NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body Friday 28 October 2016,

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1 NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body Friday 28 October 2016, 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 1. Welcome, introductions and declarations of interests Led by & Appendix number 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 (10 mins) 3. Questions from the public Clare Highton Verbal 4. Board Assurance Framework Philippa Lowe Papers 4a & 4b (5 mins) (10 mins) Pages CLINICAL STRATEGY (FOR DECISION) Page 1 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

2 5. Local Five Year Plan: Devolution Pilot across Hackney update. Clare Highton Paper 5a, 5b, 5c & 5d Pages (10 mins) 6. CHUHSE Action Plan Update Honor Rhodes / Leah Herridge Papers 6a & 6b (10 mins) Pages PERFORMANCE 7. CCG Finance update Philippa Lowe Paper (10 mins) Pages Co-ordinate My Care data overview Leah Herridge Papers 8a, 8b & 8c (10 mins) Pages Changes to the CCG Constitution Paul Haigh Paper (10 mins) Pages Delegation of decision making for 2017/19 contractual arrangements Lee Walker Paper 10 Pages (10 mins) /16 Public and Patient Involvement Annual Report Clare Highton Paper 11a & 11b Pages (10 mins) FOR INFORMATION Page 2 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

3 12. Reports from Subcommittees of the Board: a. Wednesday 28 September 2016 Finance and Performance Committee; b. Friday 30 September 2016 Local GP Provider Contracts Committee; c. Wednesday 12 October 2016 Clinical Executive Committee; d. Thursday 13 October 2016 Audit Committee. Clare Highton Papers 12a, 12b & 12c Pages (5 mins) 13. Friday 25 November 2016 draft CCG Board agenda Clare Highton Paper (5 mins) Pages Any Other Business December 2016 GB meeting date. Clare Highton Verbal (5 mins) Page 3 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

4 MINUTES OF THE NHS CITY AND HACKNEY CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING HELD ON FRIDAY 30 SEPTEMBER 2016 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 Board GP) Mariette Davis (CCG Lay Member for Governance) Catherine Macadam (CCG Lay Member for Public and Patient Involvement) Honor Rhodes (CCG Associate Lay Member) Dr Christine Blanshard (CCG Board Secondary Care Consultant) Philippa Lowe (CCG Chief Financial Officer) Paul Haigh (CCG Chief Officer) IN ATTENDANCE: Matthew Knell (CCG Head of Corporate Services) Dr Kirsten Brown (Maternity Services Clinical Lead GP) for agenda item 5 Jenny Singleton (CCG Head of Quality) for agenda item 8 Jan Annan (CCG interim Head of Outcomes and Evaluation) for agenda item 9 Richard Bull (CCG Long Term Conditions and Primary Care Quality Programme Director) for agenda item 11 APOLOGIES: Siobhan Clarke (CCG Board Nurse) Dr Penny Bevan (LBH & CoL Director of Public Health) David Maher (CCG Deputy Chief Officer) Siobhan Harper (CCG Deputy Chief Officer) London Borough of Hackney HealthWatch City of London HealthWatch Agenda Item 1 Welcome, introductions and declarations of Interests Dr Clare Highton (CH), the CCG Chair welcomed members to the September 2016 meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Governing Body (GB). Cynthia White was in attendance as members of the public. Apologies were noted and CH confirmed that the GB was quorate for decisions. CH acknowledged that the GPs present at the meeting held conflicts of interests as providers of primary care and that they would not be taking part in the discussion under agenda item 11, which would be chaired by Catherine Macadam (CM). Mariette Davis Page 4 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

5 (MD) added that she held a conflict of interest with regards to shared business with Tower Hamlets CCG, where she also held the position of Lay Member for Governance but that no agenda item at this meeting was affected by that conflict. 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. Philippa Lowe (PL) noted that the tabled note from the July 2016 GB meeting should be present on the CCGs website and that her advice on the latest STP financial asks would be circulated to the Gb following this meeting. CH recognised the need for letters regarding current recruitment issues and questions over the future of the NHS workforce to be drafted. Matters Arising No further matters arising were discussed. Agenda Item 3 Questions from the public No questions from the public were received. Agenda Item 4 Board Assurance Framework PL noted that the CCGs external audit provider was benchmarking board assurance frameworks (BAFs) in use across London and would be able to feed back their findings and recommendations in the near future to the Audit Committee (AC) and GB. PL confirmed that the AC regularly receives the BAF and discusses the document in detail, including conducting deep dives on specific areas of risk. PL recognised that the BAF needed to be refreshed in light of the changing NHS landscape and key areas, like quality, innovation, productivity and prevention (QIPP) savings expanded on. PL raised that another risk worth Page 5 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

