. To manage the NEL senior managers (NEL Executive and local Borough roles) and support them to be an effective team enabling them to work with patients and clinicians to deliver the CCGs strategic and operational plans and in doing so build the necessary capacity and capability across the managerial and clinical leadership team. To enhance and enshrine a culture that ensures the voices of member practices of the CCGs continue to be heard and that the voice of patients and clinicians is at the heart of decision making. To ensure that the values of the individual CCGs are reflected in new leadership arrangements and in how the CCG duties are exercised. To ensure all governance is effectively managed across the CCGs in line with the terms and requirements outlined within CCG constitutions, NHS England and statutory guidance and the Nolan principles. To ensure the highest standards of practice in the management and development of all staff. To work closely with the Chairs of the Governing Bodies to ensure that individual GB members and all those in leadership positions exercise proper constitutional and governance the ongoing capability and capacity of the organisations to meet their duties and responsibilities and the changing landscape. To ensure the CCGs operate in a way that maintains high standards of public service, public accountability and probity. To ensure that the CCGs, when exercising their functions, act with a view to ensuring health services are provided in a way which promoted the NHS constitution and the NHS Mandate from NHS England. To ensure that the CCGs value diversity and promote equality and inclusivity in all aspects of their business. Initial priorities The NEL AO will be reliant on good local leadership arrangements at each ACS/CCG who can: o Lead integrated commissioning with local authorities as the critical lever to take forward the ACS and improve outcomes. o Work closely with local patients and clinicians to continue to deliver local patient benefits and co-design solutions. o Lead local partnership relationships. o Ensure robust financial management and governance. o Support the transition to an ACS model and associated local organisational development activities o Work with and support the CCG governing bodies. An early priority for the AO is to develop an operating model to discharge this in with the CCG Chairs, GBs, and local partners by the NEL AO. Objectives for the local roles will be agreed between the CCG Chairs and the NEL AO. Similarly the AO will need to develop proposals with the CCG Chairs and GBs for discharge of financial responsibilities and for other collective responsibilities Management Arrangements Although the Accountable Officer will be employed by one CCG, there will be a memorandum of understanding outlining the relationship between the host employer and all the other CCGs to ensure that requirements of all the CCGs are met. As part of this objectives and performance management systems will be developed with the post holder to reflect the objectives of individual governing bodies and their oversight by the individual chairs.

85 Person Specification SPECIFIC ATTRIBUTES AND COMPETENCIES REQUIRED AS ACCOUNTABLE OFFICER (from the national AO job description) o o o o o o o o o o o o o o o demonstrable ability to exercise sound judgement; the ability to understand the limits of his or her management competencies and the wisdom to seek advice when these are reached; an understanding of corporate governance as a key element of integrated governance and of the responsibilities that the accountable officer role needs to ensure these are discharged to a high standard; the capability to secure the full range of management expertise, through their senior team, to ensure that the day-to-day management of all aspects of the CCG s business can be discharged. an understanding of the role of the accountable officer in setting and developing the culture of the organisation and leading the wider organisational development in the context of engagement with key stakeholders; the ability to oversee the development of an organisational vision and values for the organisation; a basic understanding of current legal requirements and good practice in employment practices, equality and discrimination; financially literate with the ability to review critically, challenge and effectively utilise financial information, including financial statements for decision-making; an understanding of the principles of value for money and an ability to challenge performance on this basis; an understanding of the requirements of effective financial governance and probity; a broad understanding of the NHS financial regime and an ability to develop capability within the CCG to enable interpretation of relevant legislation and accountability frameworks; an ability to understand the CCG s risk environment including knowledge and understanding of the strategies that have been adopted by the CCG and the risks inherent in any transformation strategies; good understanding of the role of effective communications and engagement with patients, public, workforce and stakeholders in achieving/delivering CCG objectives and maintaining the reputation of the NHS and CCG; ability to develop a clear and compelling organisational narrative that describes the future strategy of the CCG, and to communicate this narrative and progress to a wide range of audiences; and ability to communicate complex clinical issues in laypersons language at public meetings and through media interviews. Specific further leadership quality o Setting direction - effective leadership requires individuals to contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values. Specific understanding and skills o sound understanding of good governance; o in-depth understanding of health and care, and an appreciation of the broad social, political and economic trends influencing them; o capability to understand and analyse complex issues, drawing on the breadth of data that needs to inform CCG deliberations and decision-making; and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions; o has the confidence to question information and explanations supplied by others, who may be experts in their field; o has the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill; o has the ability to take an objective view, seeing issues from all perspectives and especially external and user perspectives; o strong skills in recognising key influencers and the capability to engage them effectively in the CCG s business; o excellent interpersonal and communication skills, and experience in engaging GPs and other health and care professionals, alongside patients in commissioning that improves quality and secures value for money; and o sufficient understanding of NHS finance and other key organisational issues, such as HR and risk management, to discharge the overall responsibilities of accountable officer. CORE ATTRIBUTES AND COMPETENCIES REQUIRED AS A MEMBER OF THE GOVERNING BODY Each individual needs to: o demonstrate commitment to continuously improving outcomes, tackling health inequalities and delivering the best value for money for the taxpayer; o embrace effective governance, accountability and stewardship of public money and demonstrate an understanding of the principles of good scrutiny;

86 o o o o o o o o demonstrate commitment to clinical commissioning, the CCG and to the wider interests of the health services; be committed to ensuring that the governing body remains in tune with the member practices; bring a sound understanding of, and a commitment to upholding, the NHS principles and values as set out in the NHS Constitution; demonstrate a commitment to upholding The Nolan Principles of Public Life along with an ability to reflect them in his/her leadership role and the culture of the CCG; be committed to upholding the proposed Standards for members of NHS Boards and Governing Bodies in England developed by the Council for Healthcare Regulatory Excellence;3 be committed to ensuring that the organisation values diversity and promotes equality and inclusivity in all aspects of its business; consider social care principles and promote health and social care integration where this is in the patients best interest; and bring to the governing body, the following leadership qualities: o creating the vision - effective leadership involves contributing to the creation of a compelling vision for the future and communicating this within and across organisations; o working with others - effective leadership requires individuals to work with others in teams and networks to commission continually improving services; o being close to patients - this is about truly engaging and involving patients and communities; o intellectual capacity and application - able to think conceptually in order to plan flexibly for the longer term and being continually alert to finding ways to improve; o demonstrating personal qualities - effective leadership requires individuals to draw upon their values, strengths and abilities to commission high standards of service; and o leadership essence - can best be described as someone who demonstrates presence and engages people by the way they communicate, behave and interact with others. Core understanding and skills Each individual will have: o a general understanding of good governance and of the difference between governance and management; o a general understanding of health and an appreciation of the broad social, political and economic trends influencing it; o capability to understand and analyse complex issues, drawing on the breadth of data that needs to inform CCG deliberations and decision-making, and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions; o the confidence to question information and explanations supplied by others, who may be experts in their field; o the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill; o the ability to take an objective view, seeing issues from all perspectives, especially external and user perspectives; o the ability to recognise key influencers and the skills in engaging and involving them; o the ability to communicate effectively, listening to others and actively sharing information; and o the ability to demonstrate how your skills and abilities can actively contribute to the work of the governing body and how this will enable you to participate effectively as a team member. Core personal experience o previous experience of working in a collective decision-making group such as a board or committee, or highlevel awareness of board-level working; and o a track record in securing or supporting improvements for patients or the wider public. PERSONAL QUALITIES REQUIRED AS STP CONVENOR A very senior figure with a track record of leading a major organisation. Deep knowledge and strong relationships in the NHS and local government. Committed to system working, partnering across organisations to deliver on key national priorities as set out in Next Steps on the NHS Five Year Forward View and managing within the total resources available to the system to make these improvements. Expert facilitation and leadership skills; able to work through and with others to achieve tangible and lasting improvements to services. Experience of leading change in an open and inclusive way, with a natural ability to communicate with patients, communities and staff as well as to manage complex political environments. Values driven, with an optimistic outlook and a strong commitment to maintaining a high-quality NHS. OTHER REQUIREMENTS

87 Qualifications Educated to Masters level or equivalent experience Evidence of continuing professional development Experience Substantial senior commissioning experience Substantial experience of managing change successfully, clarifying and establishing organisational direction Experience of inspiring and motivating teams Substantial experience of managing budgets and of planning resources within a health economy Experience of making service changes and working in an environment of accelerated and uncertain change Experience of developing both long and short term strategies across health and social care Demonstrable leadership experience sufficient to be able to command the confidence of all 7 CCGs Experience of working in collaborative and participative way to build agreement Experience of working in partnership with patients and clinicians in co-designing and implementing service plans. Experience of building collaboration and shared leadership where the individual has no line management responsibilities Knowledge, Skills and Abilities Knowledge of NHS Commissioning policy including the Five Year Forward View, Sustainability and Transformation Plans and Operating Guidance Able to think conceptually in order to plan flexibly for the longer term and continually alert to finding solutions and collaborations to improve health services Communication & Influencing Financially literate with the ability to critically review, challenge and effectively utilise financial information, including financial statements for decision-making High level negotiating skills - able to negotiate solutions across a range of partners who may have different perspectives

88 Appointment to Governing Body Roles Disqualification criteria Regulations provide that some individuals will not be eligible to be appointed to CCG governing bodies. Full details are included in schedule 5 of The National Health Service (Clinical Commissioning Groups) Regulations These disqualification criteria therefore apply to the CCG AO The regulations state that the following are disqualified from membership of CCG governing bodies: MPs, MEPs, members of the London Assembly, and local councillors (and their equivalents in Scotland and Northern Ireland); members including shareholders of, or partners in, or employees of commissioning support organisations; - A person who, within the period of five years immediately preceding the date of the proposed appointment, has been convicted - in the United Kingdom of any offence, - outside the United Kingdom of an offence which, if committed in any part of the United Kingdom, would constitute a criminal offence in that part, and, in either case, the final outcome of the proceedings was a sentence of imprisonment (whether suspended or not) for a period of not less than three months without the option of a fine; a person subject to a bankruptcy restrictions order or interim order; a person who within the period of five years immediately preceding the date of the proposed appointment has been dismissed (other than because of redundancy), from paid employment by any of the following: the Board, a CCG, SHA, PCT, NHS Trust or Foundation Trust, a Special Health Authority, a Local Health Board, a Health Board, or Special Health Board, a Scottish NHS Trust, a Health and Social Services Board, the Care Quality Commission, the Health Protection Agency, Monitor, the Wales Centre for Health, the Common Services Agency for the Scottish Health Service, Healthcare Improvement Scotland, the Scottish Dental Practice Board, the Northern Ireland Central Services Agency for the Health and Social Services, a Regional Health and Social Care Board, the Regional Agency for Public Health and Wellbeing, the Regional Business Services Organisation, Health and Social Care trusts, Special health and social care agencies, the Patient and Client Council, and the Health and Social Care Regulation and Quality Improvement Authority. A healthcare professional who has been subject to an investigation or proceedings, by any regulatory body, in connection with the person s fitness to practise or any alleged fraud, the final outcome of which was suspension or erasure from the register (where this still stands), or a decision by the regulatory body which had the effect of preventing the person from practising the profession in question or imposing conditions, where these have not been superseded or lifted; a person disqualified from being a company director; a person who has been removed from the office of charity trustee, or removed or suspended from the control or management of a charity, on the grounds of misconduct or mismanagement. August 2017

89 Appendix 2 Scheme of Delegation (Functions related to NEL Commissioning arrangements) This Scheme of Delegation relates primarily to those functions considered as part of the North East London Commissioning arrangements and provides clarity on some of the other key issues to avoid any misunderstandings. It is not intended to be a comprehensive scheme relating to all CCG functions and responsibilities. CCG Board Committee in Common Joint Committee ELHCP Board (System level functions) (NEL level functions) Delivering CCG financial balance Risk Management of delegated functions Joint CCG risk pool System control total and sector-wide capital spend Administer the transformation fund (STP) Accountable Care commissioning. Development of ACS with Committee in Common Borough implementation of the workforce strategy Development of ACSs Development of ACS Framework for utilisation at local level Produce acute strategy and reform of payment mechanism and implement across NEL Workforce strategy Manage HEE funds Commissioning local acute services Commissioning local acute/mental health/ community services where there is agreement of GBs to do so at system level Commissioning sectorwide services e.g. LAS, maternity, ITU, Mental Health Acute Beds, etc. Approval of specialist commissioning strategy and policy ( 1m) Engagement with acute providers, NHSE (for specialist services) and public on service changes Borough commissioning of Primary Care for example enhanced services Contracting of delegated Primary Care (nb. This is an existing joint committee with NHSE to govern delegated primary care contracting) Primary Care Development strategy PPE for matters reserved to the Committee in Common

90 Developing Commissioning Arrangements People Management Considerations to be considered by NEL CCG Governing Bodies September 2017 Introduction The people management programme delivery group supporting the transition programme to appoint a single Accountable Officer across North East London CCGs, asks the Governing Body to:- Agree the recruitment & selection process and timeline of the single Accountable Officer role Review and provide comments on the job description for the single Accountable Officer role and provide CCG Chairs with delegated responsibility for final approval. Agree CCG Remuneration Committee in Common arrangements and remit of decision making Agree the Host employer and funding for the single Accountable Officer Agree executive support package for the current Chief Officers Note the arrangements for discussing the implications with the current CCG COs Recruitment & Selection process of the single Accountable Officer role The recommendation is to advertise the single Accountable Officer role on NHS Jobs. This will not carry any advertising costs. In line with recruitment and selection processes for similar roles across London, the Governing Body is asked to confirm the following arrangements:- The utilisation of 3 Psychometric tests - Hogan s Business Reasoning Inventory (Strategic and Tactical Reasoning), Hogan Development Survey (personality-based performance risks and derailer behaviours) and the Hogan Personality Inventory. o Estimated costs of c 320 for each candidate, which includes all 3 tests, reports and telephone feedback to candidates. o The outcome of the tests will be fed into the interview panel. Two stakeholders events (one comprising all CCG Governing Body members and one comprising STP partners) - these will comprise of discussion topics which candidates will be assessed on based on 4 core competencies of; Leadership Style, Communication/Listening style, Clarity of Vision and Patient/Citizen Focus. o The outcome of the stakeholder discussions will be fed into the interview panel. Chair: Dr Clare Highton Chief Officer: Paul Haigh

91 o The CCG Chairs will be asked to agree the stakeholder invitation list. A formal panel interview with the following panel members o Chair of each CCG o 1 lay member from CCG GB o NHSE Regional Director for London o Independent Chair of the ELCHP Board o NHSI representative on behalf of STP providers The recruitment and selection timetable for the single AO is included below: Date 6 th October 2017 w/c 23 rd October 2017 w/c 30 th October 2017 w/c 6th November 2017 w/c 13 th November 2017 Activity Advert placed on NHS jobs Shortlisting for role Successfully shortlisted candidates invited to interview Recruitment Process: -Candidates complete Psychometric Tests online prior to attending face-to-face assessments - Day 1: Stakeholder Events x2 - Day 2: Formal Interview Panel Single AO appointment and ratification process The Governing Body is asked to agree these arrangements. Job description for the Single Accountable Officer role The Governing Body is asked to review the proposed job description for the single Accountable Officer role. This incorporates the national Accountable Officer job description and that of a CCG Governing Body member, the national STP convener role and the responsibilities in line with the local NEL operating model as agreed by the CCG Chairs. The Governing Body is asked to note that the CCG Chairs will meet after all the Governing Body meetings have taken place to consider the comments and feedback from each of the Governing Body meetings and finalise the job description. Each Governing Body is asked to provide CCG Chairs with delegated responsibility to finalise and agree the single Accountable Officer job description on behalf of the CCG Governing Bodies. Remuneration Committee in Common The Governing Body is asked to agree to a meeting in common of each CCG s Remuneration Committee. This Committee will be asked to agree the remuneration for the single Accountable Officer role for the advert. Benchmarking information will be provided to the Remuneration Committees in Common to support the decision making process. Chair: Dr Clare Highton Chief Officer: Paul Haigh

92 It is recommended that at the meeting, one of the CCG Remuneration Committee Chairs agrees to facilitate the meeting in common. Host employer arrangements The appointed single Accountable Officer will need to be employed by one of the seven CCGs. In consideration of this, the Governing Body is asked to agree the following: - that the single Accountable Officer should not be employed by the same CCG as the Chair of the proposed NEL Joint Committee. that there should be a Memorandum of Understanding between the employing CCG and the other CCGs outlining responsibilities, relationships and funding arrangements. the recommendation is that once the Chair of the proposed NEL Joint Committee is agreed a further Remuneration Committee in Common meeting is arranged to agree which CCG should be the employer of the single Accountable Officer. The recommendation is also that the agreed host employer will develop the Memorandum of Understanding and ask the Remuneration Committee in Common for final approval of this. Funding arrangements for the single Accountable Officer role It is recommended that the remuneration and on-costs for the role are divided between the CCGs on the basis of each CCG s share of the registered population of North East London. The percentages as shown in the table below will be used to calculate the contributions:- Population CCG 2017/18 % Tower Hamlets 307, City & Hackney 306, Newham 383, Waltham Forest 305, Barking & Dagenham 222, Havering 272, Redbridge 311, Total 2,109, % Chair: Dr Clare Highton Chief Officer: Paul Haigh

93 The agreed funding contribution breakdown will also be included in the Memorandum of Understanding between the NEL CCGs. The Governing Body is asked to agree to this division of funding for the costs of the single Accountable Officer. Executive support for the current Chief/Accountable Officers Whilst managing the change process to transition to the single Accountable Officer management arrangements, it is important to also put in place support for the affected staff. Working Transitions Senior Executive Programme provides enhanced tailored career management and job search support for senior professionals. There are various options for Executive Support and it is proposed that each Chief Officer can agree with the CCG chair the length of support they require dependent on individual needs. A programme of 20 modules (1 module = 1 hour) amounts to 1,600 and a programme of 30 modules amounts to 2,400. Discussions will take place with each Chief Officer to determine their programme preference. The costs of the support to each current Chief Officer will be met by that CCG. The Governing Body is asked to agree to this. 1:1 Engagement meeting with Chief/Accountable Officers (including Letter of Comfort ) The CCG Governing Body is asked to note that prior to the formal papers regarding developing commissioning arrangements being considered by each CCG Governing Body, the CCG Chairs met with their Chief/Accountable Officers to commence engagement on proposed plans. The meeting included discussions on; the implications the new commissioning arrangements had on their current posts, to advise on the change management process to be followed with likely timescales, to outline the support available and also to invite early feedback on plans. Supporting documentation for the meeting included a letter to Chief Officers and meeting outline, which covered all the points discussed at the meeting (also copied to the Chief Officers). Any relevant feedback from these meetings will be fed into the Governing Body discussions by the Chair. Following agreement by each of the Governing Bodies to these proposals, formal consultation with each of the Chief/Accountable Officers will take in line with each of the CCG s Change Management Policy. The consultation process will include discussions on the impact the changes will have on each current Chief Officer s post and proposed transitional arrangements. Transitional Period/plan for Chief /Accountable Officers and redundancy arrangements Following the commencement of a single NEL Accountable Officer, the current CCG Chief/ Accountable Officers will cease to be the statutory Accountable Officer of their CCG. This Chair: Dr Clare Highton Chief Officer: Paul Haigh