6 exploring for potential inclusion was inconsistent regulator behaviour and the fast pace of change underway currently, along with the risks attached to the North East London (NEL) Sustainable Transformation Plan (STP) that had been discussed at the GB in the past. CH highlighted that the workforce issues that were becoming ever more pressing should be included in the BAF, with risks around the upcoming changes to the 111 service also in need of assessment. Other areas that needed to be looked at for possible inclusion were demand for acute and continuing healthcare (CHC) services, Barts Health clinical coding changes driving increases in activity and charges and the lack of City and Hackney s access to eight to eight primary care funding under the clinical hub model being promoted by NHS England (NHSE). Christine Blanshard (CB) asked if the risks present in the BAF were developed at the corporate level or escalated from CCG Programme Boards. PL responded that the majority were escalated from Programme Boards, but that the Corporate team did hold a risk register as well, in addition to working with Programme Boards to develop and challenge risks. MD added that the Programme Boards were owning their risks and had been asked to certify that they are discussed at meetings and reflected on. CB stated that they key risks for her at the moment were the changing environment and policies across the NHS. Cynthia White (CW), in attendance as a member of the public asked if local mental health needs were being appropriately managed as a risk, with significant challenges in maintaining service standards and funding becoming apparent in other areas. CW continued to ask whether the risk relating to waiting lists was contradicting the CCGs objective approach, with there being potential for conflict between reducing increased access to psychological therapies (IAPT) waiting lists and meeting more serious mental health needs with only so much funding to cover both. CH responded that the IAPT service was performing well locally, especially in comparison to other areas services and that the CCG was doing well in the parity of esteem between acute and mental health services funding. CH noted that while there had been some decreases in mental health bed use and an increase in community care, the CCG was likely to reaching the limits of this approach. PL agreed with CHs assessment that the CCG had likely made the bulk of savings possible, with many re-invested to support better care or to address activity needs. PL added that the parity of esteem between acute and mental health services depended on how this data was cut and looked at. CW noted that various reports released recently were indicating worrying trends in mental health service demand and patient experience, with some patients now reporting that they were being discouraged from seeking help. CH responded that the local area was lucky to have many excellent services but that the general trend was towards fewer bed days for these patients. Page 6 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

7 Agenda Item 5 HUHFT Maternity Services Action Plan update Kirsten Brown (KB) joined the GB to present this item, with supporting papers having been circulated before the meeting. KB briefed the GB on the background behind the compilation of action plans in place against Homerton University Hospital NHS Foundation Trust (HUHFT) maternity services, with the findings of investigations into 5 maternal deaths at HUHFT between July 2013 and January 2015 and a Care Quality Commission (CQC) inspection in 2015 all included. The combined action plan contained 53 items covering 8 categories, which were staffing levels, staff competency & training, organisational culture, recognition of deterioration and escalation, governance, clinical and safety outcomes and patient feedback. Much progress had been made and 27 items have been closed since the action plan commenced, of the remaining 26 items a number are potentially covered by the same action, for example 5 items are linked to staffing and will be addressed in a staffing review, 3 relate to triage, 3 to outstanding audits, 2 to handling of serious incidents (SIs) and complaints and 2 to dashboard amendments. KB added that almost all actions had evidenced at least some progress and that some actions were not intended to ever be closed, but would be monitored from this point forwards. CH asked if the CCG Maternity Programme Board (MPB) was seeking independent feedback and assurance on the action plan and evidence against completed actions. KB responded that they were, although progress in this area had been somewhat delayed by recent changes to clinical networks across London. KB outlined the MPBs significant concerns regarding current and future staffing needs, with HUHFT undertaking a staffing review currently, supported by the CCG. KB confirmed that HUHFT were reporting a jump in deliveries with complications and that the Trust was an outlier when benchmarked against others. CH asked how the Trust was doing with caesarean section deliveries. KB responded that while they had been decreasing in number recently, the most recent data indicated a rise. Overall levels were high versus peer maternity units, with around 30% of births being via caesarean. CB asked if these issues were real and possible quality risks, or caused by the Trusts approach to coding. KB responded that she believed it was a coding issue and Penny Bevan (PB) added that the Trust had changed software quite recently, which may be driving this. KB responded that she wasn t sure on the software, but that the clinical coding was undertaken by quite senior staff in the unit, which may affect the data. KB confirmed that HUHFT was both an outlier in terms of comparison to other areas and to other level three neo-natal intensive care units (NICU). KB outlined that HUHFT say that patient acuity is up. KB continued to brief the GB on the action plan in place, with HUHFT already reporting a rate of 1:29 for midwife to consultant, which was better than the national average of 1:30. CB asked whether the actual values were reported, or planned and added that information on sickness rates and patterns of work might help indicate morale issues. KB responded that the Trust reports vacancies and agency use rate. Page 7 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