94 means the current CCG Chief/ Accountable Officer roles will be dis-established and post holders will be placed at risk of redundancy. Discussions will take place between each current Chief Officer and their Chair regarding individual Chief Officer future plans and the proposed transitional arrangements. It is proposed that the CCG Chair will agree with the current Chief Officer the objectives and transitional role for the next few months. These objectives will be shared with the new AO once appointed and with the Governing Body as agreed. The proposed transition period will be in line with each CO s notice periods which range from 3 to 6 months. The single Accountable Officer once appointed, will be tasked with developing proposals for both the local management arrangements and also joint NEL wide roles, which will be discussed and agreed with CCG Governing Bodies. Individual redundancy arrangements for each existing CCG Chief Officer will be considered by each CCGs Remuneration Committee in line with the CCG scheme of delegation. The Governing Body is asked to note these proposals. Chair: Dr Clare Highton Chief Officer: Paul Haigh

95 Legal opinion provided by Hempsons. Need to consult on appointment of SAO Turning to the question of consultation on the establishment of the AO, there is no constitutional requirement for this. The nomination process has been delegated to Governing Bodies and should be conducted in accordance with good employment practice. However, there will be a general employment duty to consult with current AOs who may be affected by the establishment of the joint AO as potentially they will be at risk of redundancy. Such consultation will be on an individual basis rather than under the collective redundancy rules, and should be commenced once the proposal to appoint a joint AO has been agreed by CCGs. Clearly, the current AOs will be party to this decision in any event as members of their respective Governing Bodies. Legal Basis of establishing Joint Committees and appointing an SAO With regard to the proposed appointment of a shared AO and a joint committee, my advice is as follows. 1. Section 14Z3 of the NHS Act 2006 contains powers for CCGs to undertake joint working, including amongst other things for all the clinical commissioning groups to exercise any of their commissioning functions jointly; and to make the services of employees or any other resources available to another clinical commissioning group. 2. Where any functions are exercisable jointly by two or more clinical commissioning groups, they may be exercised by a joint committee of the groups. 3. Schedule 1A to the Act includes a specific provision that NHS England may appoint a person to be the accountable officer for more than one CCG. 4. With regard to the suggestion that the establishment of a joint committee may conflict with a CCG s duty to promote integration, that duty as contained in s.14z1 of the Act states: (1) Each clinical commissioning group must exercise its functions with a view to securing that health services are provided in an integrated way where it considers that this would (a) Improve the quality of those services (including the outcomes that are achieved from their provision), (b) Reduce inequalities between persons with respect to their ability to access those services, or

96 (c) Reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services. (2) Each clinical commissioning group must exercise its functions with a view to securing that the provision of health services is integrated with the provision of health-related services or social care services where it considers that this would (a) Improve the quality of the health services (including the outcomes that are achieved from the provision of those services), (b) Reduce inequalities between persons with respect to their ability to access those services, or (c) Reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services. 5. Whilst this duty clearly anticipates integration between health and social care services with a local authority, it is not limited to integration of health and social care functions and also promotes integration of health services (whether across acute, community and primary care or across a wider geographic basis). Furthermore, there is no inherent conflict between a joint committee structure and the discharge of the duty to integrate. In exercising the functions that have been delegated to it, the CCG will need to ensure that it considers the objectives of s.14z1 and where appropriate exercises its functions in such a way as to achieve such integration.

97 Further governance advice in respect of joint commissioning arrangements between the North East London CCGs from Capsticks Background The 7 CCGs in North East London wish to adopt new shared commissioning arrangements in the form of a shared Accountable Officer and supporting governance arrangements. Advice has been requested on the specific constitutional steps that each CCG will need to take in order to establish a joint committee, Governing Bodies meeting in common and committees in common in order to give effect to the proposed governance arrangements. Establishing a Joint Committee 1. Barking and Dagenham CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. The formation of the joint committee will require an amendment to the scheme of delegation and as this is expressly stated to be part of the Constitution, this amendment will require the agreement of the Members Committee by Special Resolution. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 2. City and Hackney CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution.

98 Changes to the Scheme should therefore ideally be subject to the agreement of the Members Committee by Special Resolution. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 3. Havering CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution. Changes to the Scheme are subject to the agreement of the Members Committee. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 4. Newham CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution. Changes to the Scheme are subject to the agreement of the Members Committee.

99 In any event, the CCG s Standing Orders provide that where a committee of the Board is established, the details of that committee should be included in Chapter 6 of the Constitution and therefore the Constitution will need to be amended to reflect this. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 5. Redbridge CCG The relevant commissioning functions of the CCG have already been delegated to the Governing Body, so the Governing Body should appoint the joint committee. The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution. Changes to the Scheme are subject to the agreement of the Members Committee. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o the commissioning of specialist services o the strategic development of primary care o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o the agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o first line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 6. Tower Hamlets CCG Whilst the relevant commissioning functions of the CCG have already been delegated to the Governing Body, the scheme of delegation requires the Membership to approve the terms of reference for Governing Body committees, and the standing orders require the Membership to approve appointments to Governing Body committees.

100 The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCGs Constitution. Changes to the Scheme are subject to the agreement of the Membership. In addition, the CCG s Standing Orders provide that where a committee of the Governing Body is established, the details of that committee should be included in Chapter 6 of the Constitution and therefore the Constitution will need to be amended to reflect this. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o The commissioning of specialist services o The strategic development of primary care o The commissioning of services common to all such London Ambulance o Service (LAS) and services outside the scope of the ACSs o The agreement of acute services strategy including the approaches to payment o Workforce development o Development of the framework for commissioning of local ACSs o First line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV 7. Waltham Forest CCG Whilst the Constitution provides for the CCG to work jointly with other CCGs it does not specifically enable the CCG to form joint committees with other CCGs. The constitution will therefore need to be amended to include the ability to form a joint committee with other CCGs. In order to amend the Constitution, 75% of the weighted votes of Members present at a meeting of the Members Council must support the amendment. The relevant commissioning functions of the CCG have already been delegated to the Governing Body, and so, subject to the Constitution being amended to enable the formation of joint committees, any joint committee should be formed by the Governing Body. The formation of the joint committee will require an amendment to the scheme of delegation. This is stated to have effect as if incorporated into the CCG s Constitution and therefore it is recommended that the amendment is approved in accordance with the arrangements for amending the Constitution above. The amendment should specify those functions that will be delegated by the Governing Body to the joint committee, namely: o The commissioning of specialist services

101 o The strategic development of primary care the commissioning of services common to all such London Ambulance o Service (LAS) and services outside the scope of the ACSs o The agreement of acute services strategy including the approaches to payment workforce development o Development of the framework for commissioning of local ACSs o First line of communication for NHSE on critical areas of system performance and change and the delivery of the FYFV Governing Bodies meeting in common Arranging for Governing Bodies to meet at the same time, in the same location, and with a common agenda does not require specific constitutional changes. Each CCG must ensure that it complies with the requirements of its standing orders in respect of calling meetings; giving notice to members and advertising to the public. Each CCG will need to issue its own agenda and set of papers for the meeting, albeit that there may be content in common. Establishing Committees in Common ( CiC ) It appears from the governance proposals that have been tabled that the CCGs may wish to form more than one committee in common, and that not all CCGs will necessarily join each such committee. The overall approach to the formation of committees in common is as set out in our previous advice. Generally, the approach will be as follows: The CiC will be a committee of the Governing Body, and therefore the Governing Body will need to approve the terms of reference and membership, and agree to the delegation of relevant functions to the CiC. The CCG's Scheme of Delegation will need to be amended to reflect the delegation of functions to the CiC. Amendments to the Scheme of delegation must be agreed by a special resolution of the Members' Committee of the CCG. It is also recommended that the amendments to the scheme of delegation are approved by NHS England as amendments to the Constitution. In addition to these general requirements, the following CCGs have specific requirements arising from their constitutions: 1. Newham CCG

102 The CCG's Constitution will need to be amended to include details of the CiC in Chapter Tower Hamlets CCG The Constitution will need to be amended as per Newham CCG above. The membership must approve the terms of reference and membership of the CiC as well as agreeing the amendments to the Constitution and scheme of delegation. 3. Waltham Forest CCG 75% of the membership must approve the amendment to the Scheme of delegation. Capsticks Solicitors LLP 7 th September 2017

103 Paper Title CCG Specific Commissioning Intentions 2018/19 Paper Author David Maher Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) The attached paper sets out the CCGs early plans for its own commissioning intentions in 2018/19. These plans will be subject to discussion and refinement over the coming months with full partner involvement (the public, integrated commissioning partners, ELHCP and more). Purpose (delete unnecessary) For discussion and early approval Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Recognise and discuss the planning process in which these commissioning intentions have been produced; 2. Recognise, discuss and endorse the transition to a new payment mechanism actions outlined in the attached paper; 3. Discuss and feedback on the initial CCG Commissioning Intentions for 2018/19. Where else has this paper been discussed? What was the outcome of previous discussions? Clinical Commissioning Forum (September 2017) Clinical Executive Committee (September 2017) To be discussed at PPI Committee (September 28 th 2017) Clinical Commissioning Forum were prepared to provide more detailed feedback on schemes and future opportunities for quality improvement via the Consortia meetings in October and November. Clinical Executive Committee felt that a different model of outpatients should be a priority. Chair: Dr Clare Highton Chief Officer: Paul Haigh

104 CCG Specific Commissioning Intentions 18/19 CCG Governing Body: September 2017 For discussion

105 1. Context - Previously CCG agreed 2 year contracts with providers to cover 17/18 and 18/19. - NHSE guidance is asking for a revalidation of planning assumptions and contract variations (where required) to be signalled by end of September. This is not a formal contracting round as we have already agreed 2 year contracts. - Our original ambitions were to consult on commissioning intentions as part of the Integrated Commissioning process by end of the year, but we have had to fast-track some of our known plans at a CCG level for this month. - The CCG has the challenge as a planning assumption of delivering QIPP savings in 2018/19 of 2% of overall funding i.e. 7.8m (2018/19 Operating plan balance requires minimum of 5m). - We will be articulating these outline plans in a lot more details as part of the workstreams over October and November.

106 2. Transitional Payment Approaches (STP) Issues with current payment mechanisms Traditional activity based payment models such as Payment by results (PbR), incentivise increased secondary care based activity rather than prevention or improved outcomes. Fixed block funding payment arrangements have no incentive to offer activity above a planned level and do not provide transparency for continuous improvement. Neither approach in their current form reflect the national approach to support ACS development. Proposed approach (STP) Providers and Commissioners are being asked to commit to the following actions to support transition to a new payment mechanism: Joint working to explore alternatives to PbR and fixed block funding arrangements for Develop an options paper for consideration and agreement by the NEL STP to a revised contract payment form framework for the 2018/19 contract year by 31 October This framework would form the basis for further developments at local ACS level Agree the range of services that this would cover, potentially including elective, diagnostic and outpatient care Agree a detailed payment approach for each commissioner contract for December 2017 contract variations To develop and implement a work programme for the introduction of capitated / whole population budgets from , building on the recommendations from the Payment Reform Consultation

107 3. Principles of local reform The revised payment approach would be designed to support the sustainable development of the local health economy. This alternative approach for could potentially include: 1. An overall contract value that reflects the STP s financial control total and a local System Control Total in line with ACS ambitions 2. A block element that reflects the operational cost of service delivery based on a realistic affordable assessment of likely activity from agreed Q1 activity 3. A gain share between provider and commissioner that enable resources to be freed up and reinvested more effectively. 4. Safeguards to ensure that activity below plan does not impact adversely on constitutional standards such as RTT 5. A risk share element where the provider retains responsibility for any costs relating to activity above plan up to an agreed upper collar / ceiling. Cost relating to activity above this ceiling would be the responsibility of the commissioner but paid at an agreed average cost at a marginal rate 6. An agreement for commissioners to meet a provider s stranded costs on a transitional basis where QIPP schemes reduce capacity 7. A robust commissioner demand management programme clinically and operationally agreed by the provider 8. A commitment to work collectively to manage the reallocation of freed up capacity across the system

108 5. Financial Planning The CCG is in the process of establishing a local system-wide control total to deliver 2018/19 financial balance. This will take into account commissioner, provider and local authority intensions, risks and opportunities. Collectively, the partners to Integrated Commissioning will need to: Agree a joint financial plan for the totality of the health and care resources including the Integrated Commissioning Fund. Have a joint approach to prioritisation and development of business cases to access transformation funding. Develop progressive risk share arrangements, which make joint prioritisation of resources and spending decisions a necessity. Develop reporting & analytics in readiness for the full budget pooling envisaged. Set tolerances to reflect demand variations, & agree appropriate risk reserves. Agree principles by which financial savings, and impact of investment schemes will be tracked across partners using cost benefit analysis methodology and benefits sharing arrangements. Device planning cycle and approval process across the partners. In the City & Hackney workstream model, all budgets will be delegated to workstreams which will be responsible for the delivery of budgets and identification and delivery of associated saving schemes. There are a number of protected areas, e.g Mental Health and BCF, where national investment targets have been defined and this needs to be recognised within the workstreams. Workstreams are tasked with identifying the potential savings opportunities that will deliver a balanced budget and control total for the year. Whilst the NHS awaits planning guidance for 2018/19, City & Hackney as a system has the potential challenge of delivering efficiency savings of circa 24.5m overall for the system to achieve control totals and balance budgets. The requirement may increase as a result of overall system pressures with the NEL STP footprint in order for the STP to achieve overall financial balance. This has been factored into the planning model, including any risk share arrangements with our NEL CCGs, together with other known pressures. A re-fresh of the operating plan is expected to be submitted to NHSE in the final quarter of this year.

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110 Timetable Key dates 7th September 2017 Deliverables High level commissioning intentions presented at CCF. CCF 13 th September 2017 High level commissioning intentions presented at Clinical Executive Committee CEC 28 th September 2017 Review of contract approach and proposed contract changes at Finance and Performance Committee FPC 28 th September 2017 High level commissioning intentions presented at PPI PPI 29 th September 2017 Review of contract approach and high level CCG commissioning intentions at Governing Body GB 30 th September 2017 Provider commissioning intentions letters are issued October to December Transformation Board and ICB review of financial planning framing. Consultation, Workstream gateways, finance planning January 2018 onwards Implementation/mobilisation

111 Planned Care Workstream CCG Intentions 1 Outpatient Transformation: Working with the Homerton to transform our model of outpatient care locally by: Preventing unwarranted first attendance/referral- advice and guidance, MDT/GP discussion and feedback, triage to community/primary care/other pathways, GP Education/Training, Patient Self- Management Reducing unnecessary face-to-face follow ups- patient centred tools, enable self-management, virtual/telephone/primary care follow up Optimising what should be done in secondary care and by whom- links across specialties to avoid/reduce internal consultant to consultant referrals; e-consultation in patient home/gp premises; group consultations where similar patients are consulted in a group; extended scope practitioners/advanced nurse practitioners/specialist nurse for targeted follow up allowing consultants to focus on complex/surgical work Enablers: e-rs/follow up arrangements to standardize across specialties (less clinician variation) Advice and Guidance First line for GPs and where consultants can shape the next steps to the most appropriate diagnostic/service pathways Technology Appointment system updates, Skype FU/Virtual MDT review/virtual review for FU MDT review for complex multi issue patients Triage systems to review referrals for community/other services instead of secondary care

112 Planned Care Workstream CCG Intentions 2 Improving Cancer Care: Increasing Cancers detected earlier by supporting primary care with education and access to diagnostics tests, decision support tools and audits Improving screening uptake by working with Prevention Workstream on every contact counts regarding reducing risk factors and behaviours in local population Supporting patient recovery moving towards a focus on cancer as a LTC and opportunity for increasing time to talk support from GP Confederation Bereavement Services- plan for continued support of Bereavement services at St. Joseph s Hospice Anti-Coagulation: Implementation of the anti-coagulation service with the GP Confederation Continuing Healthcare and Residential Care: Improve delivery of continuing healthcare locally by implementing recommendations from recent review Review opportunities within mental health pathways for increased recovery and step-down for patients in existing placements, particularly those outside of borough Review arrangements for people with learning disabilities in receipt of health and social care packages Consider opportunities for further integration of CHC within LA arrangements for brokerage and for jointly planning against known gaps in local provision (e.g. nursing care, intermediate care) Obesity Pathway: Working with Prevention Workstream on new obesity pathway including surgical options

113 Planned Care Workstream CCG Intentions 3 Medicines Management Initial suggestions for prescribing work plan (including from medicines management team, Prescribing Programme Board and other CCG boards): Reviews of: Drugs of potential abuse Women of child bearing age prescribed valproate Quantities ordered of repeat prescriptions Blister pack provision & documentation Respiratory prescribing- (Respiratory is 1 of CCG s priority areas for RightCare) Emollient prescribing Meetings: GP Practice-Community pharmacy interface meetings Training: Polypharmacy QIPP Indicators: 2 respiratory indicators, volume of pregabalin prescribing, antibiotics (in line with NHSE targets), MOLV-LIST products, OTC products Medicines of limited Value list (MOLV-LIST) definition: List of prescribed products considered as having limited evidence, poor safety profile or poor value for money for the NHS. Includes products which could be provided as self-care with support from community pharmacists

114 Planned Care Workstream CCG Intentions 4 Mental Health Revised specification for the crisis pathway to include the provision of 24/7 home visiting, street triage and no-wait psychological therapies for people in crisis, use personalised crisis plans Commitment to improve the continuing care pathway with care delivered closer to home in more appropriate settings. Rehab Team to support the review of MH patients within the CHS continuing care service Revised specification to provide dementia continuing care within a safer more clinically appropriate environments Waiting time and access targets for psychological therapies as part of a new specification Residential Care revised contract in line with joint MH and LBH supporting living strategy Strategy for reaching national employment targets (CPA and IPS) jointly agreed with CCG and LBH CMC for all people living with Dementia. EPC to increase coverage of older adults Development of CAMHS crisis services in line with the FYFV Improved interface with physical health smoking cessation, substance misuse, diet and wellbeing New protocols for anti-psychotic prescribing and primary care support, based on the pilot Standardised discharge summaries Development of the Recovery College Expansion of IAPT LTC service and implementation of employment pilot First steps productivity QIPP and commitment to CAMHS transformation plan

115 Unplanned Care Workstream CCG Intentions 1 Implement our 24/7 local face to face/home visiting services which will take referrals from the NEL Integrated Urgent Care 111 clinical assessment service. Improve discharge and reduce delayed transfers of care by implementing the two local Eight High Impact Change Models. Implement the Neighbourhood Care Model to ensure patients at high-risk of emergency admissions receive integrated health and social care. Health, social care and the third sector will work together to provide services which best meet the needs of their local population within their neighbourhood areas. Pending local evaluation, implement the Homerton ambulatory care model to achieve a reduction in emergency/non-elective admissions and reduced length of stay. Utilise PMS Premium to commission an expanded Frail Home Visiting Service which covers patients at risk of emergency admission who would benefit from proactive case management and a multi-disciplinary care planning approach but who do not currently meet the eligibility criteria of the existing FHV service. From April 2018 consolidate Enhanced PUCC within the recurrent PUCC contract (following PIC/FPC agreement) ensuring value for money and develop a plan for PUCC to become a Urgent Treatment Centre, meeting the national UTC Standards. Local implementation of the pan-london Redirection and Streaming Guidance, which will maximise the use of primary care and PUCC to reduce any unnecessary ED attendances.