8 Honor Rhodes (HR) asked if the MPB was looking at mother and child wellbeing. KB responded that there was a large analysis of data underway at the moment, but that an initial look indicated that the local area was not an outlier on stillbirths. PB noted that she also chairs the Child Death Panel and that while HUHFT did have a higher rate than other Trusts, there was not a consistent thread running the cases and that the Panel had considered this data to be down to the presence of the NICU and patient need. CM stated that the Public and Patient Involvement Committee (PPIC) had been raising questions about HUHFT maternity services since issues were first reported on and asked why the remaining actions on the plan were taking so long to address. KB responded that many of the actions needed to be re-audited or were subject to annual reviews and that this would preclude them from being closed yet. Others, like that development of a clear vision and strategy were not done, but meetings had been set up to work on these areas of work jointly with the CCG. KB confirmed that HUHFT were taking all the work in this area seriously. KB informed the GB that the MPB were still seeking to involve some form of peer review in the monitoring process and that while the strategic clinical network for maternity had closed, a new structure was in the process of being developed and it was hoped to be up and running soon. The CCG and HUHFT were signed up to the pan London benchmarking network, receiving support for external reviews of SIs and would be starting an external review of post partum incidents and an exercise to spot any trends in HUHFT s SIs. CH stated she feels more assured regarding the service than perhaps many others, considering the oversight applied to it and asked that the MPB do look and report on any differences between planned and actual staffing levels and consultants on duty. Sunil Thakker (ST) noted that there had been recent noticeable increases in maternity related costs at HUHFT, with the CCG and North East London Commissioning Support Unit (NELCSU) taking a closer look at any changes in coding practices. Agenda Item 6 Local Five Year Plan PH updated the GB that discussions between the CCG, London Borough of Hackney (LBH), City of London (CoL) and other partners were pointing towards using section 75 agreements to allow NHS and Local Authorities to pool funding. PH highlighted that due to some historic legislation, there were a couple of areas that the NHS was not able to use this arrangement to fund, but it was hoped that this would be addressed on the national level in 2017/18. PH outlined the priority areas of exploration for joint working, including that screening and immunisations would be fully worked up in business cases, although no decision had yet been made on any end state for these services. The teams involved were looking at the services to start with and any delegation of powers or responsibilities would come as a result of that work, probably to come online in PH continued that other areas of Page 8 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

9 interest included local estates use, public health and licensing. The GB will receive a fuller update on these areas at the next meeting. PL expanded on PHs mention of the interest in estates, noting that the involved partners had wanted to align ownerships of facilities with their use across the area, but there were a range of organisations involved in this work. Local Authorities already have extensive powers around the use of estates and it was thought that these existing powers could be used to help promote health related estates priorities, along with integration of health facilities into new developments and a commitment to promoting health first in developments. This route was likely to be swifter than waiting on a national agreement on the future of estates. PB agreed, adding that the NHS was not able to utilise capital investments as the Local Authorities were, and that Local Authorities are also able to borrow funding. PL continued that some of the areas under this work being looked at included key clinical staff housing. PB expanded on the joint work underway in the Public Health area, included that it was hoped to increase the emphasis on health matters in local planning and to make health a formal consideration in local planning applications. Other proposals included increasing Public Health input to alcohol licensing and setting specific health objectives for local development and goals, for instance, setting a Hackney minimum alcohol unit pricing or considering health when looking at planning applications and changes of use for buildings near schools. It was also possible that work on positive tobacco licensing would be possible, but there was also thought to be work on this underway nationally. PH noted that discussions with both LBH and CoL were well underway, with significant meetings coming up in early October 2016 to reach a decision on whether to proceed with a pilot in 2016/17 and a possible go live in the near future. CM briefed the GB on the community engagement underway regarding this work, with quadrant based events planned to take place in November These events may double up to consult on local partners commissioning intentions for 2017/18 and be run in CoL as well. Other engagement was being looked at in two tiers CCG and partner presentations at other meetings and secondly joint events focused on the proposed changes. PH added that further work to support quadrant working and the development of a single point of access to NHS and Local Authority health services was being looked as well. Agenda Item 7 North East London Sustainability and Transformation Plan Paul Haigh (PH) updated the Governing Body (GB) on progress on the North East London (NEL) Sustainable Transformation Plan (STP), asking that two additional papers that hadn t made it into the GB papers be tabled and noting that the next deadline for submission of the plan to NHSE was due on 21 October PH flagged that this was before the next GB meeting and that a virtual circulation and discussion will need to take place in mid October PH continued that while there was no requirement for CCG GBs to sign off on the STP, the full document will come to the November 2016 meeting for discussion in public as Page 9 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

10 well. PH asked for GB delegated authority for Clare Highton (CH) and himself to compile and feedback back any GB comments on the mid October 2016 STP circulation to be fed into the 21 October 2016 NHSE return. DECISION: The GB granted delegated authority to PH and CH to compile and feedback their comments on a mid October 2016 circulation of the NEL STP and to make the submission to NHSE by 21 October PH noted that the financial section was a key part of the plan and was still being drafted by the involved Chief Financial Officers (CFOs) and finance teams. MD added that the Audit Chairs were also very interested in this section and were planning to meet with their CFOs to look at the financial assumptions underpinning the plan. MD asked whether the GB would appreciate an update on the outcome of these discussions across the region, noting that the Audit Chairs would not be providing assurance or certifying the plans. ACTION: MD to update GB on the outcomes of Audit Chairs and CFO discussions regarding the financial assumptions in the NEL STP. CM welcomed the extensive mentions of prevention, self care and independence included in the current NEL STP draft, adding that some sections appeared to refer to a strategy in place in these areas of work and asked if this strategy was available to the GB. CM also noted that this switch in strategy could be seen as a sudden move and asked if it was appropriately supported, integrated and ready for implementation. Clare Highton responded that extensive work had been carried out in these areas of work at the London wide level, but that it was possible that the NEL STP included many aspects of that work as fact, when they might be untested regionally. PB expressed concern over whether the plans outcomes and 20 million savings would be practically achievable in the four years indicated in the timescale within the document. PB continued to outline that some savings at the tertiary care level were possible and that the figures mentioned in the plan might be achievable in the future, but that even if every local resident stopped smoking at the time of the plans implementation, these kind of savings would not be achievable. PB stated that while prevention was a goal worth pursuing and did likely carry future savings, the scales in the current plan were not accurate. CH added that the self care initiatives being looked into at the London level were not yet evidenced, with work in the area at an early stage. CH continued that the current draft plan also didn t address the changes that would be needed to the local workforce to deliver the kind of care model it envisaged, with recruitment already a challenge regionally and the roles needed to deliver these plans not available. PH noted that it could be very useful to feed in the CCGs work on long term conditions (LTCs), which was supported by evidence and well supported and thought of locally. Gary Marlowe (GM) stated that if the driving force behind the STP was finances, then the last years of life were generally the most expensive to the NHS and that the focus should probably be on that area of work. Page 10 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