116 Prevention Workstream CCG Intentions 1 LTC contract: COPD prevalence?screening smokers at NHS health checks? Introduce smoking quit rate TTT Potential budget reduction in line with actual activity Social prescribing tied more closely to care planning? Including group consultations and patient activation Hypertension prevalence?more practice sensitive targets (PH) AF detection and treatment?mobile ECGs HIV screening Social Prescribing: Proposal to Transformation Board for contract award to Family Action Rightcare: (Prevention) Respiratory: Recommendations Improve diagnosis and prevalence of Asthma and COPD Improve access to smoking cessation support to reduce prevalence of smoking Improve the effectiveness of respiratory prescribing (not reduce costs as improving prevalence as above may increase costs) metric?? Increase access to psychological therapies for people with asthma and COPD improve quality of life and ability to self-manage Continue to monitor COPD admissions (against similar areas and national levels) to see continued reduction in admissions Business case going back to TB (September 8 th ) for smoking cessation adviser based within ACERS; Spirometry funding (for practitioners to be accredited and registered) and funding for increased Pulmonary Rehab capacity GP Confed development of domestic violence identification and support to be discussed Embedding of routine inquiry possibly through enhanced IRIS training / other but specific resource required

117 Children & YP Workstream CCG Intentions 1 Specifications and Reporting Commission the specialist Nurses via an agreed service specification; enabling monitoring of quality and efficiency impact and opportunity for service developments Refreshed CHS service specifications following review in September 2017 A new reporting schedule for CHS building on the draft community paediatrics schedule Health Visitor input to the GP Confederation Early Years contract to be formalised via Service Specification Changes to commissioned services The CCG will give notice on the Community Paediatric leadership and input to the Tier 2 audiology service. This will become an audiology led service based at Hackney Ark and John Scott Centre - The importance of continued access to audiology training for paediatric trainees is noted by commissioners Service Developments A Tier 3 children s obesity service will be commissioned as a pilot in 18/19; based on the recommendations of the joint service review undertaken in September 2017 Joint work with the Orthodox Jewish community in recognition of inequity of access to components of the SLT service - These may require NR funding in 2018/19 Development of Local Tariffs Review of 0 LOS activity on Starlight Ward may lead to development of a local paediatric monitoring tariff

118 Children & YP Workstream CCG Intentions 2 Early Years Maintain level of contract funding, pending PIC approval for continued NR funding Re-introduction of maternity pregnancy pack Compliance with children s safeguarding training whole practice level reporting to be included in CEG dashboard (clinical audits undertaken by Confed in September 2017 to inform any other commissioning changes) Long Term Conditions Sickle cell transition arrangements to be progressed as per plan for 17/18 Information sharing protocol to be consistent across LTCs New dashboard and reporting arrangements to be agreed for the children s components to improve evaluation of clinical impact and value for money Childhood Immunisations Reduced NR bid (compared to 220k in 17/18) for additional Nurse sessions to be utilised across practices to support achievement of herd immunity Whittington Children s special school therapy costs to be reviewed as part of the block CHS contract Bart s Commission Tier 2 audiology -led service (without HUHT Community Paediatrics) CSU Agree new commissioning arrangements for children s complex care and management of Personal Health Budgets

119 Children & YP Workstream CCG Intentions 3 Maternity HUHT maternity specification will be refreshed KPIs (including improve real time patient feedback response rate) and new guidance Continuity of midwifery care to be monitored from Q4 17/18 Recommission tongue tie pending PIC funding approval CHS contract Breastfeeding funding to be continued (pending PIC) - HUHT proposing new service model that aligns with public health s breastfeeding evaluation recommendations Maintain focus on reducing Infant Mortality - including avoidable admissions to NICU Maintain Programme Board focus on the maternity strategy, recommendations arising from the staffing reviews for midwifery and doctors and the named professional on labour ward audit Development of targeted work on maternal obesity Vulnerable women s pathway - Perinatal mental health : contribute to development of work on good emotional health in children under 5 years

120 Children & YP Workstream CCG Intentions 4 Perinatal Mental Health Draft STP bid has been shared increasing staffing of community specialist perinatal mental health services National bid not released yet, but STP well placed for submission Non Recurrent schemes to be re-commissioned pending PIC approval: Bump Buddies (Shoreditch Trust) crisis support and peer mentoring for vulnerable pregnant women Bonding with baby service (Hackney Playbus ) postnatal support for vulnerable parents GP Confed Early Years recurrent funding commissions the 16w and 6w checks; NR funding funds all other interventions including HV support for children on UPP - contract value to be maintained pending PIC NR approval - pregnancy pack to be introduced from April 2018 GP Confederation audits September 2017 to inform any other contract changes

121 CCG PPI Priorities 1 We are committed to ensuring that the voices of local patients and residents continue to inform our decisions throughout the commissioning cycle. Our high level strategic priorities for 2018/19 are focused on: 1) Ensuring that the CCG meets its legislative duties around patient and public involvement 2) Reviewing and establishing patient and public involvement structures in the context of Primary Care Co-Commissioning 3) Reviewing and establishing joint patient and public involvement structures in the context of Integrated Commissioning.

122 CCG PPI Priorities 2 Maintaining our business as usual PPI functions to ensure that the CCG s Governing Body can be assured that the legislative duties around patient and public involvement are met. Establishing City and Hackney CCG Involvement Alliance as the main forum for local patient and service user involvement extending into primary care by working closely with GP practice based patient participation groups. We want to use the alliance model to increase participation at all levels and to promote and raise awareness of services aimed at supporting local residents with staying healthy and well and manage their conditions better. Where applicable, establishing a process for aligning public engagement priorities as well as sharing and joining up PPI functions with our Integrated Commissioning partners. Continuing to work with our local authority partners in City of London and in London Borough of Hackney to deliver a joint community grants scheme (previously Innovation Fund and Healthier Hackney Fund) aligned to local clinical priorities, aimed at identifying new and innovative ways of meeting local health needs as well as maintaining and strengthening our relationship with community and voluntary sector partners.

123 Paper Title Framework for Risk Sharing in 2017/18 Paper Author Sunil Thakker Lead Presenter Paper Summary (3 bullet points of relevant background to the paper) Sunil Thakker The Governing Body has been discussing potential arrangements for risk sharing across East London Health & Care Partnership CCGs at recent meetings. These views, plus those of the other CCGs have been taken account of, and a framework agreement now available. Purpose (delete unnecessary) For discussion & approval Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: Review and consider the 2017/18 Framework for Risk Sharing for the deployment of 1.9m into the ELHCP system in 2017/18 in support of delivering a system control total. This will also contribute to system stability from a local provider and patient perspective; Confirm whether they are satisfied with the governance arrangements and, outside of the agreement, whether further internal governance arrangements are needed to cover actual proposals to deploy funds. Note the most recent high level NHSE planning guidance that requires risk a sharing arrangement for 2018/19. Where else has this paper been discussed? Previous Governing Body meetings and at the Tuesday 26 September 2017 Finance and Performance Committee (FPC). What was the outcome of previous discussions? The Governing Body will be verbally updated on the discussions having taken place at the FPC. Chair: Dr Clare Highton Chief Officer: Paul Haigh

124 Framework for Risk Sharing in 2017/18 For review and consideration by the Governing Body 29 September 2017

125 Background to 2016/17 Framework for Risk Sharing In 2016/17 City & Hackney CCG deployed its 1% uncommitted strategic reserve totalling 3.7m via the Framework Agreement for Risk-Sharing. The arrangement was extended in-year to include all seven CCGs within NEL with BHR CCGs as the new entrant into the scheme. The process of agreeing the 2016/17 arrangement was time consuming and included discussions with external audit about engaging in the risk share and specifically cost pressures identified elsewhere in the NEL system and in particular BHR. External audit considered the risk this posed to City & Hackney CCG, its main provider, the Homerton, and patients and considered it legitimate to support BHR in the arrangement without compromising statutory responsibilities, subject to proper governance. Based on the review by external audit that allowed the risk sharing to progress, this set the precedent for it to continue to include all seven CCGs, subject to proper governance.

126 2017/18 Framework for Risk Sharing In 2017/18 the draft STP Framework for Risk Sharing was re-written by the City & Hackney CCG Joint CFO incorporating principals taken from CIPFA best practice guidance. The document was also shared with and reviewed by the CFOs of Tower Hamlets CCG, Waltham Forest CCG, Newham CCG and BHR CCGs. The uncommitted strategic reserve available in 2017/18 is 1.9m equating to 0.5% as opposed to the 1% of allocation from previous year. It has been ringfenced in line with NHS business rules. The uncommitted 0.5% strategic reserve totalling 220k for core primary care is excluded as per NHSE guidance. The full agreement accompanies this document. Principals embedded include: That the seven CCGs within NEL STP have agreed to work in collaboration and the Framework for Risk Sharing sits within the collaborative partnership; That the management of this should be though CCG CFOs group and their respective Governing Bodies; That the decision to deploy the strategic reserve should not be externally influenced as funding originates from 2017/18 CCG funding allocation; and Consequently, management of the agreement will be through the NEL CFOs group, with a report to the ELHCP FSC and their Board.

127 Recommendation City & Hackney CCG Governing Body is asked to review and consider the 2017/18 Framework for Risk Sharing for the deployment of 1.9m into the NEL system in 2017/18 in support of delivering a system control total. This will also contribute to system stability from a local provider and patient perspective. City & Hackney CCG Governing Body is asked confirm whether they are satisfied with the governance arrangements and, outside of the agreement, whether further internal governance arrangements are needed to cover actual proposals to deploy funds e.g. sign off by the two ICBs as Committee of the Governing Body. The Governing Body is asked to note the most recent high level NHSE planning guidance that requires risk a sharing arrangement for 2018/19. This has yet to be formalised and agreed with NEL STP partners.

128 NEL STP Clinical Commissioning Groups East London Health & Care Partnership Waltham Forest, Tower Hamlets, Newham, City & Hackney, Barking & Dagenham, Havering and Redbridge CCGs Framework Agreement for Risk-sharing in 2017/18 April 2017

129 NEL STP Clinical Commissioning Groups Contents This document describes a framework Agreement for the Clinical Commissioning Groups (CCGs) within the ELHCP to collaborate in handling financial risk in 2017/18. It includes the following specific sections: Section Page 1. Background & Context 2 2. Principles of Collaboration 4 3. Governance & Mechanisms for Risk-sharing 5 4. Agreement 8 Schedule Page 1. Example Model for Calculating Risk Exposure 9

130 NEL STP Clinical Commissioning Groups Section 1: Background & Context This Agreement is dated March It is between: (1) Waltham Forest NHS Clinical Commissioning Group of Kirkdale House, 7 Kirkdale Road, London E11 1HP. (2) Tower Hamlets NHS Clinical Commissioning Group of 2 nd Floor, Alderney Building, Mile End Hospital, Mile End, London E1. (3) Newham NHS Clinical Commissioning Group of Warehouse K, Unex Tower, 5 Station Street, London E15 1DA. (4) City & Hackney NHS Clinical Commissioning Group of 3 nd Floor, Block A, St Leonards Hospital, Hoxton, London N1 5LZ. (5) Barking & Dagenham NHS Clinical Commissioning Group, Maritime House, 1 Linton Rd, Barking, IG11 8HG (6) Havering NHS Clinical Commissioning Group, 3 rd Floor, Imperial Offices, 2-4 Eastern Rd., Romford Essex, RM1 3PJ (7) Redbridge NHS Clinical Commissioning Group, Becketts House, 2-14 Ilford Hill, Ilford, Essex IG1 2QX North East London has developed a five year Sustainability & Transformation Plan from October 2016 onwards. The seven CCGs within the STP area have agreed to work in collaboration and this risk share document sits within the context of that collaborative partnership. Mechanisms for CCG collaboration have been established for some time and are expected based on statutory guidance for collaboration and NHS Operating Guidance. This document enables sets out how the guidance will be undertaken in NEL, whilst protecting the statutory duties of individual CCGs within the system. It is recognised that risk is best managed by those best able to address the specific risk. As such there is no single place that financial risk management will best be delivered. CCGs will encompass a range of risk management approaches. These will include: Individual CCG financial control totals and governance of the delivery of these through adequate budget provision and contingency provisions; Risk-sharing with local commissioning partners, including local government, such as through joint commissioning arrangements; Risk-sharing with providers through contractual agreements to incentivise activity management, service change and QIPP delivery; Effective governance arrangements including Board assurance processes and effective CSU support ;

131 NEL STP Clinical Commissioning Groups Effective provision for risks impacting individual organisations within the ELHCP footprint from outside the ELHCP boundaries; Consideration of the wider strategic context so that actions of one party do not destabilise the health economy. Each CCG retains individual accountability for the management of their own financial risk and will undertake to set aside a proportion of their recurrent budget for this purpose (including a minimum general 0.5% contingency reserve and other non-recurrent resources where needed). Each CCG will operate with transparency in the assessment of risks and its mitigation plan which can be scrutinised by others within the collaborative. This Agreement shall be overseen by each CCG s Governing Body in order to ensure that CCG financial statutory duties are met and that the CCG s financial objectives in support of their health strategies are achieved, whilst considering how the STP control total is delivered. The CCGs are committed to achieving best practice in risk management and governance of their risk processes, individually and collectively. Each CCG in reviewing and managing risk shall ensure that risks are reviewed and scrutinised by applicable managers and lay members in addition to CCG CFOs with an understanding of agreed actions taken or planned by whoever to manage it. Management of the Agreement will be through the NEL CFOs group, with a report to the ELHCP Financial Strategy Committee and the ELHCP Board. Other Collaborative Agreements This document should be seen in the context of other specific collaborative agreements which support future at-scale developments and commissioning from providers. The various Parties may be subscribers to some or all of the other collaboration agreements, but have agreed to abide by a collective approach to risk which is set out here. In reaching this agreement, the Parties have aimed to produce a set of principles that are adaptable to circumstances, but recognize that the approach and key principles may require future review should circumstances change.

132 NEL STP Clinical Commissioning Groups Section 2: Principles of Collaboration In defining this framework the CCGs have identified a number of principles which have framed the approach. These are: Having a clear transparent approach, based on openness and demonstrated by sharing of financial plans, the extent of exposure to risk and early warning of potential in-year risk Achieving the highest standard of governance, respect for legal framework(s), the roles and responsibilities of Governing Bodies and compliance with audit requirements. Quantifying each CCG s exposure to financial risk, and its ability to mitigate, by using a commonly-agreed methodology Establishing mechanisms which ensure that investment and support with common providers is linked to management of contractual risk and/or firm commitment to deliver strategic change in line with the STP financial plan. Establishing an agreement to pool investment and risk between specific CCGs for specific projects as set out in the STP financial plan. Incentivizing good performance. Focusing on building relationships and trust, behaving with integrity with strong ethical values. Acting responsibly (both collectively and individually) to ensure effective stewardship of NHS resources and meeting the duty to achieve VFM. A commitment that the actions of one body will not compromise the statutory duties of individual organisations. Ensuring transparency in reporting and accountability between organisations and the wider public in how public funds are managed and openness and stakeholder engagement with respect for individuals legitimate circumstances or concerns Attaining best practice for risk management. Reviewing the arrangements annually or as and when required.

133 NEL STP Clinical Commissioning Groups Section 3: Governance & Mechanisms for Risk-sharing Accountability and responsibility for decision-making sits with each CCG as outlined in their respective Constitutions, except where this has been specifically delegated or formally agreed otherwise. Each CCG Governing Body will define schemes of delegation and responsibility for individuals. Collaborative work will occur within the agreed delegation and revert back to the Governing Body as appropriate. The operation of the risk share will be overseen by a Group comprising the five CFOs. A consensus of all five is required for a decision to have effect. As laid out in Section 2, the CCGs will use a common template for assessing their exposure to financial risk and their available means to mitigate. The template is shown at Schedule 2. Chief Financial Officers (CFOs) can collectively agree to vary or change this methodology e.g. by agreement to use a standard NHS England template. The aim is to achieve best practice in risk management, by a thorough analysis of risks, the likelihood of the risk occurring, operating appropriate levels of internal control, identifying robust mitigations. This analysis will be shared with other members within the STP and open to challenge. Where the members collectively identify residual risk exists, further mitigations will be identified. A set of stress tests, such as those operated by the Bank of England but applicable to the health economy, will be devised by CCG members and applied to individual CCG commissioning plans and consolidating into the collective STP Plan. A response plan to the risks arising from the stress tests will be developed and applied in the event the stress risk materializes. The aim of the stress tests is to examine the impact of a hypothetical adverse scenarios on the financial health of the NEL health economy and the organisations within it. This will allow local NHS leaders to test the economy s resilience to future stresses, develop a plan to deal with them if they materialize and provide confidence to the public and regulators that health systems in NEL have stability. The stress tests will be run at least annually. The Parties agree that initial financial plans, risk exposure and mitigation will be shared between CCG CFOs. CFOs should provide an assurance on the collective position to the Group. Where CFOs identify potential and material risk that will impact on this agreement, it should form part of a report to the Group with a recommendation to address the problem. CFOs shall repeat this exercise during the year, no less than quarterly (more frequently if risks materialize), based on actual in-year and forecast performance and report to the NEL CCG CFOs group. In the event of a report by the CFOs which requires action, the Group will seek to find a consensus consistent with the principles of this Agreement that can be approved by officers within appropriate levels of delegation or by respective CCG Governing Bodies. The approval must also be consistent with NHSE guidance. In order to reach a decision, the Group may collectively agree to seek advice and views or resolution from other groups identified within the STP MOU. Otherwise, where a decision is outside delegated authorities, the Group will refer that decision back to each CCG Governing Body.

134 NEL STP Clinical Commissioning Groups A Party to this Agreement will be considered in breach of its provisions and principles if it has: acted recklessly or fraudulently; knowingly failed to declare risks which it should properly have been aware of; failed to comply with the requirements for information sharing or the agreed methodology; or failed to take adequate mitigating actions within its mitigation plan, in the view of the CFOs group. The success of the agreement shall be judged by the achievement of the financial control total, through the early identification of risk and taking mitigating action. CCGs are specifically mandated to hold a minimum 0.5% contingency within their individual positions. It is envisaged that this will be a first call on individual CCG risks, but will be clearly shown within the risk analysis. A further 1% is required to be spent non-recurrently, but only 0.5% has to be uncommitted at the start of the financial year by CCGs party to this agreement. Each CCG party to this agreement has set aside 0.5%. This arrangement does not include the 0.5% relating to core primary care allocation. Note, 0.5% of the local CCG CQUIN scheme will also be held to cover risk. This is subject to separate governance arrangements within NHSI/NHSE and is not directly linked to this agreement. The risk analysis will ensure that adequate provision within the 0.5% is identified to cover material risks for individual CCGs outside the STP boundaries, for example, where there are significant transactions with North Central London providers. Release of this provision will be subject to the review process during the year and sign off by the CFO with direct responsibility for these risks. Should there be a need to transact the use of these sums, and in the absence of Direction, this will be achieved by transfer via an Inter Authority Transfer to cover the risk impact, reversible in future years on terms to be determined by each organization, but expected to be in line with the phasing and mitigation of future risk. It is noted that further reserves against risk are being held nationally and release is subject to national policy.