11 CM asked if the governance processes to develop, consult and agree the NEL STP were now clear. PH responded that a Steering Group is now in place, with a good variety of local organisations present. The first meeting had taken place, with the second planned for the following week. CM asked if this Group included patient representation. PH responded that the Group had recognised that they needed both Lay Member and Patient involvement and had recognised the differences between those roles and viewpoints. Christine Blanshard (CB) briefed the GB on the makeup of the STP development group in Salisbury, with good clinical representation and a specific Clinical Reference Group to look at proposed pathways, clinical evidence and quality outcomes. The Reference Group included local GPs, Secondary Care Consultants, Nurses and Social Workers. The Transformation Board in place was made up of CCG Chairs, Chief Officers, Trust Chief Executives and Medical Directors and local GPs. CB confirmed that the local HealthWatch were also involved. CB added that all STP decisions were required to be ratified by the local organisation s own Governing Bodies and that the setup was more akin to a coalition of the willing and was focusing on adding value, not total system control. CM asked if any members of the GB had been invited to a NEL STP workshop held on 5 September MD responded that she had, but that she had not been invited to the following working group. The workshop had talked about STP governance and it was thought that probably only CCG Audit Chairs had been invited, rather than all regional Lay Members. CH drew the GBs attention to the tabled letter from the NEL STP Programme Management Office (PMO), outlining the request for all involved organisations to set aside further funds for future additional budget contributions to fund the PMO. CH noted that the figure requested in the letter was 248,000, although some of the involved Trusts were suggesting that funding should be more proportionate to the size of the contributing organisations. CH noted that the total PMO funding was increasing far beyond that originally envisaged and that some of the costs involved were concerning, for instance the breakdown included details of a payment of 160,000 to one individual for their work in the year. PL supported this assessment, noting that it was a significant spend against a weak original brief. CH added that this latest request would bring the costs into the region of 3 million for the year. PH stated how vital it was for this work to be transparent and held to clear, deliverable outcomes that can be publically reported. CH asked the GB for agreement to this additional funding, on the condition that the PMO team s work is monitored and contained appropriately. DECISION: GB agreed to additional 248,000 funding for the NEL STP PMO team, on the condition that spend is appropriately monitored and contained. PL drew the GBs attention to the circulated financial strategy paper, noting that the current draft raised concerns. CH highlighted that the current paper requested delegated powers from the involved CCGs to be granted to a sub group of CCG CFOs and NHSE to make financial decisions on behalf of those in the STP. PH added that the STP Governance Group had looked at the current and planned risk pool arrangements and recommended that that this group needed Lay Member and Chief Officer involvement and that all Page 11 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

12 decisions should be made at public meetings. CH continued that the current draft indicated that major decisions would be retained for discussion and agreement at the NEL STP Board, and then flow into the involved organisations for ratification. PH noted that there would be a significant update available in this area of work at the November 2016 GB when the final version of the document is available. PB raised her concern that the current draft appeared to be thin on the ground in terms of evidenced and supportable figures and data. PL responded that much of the financial and performance information was due to be refreshed in the coming weeks, based on month five 2016/17 data. CH raised that the current draft plan seemed to be indicating a move towards a clinical hub model for primary care and that while City and Hackney had extensively discussed this model in the past, it was not supported locally. There was now funding available from NHSE for some aspects of this model, with the eight to eight opening hour initiative being promoted. All other areas involved in the STP had agreed to support this and were now funded to deliver this initiative, with hub practices being support to open from 8am to 8pm. PH suggested that it might be time for City and Hackney to look again at this area of work and to bring it up with Homerton University Hospital NHS Foundation Trust (HUHFT) and City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) to explore options and local support. GM responded that this initiative worked against CHUHSE s approach to recruitment, which was likely to be a major sticking point for this initiatives implementation while providers might be able to be funded to deliver this initiative, recruiting GPs to work these shifts may prove very challenging. CH stated that it was worth exploring and the GB agreed, asking to be kept updated. DECISION: CCG to explore delivering the eight to eight primary care clinical hub initiative with local providers and NHSE. CB asked how specialist commissioning was being addressed with the NEL STP. PB responded that it was a hard area of work to tackle and that a recent working group had looked at making significant changes to cancer, but after costing a new model, had discovered that a new solution might cost significantly more to deliver. Agenda Item 8 Quarter Two 2016/17 Quality Report Jenny Singleton (JS) joined the meeting to present the quarter two 2016/17 Quality Report, highlighting that East London Foundation Trust (ELFT) had just received a fantastic Care Quality Commission (CQC) report result, with several of the ratings reporting as outstanding. ELFT was now one of only two Mental Health Trusts with these kind of ratings in the country. The GB asked that their congratulations be recorded. JS continued to summarise the results of the latest quality report, noting that broadly speaking, waiting times were increasing while patient experience and staff survey indicators were decreasing, not only in Hackney, but across the country. JS briefed the GB that Page 12 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