135 NEL STP Clinical Commissioning Groups Section 4: Agreement On behalf of CCG Governing Bodies, Chief Financial Officers agree the updated framework reflecting the proposed approach to collaboration on risk-sharing. IN WITNESS WHEREOF: The Parties signed this Agreement in March CCG Chief Financial Officer Date Waltham Forest Name: Signature: Tower Hamlets Newham City & Hackney Barking & Dagenham Havering Redbridge Name: Signature: Name: Signature: Name: Signature: Name: Signature: Name: Signature: Name: Signature:

136 NEL STP Clinical Commissioning Groups Schedule 1: Example Methodology for Calculating Risk Exposure & Funds to Mitigate (actual methodology deployed to be determined in accordance with prevailing circumstances).

137 Paper Title CCG Improvement and Assessment Framework (IAF) update Paper Author Anna Garner & Siobhan Harper Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) The attached paper briefs on the 2016/17 year end performance of the CCG under the Improvement and Assessment Framework, along with summarising the current action plan in place to improve the IAF assessment for cancer for City and Hackney Clinical Commissioning Group (CCG) which is in greatest need for improvement. The plan focuses on improving the assessment for City and Hackney CCG in respect of the four metrics which combine to give the rating. Purpose (delete unnecessary) For information, discussion and approval of the action plan Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Recognise the CCGs overall assessment as Good ; 2. Discuss the CCGs performance across the clinical priority areas; 3. Discuss areas of good performance and poor performance, noting that an action plan for cancer is also under discussion at this meeting; 4. Discuss, feedback and agree the action plan for implementation. Where else has this paper been discussed? This paper has been discussed at the Friday 8 September 2017 Transformation Board and the Wednesday 20 September 2017 Integrated Commissioning Boards. What was the outcome of previous discussions? Both the Transformation Board and Integrated Commissioning Boards discussed and recommended the action plan for agreement by the Governing Body. Chair: Dr Clare Highton Chief Officer: Paul Haigh

138 CCG Improvement and Assessment Framework update City and Hackney Anna Garner, Head of Performance Overall CCG assessment 2016/17 CCG Assurance ratings received by NHS England: City and Hackney CCG rated overall as Good. Clinical priority area ratings Clinical priority areas (dementia, mental health, cancer, diabetes, learning disabilities, maternity) scored and rated each year. CCGs have received ratings for dementia, mental health and cancer for 2016/17. Ratings for other areas to follow from NHS England. Ratings: Area City and Hackney rating Indicators Dementia Outstanding Dementia diagnosis Care planning Mental Health Good People with psychosis accessing treatment within 2 weeks IAPT recovery rate Cancer Inadequate Cancer patient experience 1 year survival Cancers diagnosed at stages 1 and 2 62 day cancer waits target City and Hackney achieves worse than the national mean for: cancer patient experience and does not achieve the target for 62 day cancer waits and 1 year cancer survival, leading to the low rating. Action plan for cancer drafted.

139 Indicator performance NB: some indicators where data may be unreliable: maternal smoking at delivery, injuries from falls, emergency admissions from acute and chronic conditions (numbers and inequality). Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend CQC ratings score - acute R 101a Maternal smoking at delivery Q3 4.3% 6/11 17/209 R 121a n/a Q4 65 1/11 16/209 care % classified CQC ratings score - primary R 102a 12/13 to 14/ % 10/11 206/209 R 121b n/a Q4 63 4/11 140/209 overweight/obese care Patients who achieved 3x CQC ratings score - adult R 103a n/d % 8/11 161/209 R 121c n/a Q /11 174/209 diabetes targets social care R 103b n/d R 104a Attendance at diabetic structured education course Admissions from falls in people 65yrs+ Cancers diagnosed at early % 4/11 43/209 R 122a n/d % 4/11 77/209 stage Cancer 62 days of referral to Q /11 4/209 R 122b n/d Q4 81.1% 5/11 111/209 treatment R 105a n/a Use of NHS e-referral % 1/11 #DIV/0! R 122c One-year survival from all ca % 8/11 139/209 R 105b n/a Personal health budgets Q4 5 11/11 166/ d Cancer patient experience /11 208/209 R 105c n/a % of deaths in hospital Q2 50.4% 9/11 59/209 R 123a IAPT recovery rate % 9/11 180/ d n/d R 106a R 106b R 107a R 107b % people feeling supported to manage their LTC Inequality in avoidable admissions from chronic conditions Inequality in avoidable admissions for urgent care conditions Appropriate prescribing antibiotics Broad spectrum antibiotics prescribing % 3/11 170/209 R 123b Psychosis treatment within 2 week referral % 1/11 6/ Q /11 1/209 R 123c n/a MH - CYP mental health Q4 90% 7/11 32/ Q /11 1/209 R 123d n/a MH - crisis care Q4 95.0% 2/11 20/ /11 3/209 R 123e n/a MH - out of area placements Q % 1/11 1/209 LD - use of specialist % 4/11 124/209 R 124a n/d inpatient care Q4 25 1/11 3/ a n/a Quality of life of carers /11 129/ b LD - annual health check % 2/11 16/209 Neonatal mortality and R 125a n/d Sustainability Period CCG Peers England Trend stillbirths Experience of maternity R 141a n/a Financial plan 2016 Amber 4/11 88/ b n/a services /11 148/ /11 175/209 R 141b n/a In-year financial performance16-17 Q4 Green 1/11 88/ c n/a Choices in maternity services /11 87/209 R R Rightcare: Improvement in 142a n/a outcomes RightCare: Improvement in 142b n/a spend Q3 ########### 1/11 1/209 R 126a n/a Dementia diagnosis rate % 8/11 41/ Q3 ########### 1/11 1/ b R 143a n/a New models of care Q4 N #VALUE! R 127a n/a R 144a n/a Local digital roadmap in plac Q4 Y #VALUE! R 127b Dementia post diagnostic support Delivery of an integrated urgent care service Emergency admissions for acute conditions % 1/11 2/ /11 65/ Q /11 3/209 R 144b n/a Digital interactions Q4 57.1% 9/11 166/209 R 127c A&E 4 hour target % 1/11 61/209 R 145a n/a SEP in place Y ###### #VALUE! R 127e n/d Delayed transfers of care per /11 102/209 Well Led Period CCG Peers England Trend R 127f n/d Emergency bed day rate Q /11 111/209 R 161a n/a STP Green 1/11 1/209 R 128a Avoidable admissions - LTCs Q /11 3/209 Patient experience of GP R 162a n/a Probity and corporate govern Q4 Fully Compliant 1/11 1/209 R 128b n/d services Number GP practices R 163a n/a Staff engagement index /11 6/209 R 128c n/a offering extended access Number FTE GPs and nurses R 163b n/a Progress against WRES /11 204/209 R 128d n/d per weighted population % 3/11 140/ % 8/11 79/ /11 127/209 R 164a n/a Working relationship effectiv /11 4/209 R 129a 18 week RTT % 1/11 1/209 R 165a n/a Quality of CCG leadership Q4 Amber 8/11 108/209 R 7 day services - achievement 130a n/a of standards 0.0% 1/11 #N/A Key R 131a n/a People eligible for standard N16-17 Q /11 149/209 Worst quartile in England Interquartile range Best quartile in England

140 Areas of good performance - Attendance a structured education diabetes - Antibiotic prescribing - CQC ratings acute care - Mental health indicators out of area placements, CAMHS, crisis care - Psychosis treatment within 2 weeks - Learning disabilities annual review - Learning disabilities use of inpatient care - Dementia diagnosis - Dementia care planning - 18 week referral to treatment target Areas of poor performance (all referenced within the asks of the workstreams and progress against these can be monitored via the performance reports from the workstreams) - Deteriorating performance on DTOCs - A&E 4hr target - 62 day cancer target - % of children aged who are overweight/obese - % diabetic patients achieving blood sugar, cholesterol and blood pressure targets - Personal health budgets - % of people feeling supported to manage their LTCs - Progress against workforce race inequality standard CCG and providers - Cancer patient experience - IAPT recovery rate - CQC ratings score adult social care

141 Title: Integrated Assessment Framework (IAF) Cancer Improvement Plan Date: 8 th September 2017 Lead Officer: Author: Siobhan Harper - Workstream Director Planned Care Sue Maughn NEL Cancer Commissioning Director Committee(s): Integrated Commissioning Board 20 September 2017 Public / Nonpublic Transformation Board 8 September 2017 Public Executive Summary: This paper summarises the current action plan in place to improve the IAF assessment for cancer for City and Hackney Clinical Commissioning Group (CCG) which is in greatest need for improvement. The plan focuses on improving the assessment for City and Hackney CCG in respect of the four metrics which combine to give the rating: Cancers diagnosed and staged at an early stage Delivery of the 62 day urgent GP referral to treatment standard One year survival rates Improved patient experience It should be noted that a systems approach is required to impact on these metrics and this is now in place with multiple commissioners and providers working collaboratively at the London and North East London (NEL) level to drive improvements. A particular emphasis with North Central London partners is achieved via the UCLH Cancer Collaborative (vanguard). These partners have worked together to agree action plans to support the necessary improvements across the cancer services system. To date City and Hackney CCG has had a local Cancer Board working largely with the Homerton and has participated in the East London Cancer Board which, supported by Macmillan, has seen positive improvements at Barts Health. Going forwards the newly named City and Hackney Cancer Collaborative will support the Planned Care Workstream in delivering its asks as well as the continued delivery of the NEL action plan. Taken together these actions should move towards an improved IAF assessment though some of the outcomes are likely to be improved in the longer term. The Planned Care Workstream will seek added value in its cancer work and its plans; by widening the focus and involvement of partners and providers, additional plans will identify opportunities for increased screening uptake and for better patient experience by greater attention to supporting patient recovery across the system. There will be more detail on this as part of assurance point 2. There will be more detail on this as part of assurance point 2 though it is expected this will involve working with the Prevention Workstream on the opportunity for reducing risk factors for cancer such as smoking and obesity for our patients and residents as well as implementing an Every contact counts approach with existing providers.

142 Recommendation: The Integrated Commissioning Board is asked to NOTE the report. Links to Key Priorities: Cancer is a priority project for the Planned Care Workstream Specific implications for City N/A Specific implications for Hackney N/A Patient and Public Involvement and Impact: Patient Experience Groups have been actively involved in the work of the East London Cancer Board, NEL Cancer Board and within City and Hackney Patient and Public Involvement structures, supporting the local cancer board. Discussions are on-going with the workstream patient representative regarding co-production within the development of new service plans. The IAF assessment may present a worrying picture to local residents of cancer services and providers which may cause concern, particularly to cancer patients and their families. All the relevant partners should offer reassurance to the public that improving the delivery of cancer care is a major priority. Further thought on how to convey this through working with local patient groups and organisations will be discussed with the workstream patient representative and the engagement enabler group. Clinical/practitioner input and engagement: Primary and secondary care clinicians, including nursing staff are involved in all the current planning structures and in developing action plans to date. More thought on the involvement of social care and mental health practitioners will be considered by the workstream. Impact on / Overlap with Existing Services: N/A

143 Main Report City and Hackney CCG IAF-Cancer Action plan: 3 Cancer Indicators: 3 1 Cancers diagnosed at an earlier stage: 3 Screening: 4 Pan London best practice actions for Primary Care to increase screening uptake: 5 Actions currently underway 2017/18: 5 Future actions to support improvement: 5 2. Delivery of the 62 day urgent GP referral standard: 6 3. One year survival all cancers*: 6 Earlier Diagnosis Primary care actions currently underway: 7 4. Improving patient experience 8 Areas for Action: 8 Response rate/sample Size: 8 Questions outside of expected range 9 Working across the UCLHCC Vanguard and the East London Health and Care Partnership (ELHCP) and other partners 9 Summary and next steps 10 Appendix 1 11 Appendix 2 14 Appendix 3 22 City and Hackney CCG IAF-Cancer Action plan: Cancer Indicators: There are four indicators which are used in the assessment of the IAF cancer rating. These all have a direct link to either constitutional standards or the recommendations of the national cancer task force strategy. The most recently published assessment gives the CCG an inadequate rating. This rating is given to 5 out of the 7 CCGs across the STP with improvements of all key metrics also reflected in the STP delivery plan. A full breakdown of the indicators and the scoring methodology is given in appendix 3. 1 Cancers diagnosed at an earlier stage: Stage at diagnosis of a cancer gives an indication of short term prognosis and likely survival following active treatment. A low stage makes treatment with a curative intention more likely with a better

144 survival benefit. It has also been demonstrated that costs to the NHS are reduced. The national ambition is that by % of new cancers diagnosed are at stages 1 and 2. Provider trusts are required to record stage at diagnosis as part of the Cancer Outcomes and Services dataset (COSD). The 2016/17 indicator refers to patients diagnosed in A final stage must be recorded within 6 months of diagnosis. In 2015 the national average was 51%. In % of patients with a new diagnosis of cancer resident in C&H were recorded as having stage 1 or 2 disease. It gives an indication as to the success of earlier diagnosis interventions at a local level. Reviewing trend data for this indicator demonstrates that for C&H this had varied up to 58% Actions linked to diagnosing cancers at an earlier stage can also be influential in increasing the one year survival metric too. Action 1: HUH and BH to be requested to give a current position of stage 1 and 2 cancers by providing an extract from their COSD data. To include data completeness Action 2: Trusts to provide an action for improvements for recording of stage if required. Screening: Screening aims to reduce the numbers of deaths from breast, cervical and bowel cancer by; finding the precancerous signs of cervical and bowel cancer and treating these identifying the very early signs of breast, cervical and bowel cancer, leading to a greater chance of survival and less aggressive treatments There is evidence that interventions delivered through primary care can have a significant impact on improving participation in screening, overcoming some of the barriers and inequalities experienced by different groups. Most recent data to January 2017 is shown below:

145 Performance up to Jan-17 Screening Programmes Summary to Jan-17 Bowel Bowel Breast Breast Cervical Uptake (60-74) Coverage (60-74) Uptake (50-70) Coverage (50-70) Coverage (25-64) Standard 60% 60% 80% 80% 80% Lower threshold 55% 55% 70% 70% 75% From Feb 2016-Jan 2017 there was an increase in both coverage (+2.6%) and uptake (+ 2.3%) to the bowel cancer screening programme across the CCG. Pan London best practice actions for Primary Care to increase screening uptake: Check patient contact details at each encounter and regularly maintain the practice list Designate a cancer screening lead from a member of the practice healthcare team Ensure that Prior Notification Lists (PNLs) and advance lists, where available for bowel screening are dealt with promptly Ensure that when DNA or non-responder reports are received for a patient, this is flagged on their notes, using the correct Read code Offer cervical screening opportunistically, if due or appointment missed Promote cancer screening within the practice Do not omit patients with special needs and ensure arrangements are in place for them Ensure all practice staff know how to use the gfobt bowel screening kit, and where required, the details of how to request a new kit Make screening and signposting information for each screening programme readily available. Actions currently underway 2017/18: Cervical - Dr Natalie Chandler is doing a piece of work with the confederation to produce a best practice protocol for practices on smear taking and recall. Directed at practices with poor uptake. Breast - NHSE have commissioned Community Links to call women when they are invited for breast screening to endorse uptake and also to call non-responders. No evaluation of the impact so far. Bowel - the CCG has had a contract with the GP confederation for practices to endorse bowel screening. The increase in uptake has been very modest. Future actions to support improvement: Bowel Cancer Extended Age(60-74) Uptake Bowel Cancer Extended Age(60-74) 2.5Y Coverage Breast Cancer Standard Age(50-70) 36M Coverage Cervical Cancer Target Age(25-64) 3.5/5.5Y Coverage Breast Cancer Standard Age(50-70) Uptake London 48.4% 49.2% 65.6% 65.8% 65.5% North East London 47.3% 47.8% 65.5% 65.0% 64.9% NHS BARKING AND DAGENHAM CCG 43.2% 38.5% 65.2% 62.3% 66.8% NHS CITY AND HACKNEY CCG 42.4% 44.3% 62.5% 59.6% 65.5% NHS HAVERING CCG 55.2% 50.5% 75.5% 75.3% 73.6% NHS NEWHAM CCG 40.3% 44.2% 63.3% 59.8% 63.5% NHS REDBRIDGE CCG 49.1% 44.4% 63.5% 68.4% 64.5% NHS TOWER HAMLETS CCG 39.7% 42.3% 65.8% 64.1% 62.3% NHS WALTHAM FOREST CCG 47.5% 48.7% 68.0% 68.1% 67.6% Evaluate all of the current interventions once data becomes available for planning future actions Undertake a baseline against the Pan London best practice to look for further opportunities Engage with PHE and screening commissioners for smooth transition to the new cervical screening programme

146 Prepare practices for the change to qfit and consider early adoption if possible. Work with other partners e.g. TCST/UCLHCC to promote uptake to the bowel scope screening programme 2. Delivery of the 62 day urgent GP referral standard: Residents of C&H CCG are likely to have their first definitive cancer treatment at one of four treating trusts: HUH, Bart s Health, UCLH, RFL with the vast majority at HUH or Bart s Health. NHSE has made a commitment that all providers will achieve the 62 day Urgent referral from GP standard by September Current performance at HUH is below the expected level but improving in other parts of NEL. Cancer waiting times are reviewed and plans for sustainability are produced at a NEL and Vanguard level. The current plan for sustainable waiting times applicable to HUH is reflected in Appendix 2(this is an extract of an ELHCP level plan). 3. One year survival all cancers*: The one year survival index all cancers is the aggregated survival of 14 individual cancers. It should be noted that Prostate cancer is excluded from this. In 2014 the rate of 1 year survival for this index in C&H was 69.2% set against an England average of 70.4%. The task force ambition for 2020 is 75% In order to understand what actions the CCG can take which might impact on this a further breakdown has been done and trends reviewed to inform this: Cohort (2014) C&H C&H trend England gap All cancers % 70.4% -1.2% (15-99yrs) Lung 38.4% 36.8% +1.8% Colorectal 74% 77.2% -3.2% Breast 96.1% 96.5% -0.4% All cancers 55-64yrs All cancers yrs 75% 77.9% -2.9% 59.5% 58.2% +1.3%