13 waiting times at Tavistock and Portman NHS Foundation Trust (TPNFT) were now very long, although an action plan to address the issue had been drawn up and agreed amongst partners and there had been a significant increase in referrals to their services. JS outlined increasing issues in the continuing healthcare (CHC) area, with a decreasing numbers of providers now available due to financial problems. Work was underway across the NHS to identify struggling providers early to provide any needed support and ensure that patients are being cared for in an appropriate environment that is stable. JS added that there was real concern over the increasing need to move patients from closing providers in a hurry and that securing alternative placements was becoming more and more challenging. GM stated that there was some frustration with the TPNFT services in the local GP community, with some no longer referring due to the waiting times. CH added that waiting times for primary care psychology were also increasing and expressed concern that this service was now being used to manage patients, not support their management by GPs as its original aim. JS agreed, adding that both of these services appeared to have become victims of their own successes. HR drew the GBs attention to the London Ambulance Service (LAS) indicators in the report, asking if there was anything the CCG could do to bring pressure or influence on the service to address its issues. CH responded that an individual CCG had little power over the London wide service, but that the recent implementation of a national Commissioning for Quality and Innovation (CQUIN) measure to reduce ambulance service conveyances was hoped to help support a turnaround. PL added that LAS had recently requested an additional 2 million in year funding from CCGs in London, which was now under discussion. JS noted that the service was still in special measures and there were concerns over staff morale. PL asked if it would be possible to have more information on staffing levels, actual levels and morale in the next iteration of the report. ACTION: Quarter Three 2016/17 Quality to include more information on staff levels, including planned and actual and morale in the CCGs providers. CW updated the GB on discussions from the recent ELFT annual general meeting (AGM) and PPI event, noting that the while the CQC report had found some outstanding areas of work and was overall a positive report, some areas of the Trusts work had been deemed weak. Of particular concern was reports of staff bullying and discrimination. HR asked if quality issues in primary care services were being passed to NHSE. JS confirmed that she attended the CCGs Primary Care Quality Programme Board (PCQPB), which NHSE were represented on and that this report was debated at. MD asked how the out of hours (OOH) service was performing locally, noting that several services around the country had encountered issues in staffing, resulting in the service not being able to operate at times. JS confirmed that the local OOH service had not taken these steps and that the CCG had recently examined the contingencies in place to deal with staff shortages in this service. CH noted that there were real issues present across the Page 13 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

14 country with recruiting GPs and OOH services were not always the first choice for many GPs. JS noted that the local ParaDoc service had suspended a session of the service in the quarter due to the lack of a GP to staff the service. Richard Bull (RB) joined the GB and expanded on the role of the PCQPB in primary care performance, noting that the CCG had no formal role but did look at and discuss underperforming GP practices with NHSE. CM drew the GBs attention to page 58 of the meetings papers, where it was indicated that the CCGs performance on cancer indicators was low. JS responded that this measure was an area wide indicator and was not based on a single Trust, but that it was accurate. GM noted that many specialist services were finding it challenging to secure appropriate staff and that there were known issues being addressed in the cancer pathway between HUHFT and Barts Health services. Agenda Item 9 Quarter Two 2016/17 Performance Report Jan Annan (JA) joined the GB to present the circulated papers on quarter two 2016/17 local performance. JA noted that the CCG was held to a variety of standards and that it was currently meeting two of the four Constitutional standards in the CCG Quality Premium (QP) framework, with there being an additional four national standards and three local measures. JA continued to outline the reports findings to the GB, noting that no Increased Access to Psychological Therapies (IAPT) data was yet available, however 2015/16 targets had been met. PL noted that the CCG had not planned on achieving the QP targets and that the funding had not been assigned. JA noted that it was thought that the CQUIN system would not be active in 2017/18 and CH added that it was being indicated that the funding would be added to Trusts bottom line allocations instead. CW asked if the GP information on patient experience of making an appointment on page 6 of the report was available broken down between Hackney and CoL practices. JA responded that it was available on a per practice basis and that while the CCG was aiming for a three percent increase on the current 76% performance, this was thought to be challenging. CW noted that the City only has 1 practice solidly in the City and that it appeared to be challenged currently, with reports of four week waits for appointments and appointments with named GPs being very hard to secure. CH responded that all GP practices were encountering issues recruiting currently. GM added that the future situation was not looking more positive currently, with medical courses apparently reducing in popularity. This was the first year where medical courses were available in clearing over the summer. Page 14 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