147 The increase in the index for the years old age group has been considerable over the period and is a major factor in the narrowing of the gap in the all ages index between City and Hackney and England Trend data would suggest a focus on colorectal cancer and raising awareness in the 55-64yrs age group could improve 1 year survival across the CCG. One year survival is most closely linked to stage at diagnosis which along with fitness will influence the treatment options. Therefore actions should be linked with those which will lead to an earlier diagnosis. One year survival metrics are only currently available on an annual basis but the % of patients who first present as an emergency is generally used as a proxy as this cohort has a poor 1 year survival and is measured quarterly. Therefore actions to reduce the % of emergency presentations should see a one year survival benefit. Earlier Diagnosis Primary care actions currently underway: From July 2017 GPs in C&H will have direct access to the full range of diagnostic investigations set out in NICE NG12(2015)- Referral guidance for suspected cancers A local protocol for direct access to chest CT for suspicious cases with a normal CxR Local protocol for Direct access to Abdominal and Pelvis CT being introduced Yearly visit from GP cancer lead and CRUK facilitator focussing on implementation of the pan-london recommendations on cancer care in primary care (see attached GP visit checklist) - items relevant to early diagnosis highlighted below: yearly audit of all new cancer diagnoses to encourage reflection on practice, opportunities for shared learning annual cancer profile discussion in each consortium education events held in 2016 on implementation of NG12 NICE guidance on referral for suspected cancers - reiterated during practice visits safety-netting of all fast-track referrals and now all direct access diagnostic tests for suspected cancer check on use of pan-london fast track referral forms education on new direct access to diagnostics check that practices displaying Be Clear on Cancer campaign materials review of screening practice Future actions: Extend the scope and membership of the current City and Hackney cancer board to include PH expertise for an integrated approach. Maximise the uptake of the Bowel scope programme Increase the uptake to the bowel screening programme Increase public awareness in the younger age group Link with colleagues in Tower Hamlets to consider joint activities as they are also seeing a downward trend in survival from colorectal cancer

148 Further innovation in the lung cancer pathway to improve 1 year survival further to match England s best CCGs Consider repeating the Cancer Awareness Measure (CAM) survey last done in 2009/10 to inform strategies going forward. 4. Improving patient experience CCG level results for the national cancer patient experience survey The outcomes of the national cancer patient experience (NCPES) for 2016 were published in July Due to changes that were made in 2015 to reflect feedback received, it is not possible to look back any further than 2015 to get a meaningful comparison. When asked to rate their care on a scale of zero (very poor) to 10 (very good), respondents gave an average rating of 8.4 The IAF framework uses the overall quality of care score; recent results are: City and Hackney CCG HUH An additional challenge for understanding the views of C&H cancer patients is that the methodology used in the national survey will only report where a specific number of responses are received. The local survey therefore only reports on a limited number of questions and from patients with a limited number of tumour sites due to small numbers in some specialties. It is only possible to get a full view from people with breast cancer. League tables are produced comparing the number of questions above and below the expected range. In league tables C&H CCG rates 28= in London and 200= in England. A full briefing on the survey can be found in Appendix 2. Areas for Action: Response rate/sample Size: The response rate at 51% is significantly below the national response rate of 67% this contributed to no answers being reported for some questions and insight in to a number of the tumour sites is not

149 given. The methodology only surveys those who have had an inpatient episode or are admitted for a day case in a 3 month period. Actions: To develop a local survey for the 2018/19 audit cycle with the HUH to capture the views of a larger cohort As part of the above audit ensures that there is coverage across all tumour sites as the national survey does not provide insight in to patients on a number of key pathways, Lung, Urology and Gynaecology for example. Develop a specific action plan following the local audit. Questions outside of expected range Appendix 2 provides a breakdown of where CCG responses are outside of the expected range for their cohort of patients and consideration needs to be given to these with tailored actions accordingly. Across London there are a number of stakeholders who will also be reviewing this data and it will be important to link with other pieces of work to avoid duplication and to maximise efforts for improvement. Actions: Through the City and Hackney cancer collaborative review all questions which are outside of expected range and consider local action Link with the INEL(WEL) cancer collaborative patient experience group to understand and support any actions at Bart s Health Link with the UCLHCC Vanguard to understand work planned across C&H in relation to patient experience. Working across the UCLHCC Vanguard and the East London Health and Care Partnership (ELHCP) and other partners From a cancer perspective the City and Hackney population reside within the footprint of the UCLHCC which is the overarching organisation for the UCLH cancer Vanguard and the London Cancer alliance. Many of the actions described in this paper have been developed in conjunction with the UCLHCC, local delivery systems, the Healthy London partnership cancer team (TCST), Macmillan Cancer support and Cancer research UK (CRUK).

150 Any UCLHCC pilots and studies will be subject to full evaluation and commissioning case prior to being adopted as business as usual so that the local population has access to evidenced based best practice pathways and interventions. Where evaluations demonstrates that some interventions are best delivered and or contracted for at a system level the processes currently under development within the East London Health and care partnership (ELHCP) will enable this to happen. Summary and next steps This paper sets out a number of potential actions that could be taken to improve the CCGs IAF cancer ratings. Following review by the transformation board the C&H cancer collaborative will bring this together in to an overarching work programme linked to ELHCP and national cancer priorities. The paper will be shared with the NEL cancer commissioning board for STP assurance. At the time of writing UCLHCC has not had any 2017/18 cancer transformation funding released as performance against the 62 day urgent GP standard remains non-compliant. Much of the UCLHCC transformation funding is linked to projects to support earlier diagnosis across NEL and therefore the risk this poses to the CCGs ability to improve earlier diagnosis needs to be documented. However this plan shows that by strengthening the C&H cancer collaborative and by working with other stakeholders including the ELHCP, TCST, Macmillan and CRUK.

151 Appendix 1 C&H system Specific actions from the ELHCP 62 day sustainability work plan Initiative Implement National Optimal Lung Pathway Objective/ Work plan Reduce length of pathway and commence treatment earlier Improve survival and to achieve sustainable CWT performance Q1 Actions Review Local compliance with the updated version of the optimal pathway published in August 2017 UCLH Vanguard resource i Earlier and Faster Diagnosis #16 220K pan NCEL Local resource SM/ TL/ delivery group NEL/BHR/ WEL/C&H Programme NEL/C&H Key stakeholders to make it happen Provider Trusts (BH, BHRUT, HUH) LC Lung Pathway Board Programme Manager Comments Implemented in full at HUH, but let down by histology turnaround times. Impact on performance Impact already seen in early part of the pathway but patients breaching due to histopathology and PETCT waits. Achieved 95% compliance across the STP in March milestone December 2017 RAG Implement Straight to Test/Triage for colorectal / lower GI endoscopy at all sites across NEL Consistent approach pan NEL All referrals are triaged and scoped more quickly 2WW pts. Undertake local baseline assessment (BHRUT, HUH and BH), identify gaps, develop plan Identify local working- group(s) where work will be Earlier and Faster Diagnosis #15-30K pan NCEL Project Manager SM/KK/TL/3 delivery systems NEL Lower GI leads at Trusts Endoscopy leads at Trusts Vanguard Project Manager In place at HUH and BHRUT. Audit of proportion of those who after triage have STT. Impact already seen at HUH although % going STT currently lower than expected. December 2017

152 Implement direct access for upper GI endoscopy across all site in NEL Utilisation of diagnostics go straight to test where clinically appropriate Expected conversion to STT achieved. Consistent approach pan NEL whereby: routine referrals are triaged and scoped more quickly 2WW pts. go straight to test Access to diagnostics does not feature as a delay in breach recording consistently but there is a gap over the term of the STP up to 2020 undertaken/overse en Review proportion of referrals who have test. Work with clinical leads to improve where possible Undertake local baseline assessment (BHRUT, HUH and BH), identify gaps, develop plan Identify local working- group(s) where work will be undertaken/overse en Agree a sector wide diagnostics optimisation plan for sustainability drawing on the TCST work. All providers to attend the TCST optimisation lessons learned sessions (including HUH to share best practice on the lung pathway) TCST Diagnostic Lead None SM/KK/TL NEL Upper GI leads at Trusts Endoscopy leads at Trusts Vanguard Project Manager TCST Diagnostic Lead Senior PM Capital approved within the Vanguard ED projects. Release dependent on vanguard wide performance SM/AW/KK/TL NEL Trust, CCG diagnostics leads/ TCST diagnostics team Agree actions to improve % where possible. Should reduce the number of patients on a 62 day pathway by using STT in line with NICE NG12. Roll out at HUI To have sufficient capacity to support the delivery of the 2020 find out faster standard LGI pathway was compliant in March 17 at 87.5 % Not currently highlighted as an issue in relation to performance. Actions are aimed at sustainability and closing the capacity gap going forwards End September across all sites End September End July 2018

153 Work with the vanguard on the establishment of the East London diagnostics hub To aid delivery of the 2020 find out faster standard. In line with Vanguard timescales Rapid review of histopathology A large proportion of histopathology for NEL is provided by Bart s health. Turnaround times for samples need to be improved. Conduct a rapid review of histopathology services in NEL none Darzi fellow provided by the regional recovery Team to conduct the review NEL Pathology departments across NEL Aim is to reduce the delays in work up particularly on the LGI pathway due to turnaround times for Histopathology samples. September 2017 Features in delays in the LGI pathway particularly Implement the recommendations of the rapid review. Jan 2018 Urology pathway improvement (ITT to UCLH/RFL) Urology pathways consistently account for the largest proportion of breaching patients across NEL. Introduce same day MRI as 1 st OPA across all sites. Build on the Urology admin work shop to identify quick wins to reduce avoidable delays Understanding and unpicking the reasons for delayed Urology pathways Urology pathway project manager Urology pathway board director SM/AW/KK/TL NCEL Trusts, CCG across NCEL. Oversight and delivery monitored through the NEL SLF. Aim is to speed up the diagnostic phase of the pathway. To ensure that same day MRI is available at all sites across NEL To reduce eliminate avoidable delays and Increase the proportion of To improve Urology cancer pathway performance to 80%. End December 2017

154 Adopting a robust process for local learning from RCA s Deliver interventions to minimise patient initiated delays in the pathway To provide a robust process for commissioning assurance and for proactive management of themes from breaching pathways To reduce patient initiated delays in the pathway to a minimum To introduce a joint RCA review process between provider, commissioners and clinical teams in line with LGT trust good practice. To understand why local patients initiate delays in their cancer pathway and to deliver interventions to reduce. those who are referred to UCLH and RFL by day 38. N/A SM/TL/DB/EH C&H Trust and CCG To ensure lessons are learned from all breaches, lessons are learned and acted upon N/A SM/TL/DB/EH C&H Trust and CCG To ensure that patient initiated delays in the pathway are minimised. To deliver sustainable cancer performance and assurance To deliver sustainable cancer performance and assurance October 2017 December 2017 Appendix 2

155 Briefing: National Cancer Patient Experience Survey 2016 The National Cancer Patient Experience Survey (NCPES) has been run since 2010 Following extensive consultation, the structure of the survey and the report of the findings was changed for 2015 o Fewer and less complex questions o Questions and answers re-tested to improve accuracy o To reflect changes in the care pathway o Results of the survey presented in line with CQC methodology highlighting outstanding performance and positive and negative outliers o The reports show both actual local performance as well as a case-mix adjusted figure age, sex, ethnicity, deprivation and cancer site These changes make year on year comparison difficult although some core questions were retained Report includes an Executive Summary which includes o overall rating of care o those measures included in the Cancer Dashboard developed by Public Health England and NHS England The report includes a section showing those responses that were outside of the expected range as well as the full results Full results shown in tabular and chart format Cancer Dashboard Comparison WELC CCG and Providers Questions which scored outside expected range Q No Question CITY & HACKNEY NEWHAM TOWER HAMLETS 2 Patient thought they were seen as soon as necessary WALTHAM FOREST 9 Patient felt they were told sensitively that they had cancer 14 Patient given practical advice and support in dealing with side effects of treatment BARTS HEALTH 16 Patient definitely involved in decisions about care and treatment 17 Patient given the name of the CNS who would support them through their treatment HOMERTON

156 Questions which scored outside expected range Q No Question CITY & HACKNEY NEWHAM TOWER HAMLETS WALTHAM FOREST 19 Get understandable answers to important questions all or most of the time BARTS HEALTH HOMERTON 20 Hospital staff gave information about support groups 22 Hospital staff gave information on getting financial help 26 Staff explained how operation had gone in understandable way 29 Patient had confidence and trust in all doctors treating them 31 Patient had confidence and trust in all ward nurses 32 Always / nearly always enough nurses on duty 33 All staff asked patient what name they preferred to be called by 35 Patient was able to discuss worries or fears with staff during visit 36 Hospital staff definitely did everything to help control pain 37 Always treated with respect and dignity by staff 38 Given clear written information about what should / should not do post discharge 39 Staff told patient who to contact if worried post discharge 41 Patient was able to discuss worries or fears with staff during visit 42 Doctor had the right notes and other documentation with them Patient given understandable information about whether radiotherapy was working Beforehand patient had all information needed about chemotherapy treatment

157 Questions which scored outside expected range Q No Question Hospital staff gave family or someone close all the information needed to help with care at home Patient definitely given enough support from health or social services during treatment Patient definitely given enough support from health or social services after treatment CITY & HACKNEY NEWHAM TOWER HAMLETS WALTHAM FOREST BARTS HEALTH 52 GP given enough information about patient`s condition and treatment HOMERTON 53 Practice staff definitely did everything they could to support patient 54 Hospital and community staff always worked well together 56 Overall the administration of the care was very good / good 57 Length of time for attending clinics and appointments was right 58 Taking part in cancer research discussed with patient 59 Patient`s average rating of care scored from very poor to very good Performed better than expected Performed worse than expected League table by CCG

158 London Ranking National Ranking CCG Numbers of questions better than expected range Number of questions within expected range Number of questions worse than expected range 1 18 NHS Sutton CCG NHS West London CCG NHS Bexley CCG NHS Islington CCG NHS Lambeth CCG NHS Hillingdon CCG NHS Merton CCG NHS Central London (Westminster) CCG NHS Brent CCG NHS Croydon CCG NHS Camden CCG NHS Hounslow CCG NHS City and Hackney CCG NHS Greenwich CCG NHS Kingston CCG NHS Southwark CCG NHS Tower Hamlets CCG NHS Wandsworth CCG NHS Barking and Dagenham CCG NHS Hammersmith and Fulham CCG NHS Newham CCG NHS Richmond CCG NHS Ealing CCG NHS Harrow CCG NHS Havering CCG NHS West Essex CCG NHS Haringey CCG CCG score

159 London Ranking National Ranking CCG Numbers of questions better than expected range Number of questions within expected range Number of questions worse than expected range NHS Redbridge CCG NHS Barnet CCG NHS Bromley CCG NHS Lewisham CCG NHS Enfield CCG NHS Waltham Forest CCG CCG score League table by Provider Trust London Ranking National Ranking Provider Trust Numbers of questions better than expected range Number of questions within expected range Number of questions worse than expected range 1 16 Epsom and St Helier University Hospitals NHS Trust The Royal Marsden NHS Foundation Trust Guy's and St Thomas' NHS Foundation Trust The Hillingdon Hospitals NHS Foundation Trust Royal Brompton & Harefield NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust Whittington Health Chelsea and Westminster Hospital NHS Foundation Trust Homerton University Hospital NHS Foundation Trust Croydon Health Services NHS Trust Kingston Hospital NHS Foundation Trust London North West Healthcare NHS Trust Trust score

160 Royal Free London NHS Foundation Trust St George's University Hospitals NHS Foundation Trust Lewisham and Greenwich NHS Trust Imperial College Healthcare NHS Trust King's College Hospital NHS Foundation Trust University College London Hospitals NHS Foundation Trust The Princess Alexandra Hospital NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust Bart s Health NHS Trust North Middlesex University Hospital NHS Trust Tony Lawlor Cancer Commissioning Manager (WELC POD) NEL Commissioning Support Unit Tony.Lawlor@nelcsu.nhs.uk Full Reports: CITY & HACKNEY Adobe Acrobat Document NEWHAM Adobe Acrobat Document TOWER HAMLETS Adobe Acrobat Document WALTHAM FOREST Adobe Acrobat Document

161 BARTS HEALTH Adobe Acrobat Document HOMERTON Adobe Acrobat Document

162 Appendix 3 Indicators CCG CCG overall rating Data period used for 2016/17 assessment Previous RAG methodology 2016/17 scoring methodology: Mean score for each indicator (averaged over 4 indicators) = Outstanding >1.4 Good Requires Improvement Inadequate <0.5 Cancer priority area rating Cancers diagnosed at early stage People with urgent GP referral having 1st definitive treatment for cancer within 62 days of referral One-year survival from all cancers Cancer patient experience (average score when asked to rate care) 2015 Q4 2016/ RAG rated compared to national average (51%) Significantly below national benchmark (52.4%) = 0 Not significantly +/- national benchmark = 1 Significantly above the national benchmark = 2 Achievement of 85% standard. Significantly below the national standard (85%) = 0 Below national standard (not significantly) = 0.75 Above national standard (not significantly) = 1.25 Significantly higher than the national standard = 2 CCG scores RAG rated against trajectory to achieve national target of 75% Significantly below national ambition (70.4%) = 0 Not significantly above or below the national benchmark = 1 Significantly above the national benchmark = 2 RAG rated compared to national average (8.9) Significantly below the national benchmark (8.7) = 0 Not significantly above or below the national benchmark = 1 Significantly above the national benchmark = 2

163 City and Hackney Tower Hamlets Good Outstanding Inadequate (Mean score = 0.25 or 0.44) Requires improvement (Mean score = 0.5 or 0.75) Newham Good Inadequate (Mean score = 0 or 0.44) Waltham Forest Barking and Dagenham Redbridge Havering Good Requires improvement Requires improvement Requires improvement Inadequate (Mean score = 0.56) Inadequate (Mean score = 0) Inadequate (Mean score = 0.25) Requires improvement (Score = 0.5) 53% (previously 54%) Score = % 48.3% 55.3% 41.6% 51.4% 43.7% Score = 0 Score = 0 or 1 Score = 1 Score = 0 Score = 1 Score = % (previously 79%) Score = 0 or % 81.7% 86.1% 70.6% 75.9% 73.7% Score = 2 Score = 0 or 0.75 Score = 1.25 Score = 0 Score = 0 Score = % (previously 68%) Score = % 64.7% 68.1% 66% 67.9% 70.4% Score = 0 Score = 0 Score = 0 Score = 0 Score = 0 Score = (previously 7.6) Score = Score = 0 or 1 Score = 0 Score = 0 Score = 0 Score = 0 Score = 1 Sign-off: City & Hackney CCG Paul Haigh, Chief Officer

164 Paper Title Paper Author Lead Presenter Paper Summary (3 bullet points of relevant background to the paper) National Consultation on Items which should not be routinely prescribed in primary care Rozalia Enti, Assistant Director Medicines Management, NHS City & Hackney CCG Rozalia Enti, Assistant Director Medicines Management, NHS City & Hackney CCG Prior to publication of this consultation, many CCGs including C&H (in collaboration with the other CCGs, acute trusts and mental health trusts in NEL) were working on similar proposals, so a recommendation was made to NHS Clinical Commissioners and NHSE for a nationally co-ordinated approach to ensure consistency and reduce unwarranted variation. The national consultation is made up of 2 broad sections a. A list of 18 products/product groups currently prescribed in England) for which it is proposed that these should not normally be prescribed in primary care. The majority of the products in this Part 1 are not recommended on our joint C&H- HUHFT formulary. b. Part 2 of the national consultation asks for initial views on early proposals to restrict access to over the counter medicines (OTC) through primary care prescriptions (current costs to NHS 645M across England) Ahead of NHSE s 21 st October 2017 deadline for comments, the Prescribing Programme Board is currently raising awareness of the consultation (as outlined in the paper) encouraging feedback to the CCG and direct input into the online survey. Purpose (delete unnecessary) For Approval Chair: Dr Clare Highton Chief Officer: Paul Haigh

165 Recommendation (state what you are asking for (e.g. support a proposal, debate and decide options, provide feedback etc. List all that's applicable) Where else has this paper been discussed? What was the outcome of previous discussions? The Governing Body is hereby asked to: review the paper summarising the plans for NHSE to issue guidance to CCGs for items which should not be routinely prescribed in primary care and to approve the CCG s strategy for raising awareness and encouraging feedback to the consultation. PPI Committee (27 July 2017) Transformation Board (11 August 2017) Older Peoples Reference Group (7 Sep 2017) Joint Prescribing Group (August, Sep, October 2017) Clinical Commissioning Forum (7 Sep 2017) Clinical Executive Committee (13 Sept 2017) Consortia meetings (North Hackney, South West, Rainbow & Sunshine, Well- all in Sep2017). Klear Consortia meeting 11 October 2017 Local Pharmaceutical Committee (20 Sept 2017) Upcoming meetings Health Scrutiny Commission Hackney (10 Oct 2017) Transformation Board (August & 13 Oct 2017) Integrated Commissioning Board (18 Oct 2017) Practice Nurse Forum (planned 9 Oct 2017) Part 1- generally accepted as most products listed are not recommended within local CCG-HUHFT formulary comments about a few specific drugs received, from clinicians in primary and secondary care Patient representatives call for:- recommendations on drugs to be consistent across CCG and HUHFT patients to be notified of changes to their medicines Part 2 - comments primarily about Impact of low income/ deprivation on ability to fully implement proposed recommendations on restricting NHS supply of OTC products Need to review and relaunch local Pharmacy First Need for public education- locally/ nationally about self-care Potential for restrictions on GP prescribing of OTC medicines to increase use of A&E Consideration for vulnerable groups unable to access Pharmacy First Chair: Dr Clare Highton Chief Officer: Paul Haigh

166 Prescribing Programme Board Update on Medicines of limited value for NHS funding [MOLV-LIST] Rozalia Enti Assistant Director Medicines Management NHS City& Hackney CCG

167 Medicines of limited value for NHS funding What is the MOLV-LIST? the list of prescribed products considered as having limited evidence, or for which there are safer alternatives, or represent poor value for money for the NHS. It also incorporates products which could potentially be provided as self-care, with advice and support from the community pharmacists, or not within NHS provision. On 21/7/2017:- NHSE in conjunction with NHS Clinical Commissioners has issued a 3 month national consultation: Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, available via the following link The consultation is accompanied by: an equality impact assessment: FAQs:

168 Why? Medicines of limited value for NHS funding We need to do more of the things that have good evidence of improving clinical outcomes for patients To help to do more of the things that work, we need to also do less of things that the NHS resources, that: do not have good evidence for working well are unsafe are not good value for the NHS These work areas are not all new positions most of the recommendations are within current formulary / medicines management guidelines, informed by national guidelines - This is a work stream that supports our ongoing programme of work to improve quality, safety of prescribing and can support delivery of savings that can be invested in treatments representing better value for money for NHS - As with all changes in prescribing, patients will need to be considered individually to determine whether a particular switch is suitable for them.

169 Medicines of limited value for NHS funding What are we asking of the GB? Make the GB aware of the national consultation Update the GB of the process by which the CCG is engaging with local stakeholders on the national consultation Provide themes of feedback received to date Provide an early indication that likely CCG response to the consultation [subject to further comments to be received by the prescribing board] would include: Support of Part 1 recommendations highlighting that final recommendations should be made to the wider NHS and not just CCGs in order to keep consistency of prescribing for patients across primary & secondary care as well as mental health trusts Provide initial input that whilst CCG recognises need to streamline and make prescribing & supplies of over the counter (OTC) medicines cost effective, local demographics in CCGs such as City & Hackney where there is significant deprivation- would make full implementation of restrictions on these products challenging. A national public awareness campaign on self care and how to manage the minor ailments listed in the consultation would be beneficial The documents underpinning the national consultation available at:-

170 Medicines of Lower Value to the NHS Expected outcomes from review of MOLV-LIST work Treatments of limited clinical value are not routinely used Optimal patient outcomes are obtained from choosing a medicine using best evidence (e.g. following NICE guidance, local formularies etc.) Medicines wastage is reduced The NHS achieves greater value for money invested in medicines. Patients are more engaged, understand more about their medicines and are able to make choices, including choices about prevention and healthy living. It becomes routine practice to signpost patients to further help with their medicines Incidents of avoidable harm from medicines are reduced.

171 National Consultation on items not to be prescribed in primary care Part 1 Product National Spend Category for inclusion on national list* Was this part of original C&H CCG MOLV-List C&H Formulary Position & [annual spend to May2017] Co-proxamol 9,002,824 A Y Non Formulary [ 15,541] Doxazosin modified release 7,769,931 B Y Formulary [ 45,660] Fentanyl - immediate release 10,952,130 B Y Some products are within Formulary [ 74,287] Glucosamine & Chondroitin 444,535 A Y Non Formulary [ 7,476] Herbal Treatments 100,009 A Y (already in POLC-V) Non Formulary [ 2,543] Homeopathy 92,412 A Y (already in POLC-V) Non Formulary [ 392] Restricted Formulary position & specialist Liothyronine 34,802,312 B Y initiation [ 69,713] Lutein & Antioxidants 1,500,000 A Y No change to current position [ 6,005] * Categories A: Products of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns B: Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation C: Items which are clinically effective but due to nature of the product are deemed a low priority for NHS funding Oxycodone+Naloxone combination 5,062,928 B Y Restricted Formulary position [ 33,748] Perindopril arginine 529,403 B Y - but did not produce supporting info as most prescribing from C&H is from 1 practice Non Formulary [ 9,166] Travel vaccines 4,540,351 C Y No change to current position [ 59,961] Dosulepin 2,651,544 A N Non-formulary ELFT [ 5,537] Lidocaine plasters 19,295,030 A N Hospital Only prescribing [ 33,112] Omega-3 fatty acids 6,317,927 A N - but this area reviewed years ago Limited formulary recommendation; initiation by hospital specialist [ 20,190] Rubefacients 4,301,527 A N Not currently included in Formulary [ 47,756] Tadalafil Once Daily 11,474,221 B N Formulary restricts to post prostatectomy patients only [ 35,161] Tramadol+Paracetamol combination 1,980,000 B N Non formulary [ 8,733] Trimipramine 19,835,783 B N Formulary ELFT [ 58,405]

172 Medicines of Lower Value for NHS funding Over the last 12months (from Oct-Nov 2016) and before the national consultation was announced we in City & Hackney (& in the other NEL CCGs) had prioritised 15 products on a local NEL proposed MOLV- LIST. Eleven (11) products are common to the NEL list and the national list of 18 products. The differences in the local and national lists are as below Differences summarised from 1 st part of NHSE proposal Items included in the NHSE List which were not originally included in the local MOLV-LIST Dosulepin Lidocaine plasters Omega-3 fatty acids Rubefacients Tadalafil Once daily Tramadol+Paracetamol combination Trimipramine Items included in the C&H MOLV List which are not in the current NHSE proposal Dental products from general practice Eflornithine Probiotics where no ACBS approval Vitamins & Minerals where no clinical deficiency diagnosed

173 Over the Counter (OTC)Products- Part 2 of national consultation The national proposal includes a 2 nd part detailed recommendations will be released in the next phase, but NHSE plans to recommend to CCGs that certain products available over the counter may be considered appropriate for restriction These include products that: can be purchased OTC, sometimes at a lower cost than that which would have been incurred by the NHS treat a condition that is considered self-limiting & so does not need treatment as it will heal of its own accord &/ or treat a condition which lends itself to self-care i.e. person presenting does not normally need to seek medical care/ treatment for the condition. The areas to be included are listed below

174 Communications and Engagement The communications and engagement team is seeking as part of the consultation, engagement with patients, the public, GPs and other stakeholders about guidance and feedback on the items which are being suggested, should not routinely be prescribed in primary care. Engagement activities will involve local people and stakeholders, particularly those likely to have an interest in these services, so that NHS England receives strong feedback, which is representative of the views of local people. Communications and engagement objectives 1. To understand the views of stakeholders on the guidance proposals, to help inform decisions and processes 2. To be open and honest about why these proposals are being made, the financial position of the NHS and its possible consequences. 3. To engage with key stakeholders so they understand the rationale behind the guidance 4. To ensure a smooth transition to the point where items may be stopped being prescribed

175 Comms and Engagement activities City and Hackney CCG are responsible for engaging with stakeholders, to ensure their views help to shape any changes. Our comms and engagement team have/ will: manage proactive and reactive media on the issue manage public affairs (communications with local politicians and political groups) in tandem with our local authorities who have existing relationships manage two way stakeholder communications including making use of our own channels advise on engagement with staff and service users engage with and update our GP members on the issue draft comms materials as required Ensure feedback is recorded and presented in the right way

176 Comms and Engagement Stakeholder activities Stakeholder Activity Responsibility Patients and the public Engage via media, digital channels and patient groups and offer to present at meetings and send through proposals for them to consider Press release sent out to local press Public webinar link also distributed to various stakeholders Inclusion in Hackney Today issue out 9 th of October in Have your say section. Communications manager Head of Medicines Management Engagement manager Clinicians, staff, service providers advising of engagement Send engagement document and questionnaire Stories in newsletters/internal comms Head of GP membership engagement and engagement officer Councils and elected representatives advising of engagement Send engagement document and questionnaire Ask councils/mps to mention in their internal comms/newsletters/websites Offer briefing in person CCG communications manager to distribute comms Community and voluntary groups National groups Actively engage with key groups and request to speak at their meetings advising of engagement Send engagement document and questionnaire CCG to present and provide opportunity for feedback NEL CSU to approach NHS England Keep updated as required Briefings team - CSU Medicines management team CCG Media Through media releases and offer interviews/case studies to explain detail CCG communication manager to draft and manage media, as required

177 Comms and Engagement activities Patient engagement forums contacted Hackney Community Voices City Stroke Project MSLC Age UK East London HealthWatch Hackney Toynbee Hall TLC Care Patients Network (patients with LTC) HealthWatch City of London LBH Adult Social Care LGBTQ+ forum Hackney Refugee and Migrant forum NHS Community Voice Integrated Commissioning PPI reps City Advoc City Crossroads Carers Practice based PPGs (43) OPRG Health and Social Care Forum Hackney Refugee Forum Connect Hackney London Gypsy and Traveller Unit Interlink Foundation (Orthodox Jewish) Bikur Cholim (Orthodox Jewish) POHWER CHOICE Hackney People First City Education and Early years City Elders Voice City Healthwatch Young Hackney Youth Parliament Children's Disability Forum Hackney Carers Male Carers CCG & LBH Mental Health Service User Forum City Housing Advice City over 50s

178 Comms and Engagement activities Local groups and Committees where discussions have taken place/ planned Joint Prescribing Group of CCG & HUHFT Patient Participation and Involvement (August, Sept meetings, & planned for Oct) Committee [feedback from HUHFT clinicians collated by HUHFT pharmacists & fed into discussions at JPG] Clinical Commissioning Forum Clinical Executive Committee Practice Consortia [North Hackney, South West, Rainbow& Sunshine, Well; Klear due on 11/10/17] Older Peoples Reference Group Joint Community Voices & Patient Network focus group- [planned 03/10/2017] Health Scrutiny Commission Hackney Transformation Board [planned 13/10/13] Integrated Commissioning Board [planned 18/10/13]

179 Feedback received to date Feedback on Part 1: Feedback on Part 1 generally positive and supportive Most of the 18 drugs / drug groups are not in the joint City & Hackney- HUHFT formulary Of those that are on formulary, comments received include:- Modified release doxazosin (for hypertension) suggestion from HUHFT consultant to continue to initiate but supportive of switch to immediate release in primary care Immediate release fentanyl (opiate for management of severe pain) feedback from cancer clinician HUHFT, that immediate release fentanyl should continue to be available, not as 1 st line pain rescue in cancer but where pain remains with 1 st line product (morphine) recommended by NICE Feedback from Public Health, Hackney about concerns (also increasingly highlighted in health press) about association of fentanyl (over and above other opiates used in clinical care) re higher propensity for dependence Tadalafil once daily preparation Request from urology consultant to extend rather than restrict use of once daily tadalafil All discussions to date at CCF & Consortia highlight recommendations from secondary care of once daily tadalafil not in line with local formulary and not in line with principles of cost effective prescribing decisions

180 Feedback received to date Feedback on Part 2 of the national consultation: provision of over the counter (OTC) products General agreement that: In City & Hackney we continue to have available the community pharmacy minor ailment scheme [Pharmacy First] to manage minor ailments for patients registered with a local GP and that this is very helpful the Pharmacy First scheme needs a relaunch to make residents & patients aware of the scheme That it covers the conditions for which the initial national proposal suggests restrictions for Accompany a wider educational programme to help raise public awareness about self-care especially when it is safe to self treat and when to self-refer to a pharmacist / to a GP Increase GPs awareness of what products are accessible through Pharmacy First Other feedback received includes:- In much of the feedback received by the CCG to date, concerns have been raised that the exceptional levels of deprivation in City & Hackney restricts many local patients ability to purchase OTC, in a way that would significantly restrict full implementation of any national policies/ guidance on stopping the supply of OTC products through GP prescriptions. Though Pharmacy First is free of charge (to those meeting free NHS prescription criteria), other patients who are on lower incomes but not on benefits who require multiple products would be severely disadvantaged Pharmacy First may not meet needs of some patients e.g. homeless, and those not C&H GP registered, other vulnerable groups, those requiring OTC product for a non-minor ailment Concern raised by HUHFT A&E consultant that patients not receiving OTC products may turn up at A&E, thus increasing pressure on A&E and hospital drug budgets and clinical deterioration of patients e.g. children not receiving antipyretics from their GP

181 Paper Title Paper Author Lead Presenter Paper Summary (3 bullet points of relevant background to the paper) Purpose (delete unnecessary) Partnership of East London Co-operatives (PELC) Invoice Payments for 111 Services - commuters Richard Quinton (on behalf of ELC Lead Commissioner, Tower Hamlets CCG) Richard Quinton There are outstanding invoices totalling 950K that are related to PELC from C&H CCG The GB of C&H made the decision in 2013 not to pay for commuter 111 calls as it was believed that the responsibility for commuters lay with NHS England The paper sets out the reasons why these costs, that have been fully reserved in the C&H Accounts so far, should be paid by the CCG The April 2017 paper on the contract extension for PELC for 2017/18 was approved by the Finance Committee and GB of the CCG. The GB agreed the principle for 2017/18 that is now proposed for the period up to end March The principle reason, based on the latest data analysis, is that the data shows that registered C&H patients cost other CCGs similar to the cost to C&H of commuters from other CCGs. For Approval Recommendation (state what you are asking for (e.g. support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: Approve the remaining payments due to PELC/the Lead Commissioner, as appropriate, for 111 services provided up to 31 March Where else has this paper been discussed? What was the outcome of previous discussions? This is only being presented to the Board N/A Chair: Dr Clare Highton Chief Officer: Paul Haigh

182 Report to the City & Hackney CCG Governing Body on the Partnership of East London Co-operatives (PELC). 29 th September 2017 Introduction The CCG Governing Body is requested to approve payment of all the outstanding invoices for the 111 Service for the period from 2014/15 to 2016/17 amounting to 950K to Partnership of East London Co-operatives (PELC) or the lead Commissioner, Tower Hamlets CCG, as appropriate. All these sums have been fully provided in the CCG Accounts and therefore no additional charge will be made in 2017/18. In so doing the Board would be agreeing to payment in relation to commuters utilising the service in the C&H area and thereby reversing the decision made in late 2012 by the GB. The paper below provides reasons with backing data for accepting the change in policy with which I hope the Governing Body will agree. As previously agreed by the Governing Body, the PELC 2017/18 allocation of calls methodology adopts the same policy on commuter calls as now requested. In addition, the 2018/ year contract and methodology has been specified in line with national guidance that also includes commuters and C&H are a full partner in that Integrated Urgent Care Tender process. This has now been completed and the appointment of the provider across all 7 ELHCP CCGs is due to be confirmed shortly with the service due to start in April Background and context Following a competitive tender and Department of Health assurance process, the NHS 111 service for East London and the City (ELC), comprising Newham, Tower Hamlets and City & Hackney CCGs, was launched on 12 March 2013 and provided by NHS Direct. In June 2013, NHS Direct informed Commissioners of their intention to withdraw from the provider market. Following a successful expression of interest process, PELC was appointed and fully mobilised as the step-in Provider for the ELC 111 service on 5 November In the years since then the service provided by PELC has been good and there are no underlying performance and quality questions that give rise to the unwillingness to pay their invoices. However, I also understand that there was a principle that was adopted by the Governing Body when 111 services were originally initiated in late 2012 that payment by City & Hackney of call costs that were within the City & Hackney area but generated by persons who had commuted into the area, would not be paid. This was noted in the GB Board meeting of 26 October 2012 and covered in a letter to Jane Milligan in January This policy still applies for the period up to 31 March 2017 and has resulted in the underpayment noted above. Progress and Current Position I understand that the GB position on commuters has been the subject of many discussions with senior NHS management and particularly the NHSE office in London over a number of years.

183 Report to the City & Hackney CCG Governing Body on the Partnership of East London Co-operatives (PELC). 29 th September 2017 I attach a schedule (Appendix A) showing the timeline of action by ELC/CSU to challenge the discrepancies. It includes certain attachments that will help GB members to understand the details of the action that has been taken by ELC, including on C&H s behalf, over the years. The responses have been very slow, extending the time it has taken to rectify a particular set of circumstances that seemed to distort the position as well as take the commuter argument forward. However, it is important to note that the basis for the discrepancies was eventually established and corrected from mid-september last year. In effect there were 02 mobile calls that were being attributed to ELC that were not ELC, but BHR calls. In addition, a further detailed review of the data has been completed recently in light of the concerns expressed by City & Hackney CCG and the importance of gaining an understanding of the underlying data. This has clarified the commuter position with results that indicate that the amount of charge that C&H suffers from commuters registered elsewhere but using the 111 service are little different to C&H residents utilising 111 services out of the C&H area and therefore paid for by other CCGs. The analysis is attached at Appendix C that covers the first 4 periods of 2017/18. Commentary is as follows:- 1. C&H have calls from registered patients amounting to 47.6% (7,234) of the total calls allocated; 2. C&H have a further 23% (3,509) calls allocated where the caller s details are not taken because they are either asking for the location of pharmacists etc; are following up on a previous call or are calling by mistake and wanted to contact their own GP; 3. These first two categories cover 70.8% of all calls charged; 4. The remaining calls are for unregistered patients (6.5%, 998); other ELHCP callers (6.6%, 989) and outside ELHCP callers (16.2%, 2,454); 5. The total number of callers that are clearly from other CCGs is therefore 3,443 (989+2,454); 6. The number of calls from C&H patients paid for by ONEL because they ring from the ONEL area is 1,493. Work related to 2016/17 shows that approx. 500 C&H patients called the NCL 111 service over 4 months i.e. a total of approx for the NCL and NEL areas. 7. On the basis of 6 above it is not unreasonable to estimate that at least 3,500 C&H patients are ringing other CCG 111 services from across London. The conclusion is that data that we are able to extract indicates that C&H is not significantly adversely affected by commuters because of its location. The position is further reinforced by the contractual rules see Appendix B. These set out the regulations that establish the CCG s legal responsibility for commissioning urgent and emergency care services, including 111, for everyone present in their geographical area. Even if this were not the case, the recharging mechanism that would be necessary to determine commuter spend both in terms of data collection and administration would be in excess of the benefits of using such a system. It would also not resolve the position for those calls in 2 above where, necessarily, details are not taken.