15 Agenda Item /17 Improvement and Assessment Framework initial baseline rating CH briefed the GB that this was new Improvement and Assessment Framework (IAF) for CCGs to assure NHSE of their performance and delivery and outlined the changes from the old assurance system. HR noted that it was a useful document to help focus the GB on what was required of the CCG and that it would be helpful to look at what the measures meant in the future. PH suggested that it would be useful to ask the CCGs Programme Boards to detail their plans to address the framework and how they intend on using CCG contracts to deliver their goals at a future GB meeting. ACTION: CCG Programme Boards to detail their action plans and use of contracts to deliver the new 2016/17 IAF at a future GB meeting. HR noted that the framework needed to be taken seriously and CB asked if the CCG held responsibility for all the measures in the document. CH responded that since the CCG had not taken on delegated responsibility for the commissioning of primary care from NHSE, they had no direct control over GP practices, making measures like those around the GP surveys challenging. Agenda Item 11 Long Term Conditions Contract with the City and Hackney GP Confederation RB briefed the GB that the Long Term Conditions (LTC) Contract with the local GP Confederation (GPC) had been updated and the revisions approved by the Prioritisation and Investment Committee. Following those discussions, which had focused on the use of non-recurrent funding, it had been established that the CCG was in a position to be able to make the funding of this contract recurrent. PH added that this change had also been debated at the Local GP Provider Contracts Committee (LGPPCC) prior to the GB and that the Committee had recommended that this be agreed. PL noted that the contract had produced measurable results over the years and that its successes should be widely communicated. CB noted that the contracts continuation should be made contingent on continuing to meet relevant, clinically evidenced targets. RB responded that while this was a standard part of the CCGs contract management procedures, it was thought that performance improvements would level off under this contract as the service fulfilled the capacity available in the area. Agenda Item 12 CCG Finance update PL briefed the GB on the CCGs latest financial position and progress made in the last month. PL flagged that while the CCGs position was stable, familiar pressures were Page 15 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

16 materialising, with acute services spend rising and approaching the CCGs maximum reserve levels. A review of the CHC service is underway and the GB would be kept updated on its findings at a future meeting. CH noted that very challenging medical decisions were starting to need to be made with regards to CHC services, and that HR had been asked to join the panel assessing cases to help. PL informed the GB that planning guidance for 2017/18 was expected by the end of 2016 and that contracts were expected to be agreed in December 2016 with providers to cover two years. In light of changes occurring across the NHS and locally, the CCG was changing its financial golden rule of recurrent expenditure not exceeding future recurrent allocation to that recurrent expenditure should not exceed future recurrent expenditure plus 4.15%. This change had been made due to updated five year indicative allocation information from NHSE and allowed, for instance, the LTC contract to be funded recurrently. Agenda Item 13 Recommendations for Recurrent and Non-Recurrent Funding from Prioritisation & Investment Committee CM chaired this item under the CCGs quorum for a conflicted GB. The GPs present at the meeting were allowed to comment on this item, but did not take part in the decision making process. CM briefed the GB that the Prioritisation and Investment Committee (PIC) had met the previous week, where it was informed that the CCG now had in the region of 8 million recurrent funding available for the potential transfer of non-recurrent (NR) services to be recurrently funded. The Committee had carefully considered the impact, demand and meeting of the CCGs strategic needs for the services put forward for consideration. CM drew the GBs attention to page 284 of the circulated papers, which set out the 30 services recommended to move from NR funding to recurrent, main stream funding. PH noted that the LGPPCC had also considered many of these services and that both Committees were recommended that the GB agree this change. HR asked if the services would continue to be evaluated and performance managed as they been under the NR process. PH confirmed that this would be the case. CM noted that the PICs findings had provided a good spread of services types and organisations delivering the services. PL highlighted that some NR funding had been committed outside of the PIC process, chiefly the One Hackney project. DECISION: The GB agreed to fund the 30 services indicated in circulated papers on a recurrent basis, transferred from their previous NR status. Page 16 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