184 Report to the City & Hackney CCG Governing Body on the Partnership of East London Co-operatives (PELC). 29 th September 2017 Finally, in order to ensure that PELC is paid for its calls as per the contract, Tower Hamlets has made some payments on behalf of C&H in line with the contract and to ensure that cash flow does not become a problem. As I mentioned earlier in the report the position for 2017/18 has been agreed by the GB. Similarly the contract for 2018/19 onwards is part of the tender for IUC services currently in process. This will therefore fix the position for the future from April In the circumstances, it is requested that the CCG agree payment of the remaining outstanding sums that will clear the position for all ELC CCGs (Newham and Tower Hamlets have cleared their outstanding sums) and for PELC up to 31 March RECOMMENDATION: The Governing Body is asked to approve the following 1. The outstanding invoices due to PELC/THCCG for 2014/15; 2015/16 and 2016/17 amounting to 950K and fully provided for in the accounts for last year, now be paid in full. RNH Quinton Finance Adviser Tower Hamlets CCG 20 September 2017

185 Paper Title Recommendations from the Friday 30 June 2017 Local GP Provider Contracts Committee Paper Author Jennifer Nabwogi / Lee Walker Lead Presenter Catherine Macadam Paper Summary (3 bullet points of relevant background to the paper) The payment and contract recommendations made at the LGPPCC meeting on 30th June presented for endorsement by the Governing Body. Purpose (delete unnecessary) For approval Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Review the recommendations made by the LGPPCC, note the payment recommendation and approve the recommendations for award of contracts; 2. The members of the Contracts Committee have reviewed the requests for payments and requests for issuing contracts to primary care providers, on behalf of the GB, without potential conflict of interests. Where else has this paper been discussed? LGPPCC 30th June 2017 What was the outcome of previous discussions? Approval of payments as indicated in the attached paper and agreement to a series of recommendations to the Governing Body for their approval. Chair: Dr Clare Highton Chief Officer: Paul Haigh

186 Recommendations from the Friday 30 June 2017 Local GP Provider Contracts Committee Decisions made by the Local GP Provider Contracts Committee presented to the Governing Body

187 Payments agreed by the LGPPCC (for information) The LGPPCC approved the following payments for the delivery of contracted services: Contract name Provider Contract summary Payment period Payment amount Notes Primary care anticoagulation service GP Practices Long term management and maintenance of patients taking Warfarin Quarter four, 2016/17 39,690 Committee also approved the change in the penalty applied to practices not meeting adherence to the external quality assurance. Prescribing Incentive Scheme GP Practices Prescribing element of Clinical Commissioning and Engagement Contract FY 2016/17 88, Clinical Commissioning and Engagement GP Practices Other RAG rated elements of Clinical Commissioning and Engagement Contract FY 2016/17 686, Pot B, PPI and Ethnicity elements

188 Payments agreed by the LGPPCC (for information) The LGPPCC approved the following payments for the delivery of contracted services: Contract name Provider Contract summary Payment period Enhanced Primary Care and Depot service Primary Care Mental Health Alliance GP Confederation GP Confederation Long term monitoring of patients with psychotic disorders Phase 1: register cleansing; & Phase 2: reviewing patients with depression/frequent attenders Quarter three, four and Year End, 2016/17 Payment amount Q3: 9,150 Q4: 9,750 YE: 1,050 TOT: 19,950 YE: 2016/17 424,410 Notes

189 Payments agreed by the LGPPCC (for information) The LGPPCC approved the following payments for the delivery of contracted services: Contract name Provider Contract summary Payment period Long Term Conditions Early Years Community Minor Surgery Phlebotomy GP Confederation GP Confederation Lawson Practice, Nightingale Practice, Well Street GP Confederation Year end reconciliation of KPIs achieved and performance related payments Maternity and Children services Enhanced minor skin surgery directly enhanced service Blood collection service year end reconciliation of activity Payment amount Notes YE 2016/17 Core: 500,000 Time to Talk: 398,950 Cancer: 124, TOTAL: 1,023, Q4 and End of Year 2016/17 Nb 2,061,698 of this contract has already been paid in monthly instalments 178,194 Q4 2016/17 28,960 Q4 and Year End 2016/17 75,010

190 Payments agreed by the LGPPCC (for information) The LGPPCC approved the following payments for the delivery of contracted services: Contract name Provider Contract summary Payment period Pathology (no contract) Nursing Home Nursing Home GP Practices Latimer Health Centre Barton House Group Reimbursement of pathology consumables Enhanced service for Nursing Homes Enhanced service for Nursing Homes GP Out of Hours CHUHSE Out of Hours KPI payments Duty Doctor Enhanced Access Frail Home Visiting GP Confederation GP Confederation GP Confederation Payment amount Q4 2016/17 4, Q4 2016/17 17, Q4 2016/17 5,993 Q4 2016/17 62, Duty Doctor Services Q4 2016/17 370,212,36 Extended Access to GP Appointments outside of normal practice hours Maintain and update the FHV Register Q4 2016/17 90, Q3 and Q4 2016/17 670, Notes

191 Paper Title CCG Corporate Policies Paper Author Matthew Knell Lead Presenter Matthew Knell Paper Summary (3 bullet points of relevant background to the paper) One revised and two new CCG policies are available for Governing Body discussion and agreement. Further details and links to the full policies are available in the attached paper. Purpose (delete unnecessary) For discussion and approval Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Discuss and agree the revised Conflicts of Interest policy; 2. Discuss and agree the new CCG Complaints policy; 3. Discuss and agree the new Joint Working with the Pharmaceutical Industry CCG position statement. Where else has this paper been discussed? Various see attached paper for details. What was the outcome of previous discussions? Recommendations to the Governing Body for agreements. Chair: Dr Clare Highton Chief Officer: Paul Haigh

192 New and revised CCG Corporate Policies for decision For Discussion and Decision

193 Background This agenda item covers the following policies, which have been available for review at the links below: A revised Conflicts of Interest policy that has been updated in track changes to reflect the latest national guidance. This policy is available from A new CCG Complaints policy that has been produced based on North East London Commissioning Support Advice, local and national best practice. This policy is available from A new Joint Working with the Pharmaceutical Industry CCG position statement that has been produced from local and national best practice. This policy is available from Each policy is covered in the following slides and the Governing Body is asked to discuss, request any changes to the contents of each document and agree the policies for use across the CCG.

194 Revised Conflicts of Interest policy The CCG Conflicts of Interest policy was last discussed and agreed at the Friday 25 November 2016 Governing Body meeting; CCG statutory guidance on managing conflicts of interest was revised by NHS England and communicated to CCGs in on 16 June 2017 (see letter available at The Thursday 13 July 2017 CCG Audit Committee discussed these changes, which broadly constitute a slight relaxation of the previous guidance and clearer advice on what gifts can and can t be accepted; The national guidance also included guidance that CCGs can satisfy themselves on an annual basis that Conflicts of Interest from all colleagues are accurate and up to date. This is a change from the previous six monthly position and at this time, the CCG is staying with six monthly updates. All other guidance from NHS England has been included in the updated Conflicts of Interest policy available from with changes marked up in tracked changes; The Governing Body is requested to discuss and agree these changes for implementation.

195 CCG Complaints policy The CCG Complaints Policy was last discussed and agreed by the CCG Governing Body in the CCG authorisation process on Friday 28 September 2012; The CCG s complaints process is largely supported by the North East London Commissioning Support Unit (NELCSU) and changes in their structure have necessitated a revisit of the policy in totality; The CCG has taken into account best practice advice from the Health Service Ombudsman, NELCSU and learning from working with complaints since the last iteration of the policy; The policy is presented in two halves, with the first half of the document being public focused and suitable for transfer to a series of webpages on the CCGs website; The second part of the policy focuses on the CCGs and NELCSU s role and processes in dealing with complaint. The policy in totality will be available publically to provide the public with details of how we work with complaints; The policy is available at and the Governing Body is requested to discuss and agree the policy for implementation.

196 Joint Working with the Pharmaceutical Industry CCG Position Statement Aligned with recent work across the NHS on Conflicts of Interest policy, the CCG Medicines Management Team have developed our CCG Joint Working with the Pharmaceutical Industry position statement; This statement has been discussed with partners through the Joint Prescribing Group and as a result, the statement applies to CCG staff and colleagues; A further policy, Corporate Policy and Guidance for Joint Working with the Pharmaceutical Industry across North East London CCGs and their Commissioned Providers is referenced in the CCG statement. This document is currently under development and discussion across NEL partners and will return to the Governing Body for agreement when ready; If agreed by the Governing Body, the statement will be included in the CCGs induction process for all new staff and promoted across the organisation and with colleagues working with us (including Clinical Lead GPs); The position statement is available at and the Governing Body is requested to discuss and agree the statement for implementation.

197 Paper Title CCG Chair election process and changes to the CCG Constitution Paper Author Matthew Knell Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) The current CCG Chair, Clinical Vice Chair, Governing Body GP, Governing Body Consultant and Governing Body Nurse are coming to the end of their terms of service at the end of March The attached paper lays out the CCGs plans for movement to an open election system for the CCG Chair role and the selection or appointment process for other Governing Body positions. Purpose (delete unnecessary) For discussion and approval Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Committee/Governing Body is hereby asked to: 1. Note the outcomes of the September 2017 Members Forum; 2. Discuss and agree the changes to the CCG Constitution; 3. Note and discuss the timeline towards election, selection and appointment of Governing Body members. Where else has this paper been discussed? The proposals for an open election system for CCG Chair have been consulted on with CCG Consortia over the summer of 2017 and key aspects of the process agreed at the Thursday 7 September 2017 Members Forum. What was the outcome of previous discussions? See attached paper for outcomes. Chair: Dr Clare Highton Chief Officer: Paul Haigh

198 Changes to the CCG Constitution following discussion with the September 2017 Members Forum Presentation to the Friday 29 September 2017 Governing Body and Thursday 5 October 2017 Members Forum FOR DECISION

199 Background Clare Highton and Haren Patel reach the end of their terms of office in March 2018 and can not carry on as Chair and Clinical Vice Chair; At present the Chair is appointed through being elected as a Consortia Lead onto the Clinical Executive Committee and then elected by those Leads onto the Governing Body; The Thursday 7 September 2017 Members Forum debated moving to a presidential style system of open Chair elections, following consultation across Consortia in the summer; Member practices confirmed their preferences on the details of how an open election system could work and those decisions have been worked up into a revision of the CCG Constitution; The Members Forum requested that these Constitutional changes, along with a job role and specification return to the October 2017 meeting for agreement and enable us to run the upcoming election process towards the end of this year / early next year (depending on NHSE agreement of our Constitutional changes!).

200 Assumptions 1. We are discussing changing the election process for the CCG Chair only the Consortia Lead election / selection process has remained unchanged; 2. The Consortia Leads will continue to elect / select two of their number to serve on the CCG Governing Body as Clinical Vice Chair and Governing Body GP; 3. One individual cannot hold both the Consortia Lead role and CCG Chair role. Similar to the current system, should this become the case, the individual will need to stand down from their Consortia Lead role and that Consortia will need to re-run their election / selection process without the new CCG Chair in the running; 4. Any Chair of the CCG would not be able to hold corporate or governing positions with the local GP Federation or Local Medical Committee as these would constitute a major conflict of interest. Any individual in this position would be able to stand for election, but would need to step down from any competing role if elected CCG Chair; 5. That the CCG Governing Body and Members Forum will still need to vote in the new CCG Chair in a majority (2/3rds Practices for the Members Forum) vote; 6. The same criteria that apply to other Governing Body Members will also apply to the elected Chair.

201 Decisions from the September 2017 Members Forum The Members Forum meeting on Thursday 7 September 2017 decided that: Partnered or salaried GPs could stand as a candidate for CCG Chair; Any CCG Chair candidate must have been working in the City or Hackney for at least two years; Any CCG Chair candidate must have the support of two sponsors, who must also be partnered or salaried GPs working in the local area for at least two years; An application will be required to be completed by all candidates, details of which will be accompanied with a job role and person specification to be agreed by the Members Forum; Applications will be shortlisted by a panel of the current CCG Chair, CCG Governing Body Lay Member, Consortia Lead GP that is not standing for the Chair role and the Chair of the Health and Wellbeing Board; The same panel will then interview shortlisted candidates against a consistent set of questions; Those candidates passing the interview process will take part in a hustings style event, open to all CCG Member Practice staff; The candidates will be questioned in public at the event, with the questions being drawn from the CCG Member Practices staff; Each partnered or salaried GP working in City and Hackney for at least two years will be able to exercise one vote each through an electronic voting platform for their chosen candidate; The CCGs Head of Membership Engagement or Head of Corporate Services will act as the returning officer.

202 Changes to the CCG Constitution Changes to the CCG Constitution marked up in track changes are available from An extract of the changes in plain text is available from this version is more accessible and reflects how the new text will read when agreed; If the Governing Body agrees these changes to the Constitution, the Members Forum on Thursday 5 October 2017 will also be asked to agree the changes; Once agreement to the changes had been secured from both the Governing Body and Members Forum, the changes will be submitted to NHS England for their agreement.

203 Other upcoming Governing Body changes In addition to the move to an open election system for CCG Chair, we will need to undertake recruitment exercises for the CCG Governing Body Consultant and Nurse in the coming months; Both Christine Blanshard and Siobhan Clarke are coming to the end of their maximum terms of service on 31/03/2018; CCG Consortia will also be selecting or electing their own leads as well in the coming months the process for this is unchanged from previous years; The timeline for these processes is on the next slide.

204 Timeline Governing Body Members Advertise upcoming positions Friday 20 October 2017 Closing date for applications Friday 10 November 2017 Shortlist applicants Friday 17 November 2017 Interview Panel held Friday 08 December 2017 Notify preferred candidate Tuesday 12 December 2017 Members Forum approval of candidate Thursday 11 January 2018 Appoint sucessful candidate Monday 15 January 2018 Consortia Leads Consortia Lead election process starts Monday 09 October 2017 Consortia Lead election process ends Thursday 30 November 2017 Consortia Lead election results ratified at Members Forum Thursday 07 December 2017 Meeting of 'new' CEC to agree 2 GPs (one Vice Chair/CEC Chair) as members Friday 15 December 2017 of GB CCG Chair Clear revised Constitution through Members Forum Thursday 05 October 2017 Clear revised Constitution through Governing Body Friday 29 September 2017 Clear revised Constitution through NHS England Thursday 07 December 2017 Chair application process opens Monday 6 November 2017 Chair application window closes Friday 17 November 2017 Shortlisting of applications complete Wednesday 22 November 2017 Panel interviews taken place Friday 1 December 2017 Hustings event held Friday 8 December 2017 CCG Chair election ballot voting starts Monday 11 December 2017 CCG Chair election ballot voting ends Monday 01 January 2018 New CCG Chair results confirmed Wednesday 03 January 2018 All new GB members ratified by Members Forum Thursday 11 January 2018 All new GB members ratified by GB Friday 26 January 2018

205 Paper Title Finance & activity report, month /18 Paper Author Sunil Thakker Lead Presenter Sunil Thakker Paper Summary (3 bullet points of relevant background to the paper) Attached is the regular summary of the month 5 financial position and month 4 activity to the Governing Body. Purpose (delete unnecessary) For information and discussion Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Receive and discuss the latest Finance and Activity report for the CCG. Where else has this paper been discussed? An expanded version of this report was discussed in depth at the Tuesday 26 September 2017 Finance and Performance Committee. What was the outcome of previous discussions? Discussions will be updated on verbally at the Governing Body. Chair: Dr Clare Highton Chief Officer: Paul Haigh

206 FINANCE & ACTIVITY REPORT Month /18 NHS CITY & HACKNEY CCG 29 September 2017 NHS City & Hackney CCG

207 Contents Executive summary Finance and activity dashboard & trend Key risks narrative Running costs performance Financial Statements Primary Care Co-Commissioning NHS City & Hackney CCG

208 Executive Summary A review of month 5 financial position and month 4 activity was undertaken to compile this report. At month 5 City & Hackney CCG declared a breakeven position. The acute portfolio was risk assessed and reviewed with several cost pressures recognised and contained by releasing the Acute Reserve combined with provider underspends. The overall YTD position was a combined overspend totalling 123k. The non-acute portfolio recognised continued cost pressures relating to CHC and FNC ( 267k) and within Other Commissioning areas ( 106k). These were managed and contained by recognised underspends in Prescribing, Property Services and Running Costs. The 30.19m forecast outturn surplus was risk assessed with delivery expected to be on-target. The non-recurrent programme for 2017/18 is a key deliverable and most are now in contracts. All investments on an individual basis continue to be reviewed and monitored. As previously reported, City & Hackney CCG as part of the national Capped Expenditure Programme identified further QIPP totalling 1.4m. The chronology behind the additional QIPP was in support of delivering the STP control total and mitigating risk around unidentified QIPP within the NEL system. NHSE subsequently directed City & Hackney CCG not to declare it and hold the amount as a contingency to be deployed on a year to go basis. The 1.4m is being managed and accruing pending direction from NHSE. This is also reflected within the accompanying Risks & Opportunities summary. Previously reported disputes from prior years are expected to be concluded during the course of the financial year. As previously reported an application to drawdown funds to support the Integrated Commissioning programme of work was rescinded by NHS England. The CCG is working with local partners to manage the situation. The Dashboard (page 4) highlights a GREEN RAG rating against the CCG Income & Expenditure position. QIPP for month 5 delivered a GREEN RAG rating with the expectation that it will be maintained for the full year. NHS City & Hackney CCG

209 INCOME & EXPENDITURE MONTHLY ACTUAL YTD vs BUDGET EXPENDITURE YEAR END FORECAST v PLAN 445m TREND THIS IS THE ACHIEVEMENT OF YTD PLAN, UNDERLYING PERFORMANCE AND PROJECTED FORECAST. 65m 55m 45m 35m 440m 435m 430m 425m 420m 415m 410m 4795 FINANCE DASHBOARD 25m 405m 400m 15m m ACUTE SPEND HUHT SPEND VARIANCE vs PLAN (%) ALL ACUTE SPEND VARIANCE vs PLAN (%) NCA SPEND VARIANCE vs PLAN (%) 30% % % % 20% 20% TREND 10% 0% 10% 0% 10% 0% THIS IS THE ACUTE PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. -10% -20% -10% -20% -10% -20% -30% -30% -30% Sep Sept Total of pre GW3 CRES ideas - valued at 35% which is the % required to be achieved of general CRES schemes QIPP PERFORMANCE vs PLAN PRIMARY MEDICAL SERVICES PERFORMANCE vs PLAN NON-RECURRENT INVESTMENTS PERFORMANCE vs PLAN THIS IS THE DELIVERY OF QIPP AGAINST THE PROFILED ANNUAL PLAN. THE TREND REPRESENTS THE FULL YEAR DELIVERY AGAINST TARGET WHICH WAS BREAKEVEN AT MONTH 5. THIS IS THE SPEND ON PRIMARY MEDICAL SERVICES BUDGETS VS ANNUAL PLAN. MONTH 5 FORECAST OUTTURN IS BREAKEVEN. THIS IS THE SPEND ON NON-RECURRENT INVESTMENTS VS ANNUAL PLAN. NHS City & Hackney CCG

210 Key Risks - Finance The Finance & Performance Committee will review the month 5 financial position on 26 September and any further issues will be reported to the Governing Body members thereafter. The year to date acute position declared across the portfolio was a 123k overspend with limited detail available on activity; the recent system IT issues are beginning to be resolved and addressed. Agreement on the Whittington CHS contract position was reached with a follow on programme of work relating to disaggregation of activity. Agreement on the LAS SLA is pending conclusion at the time of writing this report. CEP/QIPP requirements may further impact the expenditure pattern in-year. Homerton shows the year to date position as being on plan at 52.8m and the forecast anticipating the QIPP savings to be varied from the contract. Work continues with the Homerton to collectively develop and deliver sustainable transformation schemes that will deliver savings for the CCG and reduce and eliminate costs within the provider setting. Allocation of 1.7m for Identification Rule changes (IR) included in the Homerton contract baseline was agreed and varied out of the contract. NHSE will process the subsequent change to CCG allocation in September. Bart s Health year to date position at 11.4m was 167k adverse to plan with a forecast overspend of 400k. Despite a slight improvement in month, this contract remains a key area of risk, not just for City & Hackney CCG, but for the wider NEL system due to material unmitigated financial risks sitting with the provider. During 2017/18 the Finance and Performance Committee will continue to undertake monthly deep dives in rotation of Worksteams as in the previous year with Programme Boards. Actions: Pursue the claims challenges across the acute portfolio. Liaise with NEL CSU to conclude contract negotiation. Review, monitor and manage the impact of Specialist misattributions. Action: Non-Acute portfolio reported a forecast over spend of 628k mainly due to CHC and FNC. Work continues on CHC and FNC with a possible cost pressure emerging despite a material increase in budget compared to prior year. This is included within the Risks and Opportunities table and will be managed on a year to go basis. Primary Medical Services was reported on plan, however, there are emerging risks developing with rental charges where landlords in some cases are pursuing retrospective rent revaluations resulting in possible increased rental charges. This situation is made worse by the impact of rates increases due to increases in property rateable values. City & Hackney CCG is liaising with NHS Property Services on this matter. Prescribing expenditure on a year to date and full year basis was reported on plan. The budget is set net of QIPP with full year delivery expectation. QIPP delivery totalling 5.0m was on plan on a year to date and full year basis. The additional QIPP identified of 1.4m which is over and above the 5m target is not reflected in the M3 position, as directed by NHSE. The non-recurrent (NR) investment programme in 2017/18 was risk assessed and considered to be on plan. The risk around non delivery and slippage will be managed accordingly. All investments will be recognised through contract and or contract variations. Significate progress was made in the first quarter of the financial year to agree and settle prior year disputes with NHS Property Services. Work continues in resolving other areas of long standing prior year disputes with an anticipation that these disputes will be concluded in 2017/18. The CCG has assessed the risks in making year end provisions to cover these known risks. Monitor, manage and mitigate where possible CHC and FNC cost pressures Work with NHS Property Services and practices to mitigate the impact of rent increases Monitor, manage and mitigate slippage within the NR programme of spend Conclude in 2017/18 long standing disputes NHS City & Hackney CCG

211 Running Costs Performance on CCG Running Costs is shown below. The CCG is not permitted to exceed its allocated Running Cost Allowance, but is permitted to allow any unspent balances to be used for Commissioning. The 2017/18 Running Costs allocation is 6,215k with a recurrent 600k QIPP commitment. The risk attached to this is minimal. Monthly Running Costs vs.plan Total Planned Spend CCG Planned Spend CSU Planned Spend NHS City & Hackney CCG

212 Risks and Opportunities Ref: Description Risks/ (Opps) '000 Prob. % Adj. Recurrent '000 Adj. Non Recurrent '000 1 Homerton Acute performance 1,500 37% Gross position based on historic trend. Net risk based on the trend relating to claims and challenges. 2 Homerton Identification Rule (IR) changes 1,700 0% Bart's Acute performance 1,250 68% Narrative 4 Outer sector - Acute performance 2,500 44% 1,112 0 Increased NCL provider over-performance risk contained by reserves. Agreed adjustment to action in month 6 of Identification Rule changes relating to high cost drugs within the Homerton acute contract. Net impact will be a reduction in CCG allocation contra a reduction in the Homerton acute contract. Gross position reflects over-performance risk and possible NHSE disputed misattribution.net risk based on the trend relating to claims and challenges. 5 Non-Contracted Activity (NCA) performance 500 0% 0 0 Applicable risk that reflects uncertainty of costs, including mental health choice, resulting in a recognised cost pressure. 6 Continuing Healthcare, LD & EOL 2,000 31% Summary and Progress Report on Financial Risks and Opportunities to 31 August Risk Non Acute performance % Non acute cost pressure across the portfolio. Risk relating to activity increase above plan, high cost patients packages and service provision. Gross risk high given worsening 2016/17 trends and increased FNC tariff pressure. 8 Programme Costs 750 0% 0 0 Possible in-year non-recurrent cost pressures in support of the integrated commissioning programme and other non-recurrent schemes. 9 Property Costs 550 0% 0 0 Property services potential cost pressure. 10 Non Recurrent Investment Cost Pressure 2,500 43% 0 1,080 Underwriting NR investment programme, dispute resolution and other pressures. 11 Primary Care - Rent Revaluation 750 0% 0 0 Consequence of retrospective rent increases in 2017/ Primary Care - Rates 250 0% 0 0 Consequence of increased rateable value on properties in 2017/18 13 QIPP Under Delivery 900 0% 0 0 Potential under-delivery of QIPP schemes. Total Risks 15,950 27% 3,296 1,080 1 Acute contract Claims and Challenges (1,750) 57% (1,000) 0 Based on historic trend. 2 Homerton Identification Rule (IR) changes (1,700) 0% Acute Reserves (500) 100% (500) 0 Release of reserve to offset activity pressures. 4 Non-Contracted Activity (NCA) performance (500) 60% (300) 0 Projected underspend based on current trend. 5 Contingency (0.5%) (2,200) 37% (810) 0 Release of contingency. 6 Opps Prescribing (500) 17% (86) 0 Projected underspend based on current trend. Agreed adjustment to action in month 6 of Identification Rule changes relating to high cost drugs within the Homerton acute contract. Net impact will be a reduction in CCG allocation contra a reduction in the Homerton acute contract. 7 Running Costs (1,400) 43% (600) 0 Headroom/underspend declared and allows cost pressures to be contained elsewhere in the portfolio. 8 Prior year Items (4,000) 27% 0 (1,080) 9 Non Recurrent Investment slippage (500) 0% 0 0 Reviewed and risk assessed with position contained at month 5 10 QIPP Over Delivery (500) 0% 0 0 Possible over delivery of QIPP. Opportunities arising from settlement of disputed items, accruals etc. invoices provided for in prior year resulting in an upside available 2017/ QIPP - new schemes / CEP Programme (1,434) 100% (1,434) 0 Total Opportunities (14,984) 39% (4,730) (1,080) QIPP in addition to the 5.0m recognised within the Operating Plan, to be ring-fenced and deployed on a year to go basis as directed by NHSE. (1,434) 0 Net Underlying Forecast Outturn Net Cumulative Brought Forward surplus Headline Forecast Outturn Cumulative (1,434) (30,198) (31,632)

213 ACUTE ACTIVITY PLANNED CARE ACTIVITY ALL PLANNED ADMISSIONS VARIANCE vs PLAN (%) ALL OUTPATIENT VARIANCE vs PLAN (%) TREND THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% -10% -20% % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% -10% -20% ACTIVITY DASHBOARD URGENT CARE ACTIVITY ALL A&E ACTIVITY vs PLAN (%) ALL ADMISSIONS vs PLAN (%) HUHT ADMISSIONS vs PLAN (%) 100% 90% 80% % 90% 80% % 90% 80% % 70% 70% TREND 60% 50% 60% 50% 60% 50% THIS IS THE ACUTE ACTIVITY PERFORMANCE AGAINST PLAN. THE TREND REPRESENTS THE RAG RATED MONTH ON MONTH CHANGE. 40% 30% 20% 10% 40% 30% 20% 10% 40% 30% 20% 10% 0% 0% 0% -10% -10% -10% -20% -20% -20% NHS City & Hackney CCG

214 Financial Statements - 1 NHS City & Hackney CCG Annual Budget 000 INCOME & EXPENDITURE ACCOUNT YTD Budget 000 YTD Actual 000 YTD (Under)/ Overspend 000 Forecast Actual 000 Forecast (Under)/ Overspend 000 Improvement/ Deterioration vs M4 Improvement/ Deterioration vs M4 '000 In Area Acute Trusts 126,755 52,815 52, ,199 (556) 0 Out of Area Acute Trusts 76,516 31,882 32, ,130 1, Other Acute 3,468 1,737 1,187 (550) 2,566 (903) (222) Subtotal Acute 206,739 86,433 86, , Mental Health Services 50,996 20,912 20, , Community Health Services 35,802 14,917 14,911 (6) 35, Other Non Acute 37,875 15,781 16, , Subtotal Non Acute 124,673 51,610 51, , Prescribing 28,776 11,990 12, ,696 (80) 0 Primary Care Co-Commissioning 44,183 17,581 17,581 (0) 44, Other Primary Care Services 15,016 6,256 6,253 (3) 15,009 (6) (1) Subtotal Primary Care 87,975 35,827 35, ,888 (86) (1) NHS Property Services 3,166 1,319 1,227 (92) 3,074 (92) (0) Reserves 6,408 0 (410) (410) 6,247 (162) (206) Subtotal Other 9,574 1, (502) 9,321 (254) (206) Total Programme 428, , , , (0) Corporate 6,215 1,909 1, ,615 (600) 0 Total Corporate 6,215 1,909 1, ,615 (600) 0 Grand Total 435, , , ,176 0 (0) Total Resource Limit (465,374) (189,682) (189,682) 0 (465,374) 0 0 Surplus (30,198) (12,582) (12,582) 0 (30,198) 0 (0)

215 Financial Statements - 2 KEY BALANCE SHEET INDICATORS Compliance with Public Sector Payment Performance Target 97% The national target relating to cash balance at month end being 1.25% of drawdown amount was achieved. NHS City & Hackney CCG

216 Paper Title Refresh of CAMHS Local Transformation Plan and KLOEs Paper Author Greg Condon Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) In implementing the Five Year Forward View for Mental Health, we have expanded, refreshed and republished our Local Transformation Plans (LTPs) for Children and Young People s Mental Health. Our plan has received positive feedback from NHS England in their assurance process and is attached. Purpose (delete unnecessary) For information and discussion. Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Receive the feedback on the CCGs plan and discuss any aspects of the attached document. Where else has this paper been discussed? This paper has not been discussed elsewhere. What was the outcome of previous discussions? This paper has not been discussed elsewhere. Chair: Dr Clare Highton Chief Officer: Paul Haigh

217 Regional Assurance of CYP MH Refreshed Local Transformation Plans London Region DCO team: NCEL LTP: City & Hackney CCG PROCESS OVERALL FEEDBACK This was a strong overall plan with good information on progress to date and clear priorities for transformation Details regarding KPIs were good although it would be useful to understand the KPIs against the future priorities The plan had a clear overarching vision and a clear outline of how services will be different in 2020 The plan outlined good details on engagement with children, young people and parents/carers and other stakeholders and a good structure for ongoing engagement Good breakdown of financial spend Excellent governance section showing full accountability and reporting with evidence of cross sector working 1

218 KLOE Rating Further information required Please specify the page number in the refreshed LTP where the additional information is located 1 Transparency and governance A Will the LTP be both refreshed and republished by the deadline of 31 October 2016 and is it included in the STP? B Does the LTP include a baseline (15/16), including figures for: - finance; - staffing (WTE, skill mix, capabilities); - activity (e.g. referral made/accepted; initial and follow-on contacts attended; waiting times; CYP in treatment) C Is the refreshed LTP the result of engagement with a wide variety of relevant organisations, including children, young people and their parents/carers, youth justice and schools & colleges? Does it evidence their participation in: - Governance - Needs assessment - Service planning - Service delivery and evaluation No further information required Please provide baseline spend figures for 2015/16 for NHSE Page number:. No further information required If information is unavailable, please state: - Why this is unavailable - When it be available - And how it will feed into the refreshed LTP This was in the original plan submitted See page 21 Updated rating Comments Rating unchanged. NHSE/Spec comm spend not specified 2

219 D E F G H - Treatment and supervision Has the LTP been signed off by the Health and Wellbeing Board and other relevant partners, such as specialist commissioning, local authorities etc.? Are there clear and effective multiagency governance board arrangements in place with senior level oversight for planning and delivery? Does the plan clearly identify areas of effective provision alongside current challenges and priorities? Are there clear mechanisms and KPIs to track progress? Is the refreshed LTP published on local websites for the CCG, local authority and other partners? Is it in accessible format, with all key investment and performance information from all commissioners and providers within the area? No further information required Page number:. No further information required No further information required No further information required Please provide confirmation that the refreshed LTP is published on local websites for the CCG, local authority and other partners in an accessible format and with all key investment and performance information Now published Rating changed. 2 Understanding local need A Has the plan been designed and built around the needs of CYP and their families? B Does the plan evidence a strong understanding of local needs and meet those needs identified in the published Joint Strategic Needs Assessment (JSNA)? C Does the plan make explicit how health inequalities are being addressed? Page number:. No further information required Please confirm that the information provided is linked to your JSNA Page number:. No further information required Linked and refreshed to reflect new JSNA see Local Needs on page 7 onwards 3

220 D Does the plan contain up-to-date information about the local level of need and the implications for local services? 3 LTP ambition A Does the LTP identify a system-wide breadth of transformation of all relevant partners, including the local authority, third sector, youth justice and schools & colleges? B Does the plan have a vision as to how delivery will be different in 2020? (is there a visions, and how differs) C Does the plan address the whole system of care including: early prevention and early intervention, early help provision with local authorities, routine care, crisis care and intensive interventions, groups with extra vulnerability, inpatient care, specialist disorders 4 Workforce A Does the LTP include a multi-agency workforce plan? B Does the plan identify the additional staff required by 2020 and include plans to recruit new staff and train existing staff to deliver the LTP's ambition? C Does the plan detail the required work and engagement with key organisations, including schools and colleges and detail how the plans will increase capacity and capability of the wider system? No further information required No further information required No further information required No further information required No further information required No further information required No further information required 4

221 5 Collaborative commissioning A Does the LTP include details about creating joint plans to develop a local integrated pathway for CYP requiring beds that includes plans to support crisis, admission prevention and support appropriate and safe discharge? B Does the LTP include details about creating joint plans to ensure join up with Health and justice Commissioners to develop local integrated pathways,(including transitioning in or out of secure settings, SARCs and liaison & diversion) A good joint plan will identify: the aim; the pathways concerned; the partners involved with a joint commitment to deliver; a project plan including planning structures; resources (including resource transfer); time scale; benefits and outcomes and; risk assessment and potential barriers. 6 CYP IAPT A Does the LTP evidence full membership and participation in CYP IAPT and its principles? These principles include: - collaboration and participation; - evidence-based practice; - routine outcome monitoring with improved supervision? B If not a CYP IAPT member, is there a clear commitment to join a CYP IAPT learning collaborative? No further information required No further information required No further information required No further information required 5

222 C Is there a commitment to support the participation of staff from all agencies in CYP IAPT training, including salary support? 7 Eating disorders A Does the LTP identify current baseline performance against the new Eating Disorder access and waiting time standards ahead of measurement beginning from 2017/18? B Does the plan clearly state which CCGs are partnering up in the eating disorder cluster? 8 Data A Does the LTP identify the requirement for all NHS-commissioned services, including non-nhs providers to flow data for key national metrics in the MH Services Data Set? (MHSDS) No further information required No further information required No further information required No further information required 9 Urgent and emergency care (crisis) mental health for CYP A Does the LTP identify an agreed plan and its implementation to expand provision for CYP in crisis care and the need for a 24/7 crisis service? 10 Early Intervention in Psychosis (EIP) A Does the LTP identify an EIP service delivering a full age-range service, including all CYP, experiencing first episode in psychosis and that all referrals are offered NICErecommended treatment (from both internal and external sources)? B If so, does this include the full pathway for all CYP, including those who present to the specialist CYP MH No further information required No further information required No further information required 6

223 service? 11 Impact and outcomes A The LTP is a five-year plan of transformation. Do you have: - a roadmap to achieve the LTP vision, including trajectories which include clear year on year targets for improving access and capacity to evidence based interventions? B The LTP is a five-year plan of transformation. Do you have: - examples of projects which are innovative and key enablers for transformation? C The LTP is a five-year plan of transformation. Do you have: - examples of how commissioning for outcomes is taking place? 12 Other comments A Does the plan highlight key risks to delivery, controls and mitigating actions? Workforce, procurement of new services not being successful or delayed B Does the plan highlight or prompt the use of innovation particularly in relation to the use of social media and apps that can be shared as 'best practice' C Does the plan state how the progress with delivery will be reported encouraging the transparency in relation to spend and demonstration of outcomes D Does the plan fit in with the STP and other local CYP LTPs; (CCGs are No further information required No further information required No further information required No further information required No further information required No further information required No further information required 7

224 requested to provide a paragraph on alignment) 8

225 Paper Title June 2017 NHS England Assurance Meeting Paper Author NHS England Lead Presenter Clare Highton Paper Summary (3 bullet points of relevant background to the paper) Attached is the latest assurance letter from NHS England as a result of the meeting with the CCG on Wednesday 21 June Purpose (delete unnecessary) For information and discussion Recommendation (state what you are asking for (eg support a proposal, debate and decide options, provide feedback etc. List all that's applicable) The Governing Body is hereby asked to: 1. Acknowledge the assurance letter from NHS England and discuss. Where else has this paper been discussed? This paper has not been discussed elsewhere. What was the outcome of previous discussions? Not applicable. Chair: Dr Clare Highton Chief Officer: Paul Haigh

226 NHS England (London Region) Skipton House 80 London Rd London SE1 6LH 2 August 2017 Sent via To: paul.haigh@nhs.net, clare.highton@nhs.net, philippa.lowe@nhs.net Dear Paul, Clare, Philippa City & Hackney CCG Assurance Meeting 21 June I would like to thank your teams for meeting on 21 June to discuss City & Hackney CCG performance and quality agenda items. Discussion at the Meeting The following notes the key points from the discussion and any actions arising. 1.0 IAF Domains 1 and 2: Better Health and Better Care Key points of discussion 1.0 Homerton ED Visit Homerton ED was visited by NHSE and NHSI colleagues in May as a benchmark, on the basis they are currently one of the highest performing system in London for the 4-hour quality standard. NHS England was encouraged by the positive feedback, recognising all the good work and robust processes in place, in particular the positive organisational culture with all staff identifying a can do attitude and who talked positively about their role, the organisation and the system they worked in. 1.2 A&E Performance Low diversion rates to Primary Urgent Care Centre (PUCC) You informed us of the actions in place to improve the diversion rates to PUCC which