17 DECISION: The GB agreed to continue funding the 11 services indicated in circulated papers on a NR basis to allow for further evaluation in 2017/18. DECISION: The GB agreed to fund the eight new services recommended by the PIC and detailed in the circulated papers on a NR basis through 2017/18 for evaluation. Agenda Item 14 Safeguarding Policies for approval HR informed the GB that the Safeguarding Group (SG) had previously received and discussed these policies now before the GB for approval and implementation in the CCG. All policies were updates on existing documents. PL asked why the CCG was indicated as being responsible for GPs in these documents. CH responded that it was complicated, but that the CCG did manage training in this area for local GPs and that it was an anomaly in comparison to NHSE s responsibility for the commissioning of primary care. PB noted that OFSTED had visiting the local Looked After Children (LAC) service and Safeguarding Board. Both had been reported on as good services, while the local Safeguarding Children s Board had received the first outstanding rating in the country. Agenda Item 15 Reports from Subcommittees of the Board The GB received and noted updates from its sub-committees. Agenda Item 16 Friday 28 October 2016 draft CCG Board agenda The GB received the following meeting s draft agenda. Agenda Item 17 Any Other Business CM highlighted that the PPIC meeting the previous evening had expressed concern regarding the plans for the HUHFT pathology service and that there was significant support for keeping the service local. CH responded that the CCGs member practices had mandated her to write to HUHFT and investigate the CCGs commissioning powers to see if influence could be bought to bear. The CCG was not able to specify that these proposed changes not be undertaken, but that the service will continue to be managed to provide an excellent local service. PL added that this matter had been covered in the CCGs commissioning intentions letter to HUHFT and that the CCG was also looking at whether an estates issue was driving the change, which might be able to be addressed under the devolution proposals. No further business was discussed. Page 17 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

18 AGREED BY: AGREED ON: Page 18 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

19 2015/16 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 GB0053 CCG to write to the NHSE Medical Director and Royal College to seek advice on issues in recruiting obstetric consultants on a permanent basis. Clare Highton CCG Governing Body 29/07/ /11/2016 Open MK picking up with colleagues. MK GB0054 GB0055 CCG to contact Health Education England for information on expected workforce planning in the coming years to inform future development of CCG services. MD to update GB on the outcomes of Audit Chairs and CFO discussions regarding the financial assumptions in the NEL STP. Matthew Knell Matthew Knell CCG Governing Body CCG Governing Body 29/07/ /11/2016 Open MK picking up with colleagues. MK 30/09/ /10/2016 Open Verbal update can be provided at meeting. MK GB0056 Quarter Three 2016/17 Quality to include more information on staff levels, including planned and actual and morale in the CCGs providers. Jenny Singleton CCG Governing Body 30/09/ /12/2016 Open Scheduled for Q3 2016/17 report in December 2016 MK GB0057 CCG Programme Boards to detail their action plans and use of contracts to deliver the new 2016/17 IAF at a future GB meeting. Matthew Knell CCG Governing Body 30/09/ /11/2016 Open On forward plan for November 2016 GB meeting. MK Page 19 of 235

20 NHS City and Hackney Clinical Commissioning Group Register of Interests - September 2016 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Janine Aldridge 29/02/2016 Healthwatch City of London Officer Age UK London Employed as Development and Engagement Officer Janine Aldridge 29/02/2016 Healthwatch City of London Officer CHUHSE City of London Healthwatch are represented on the CHUHSE Board by a colleague Penny Bevan 13/01/2016 Director of Public Health London Borough of Hackney Employed as Director of Public Health Penny Bevan 13/01/2016 Director of Public Health City of London Corporation Employed as Director of Public Health Jaime Bishop 03/11/2015 CCG Board Associate Lay Member CCG GP Confederation Oversight Group Member CCG Local GP Provider Contracts Committee Chair Fleet Architects LTD Director and 50% shareholder in Fleet Architects LTD (2009-present), architectural practice with some experience of healthcare design. Clients include organisations contracted by the NHS. Currently Fleet are directly contracted to work with the Northamptonshire Healthcare NHS Foundation Trust. Jaime Bishop 03/11/2015 CCG Board Associate Lay Member CCG GP Confederation Oversight Group Member CCG Local GP Provider Contracts Committee Chair HealthPorts LTD Director (2012-present) of this dormant company. Jaime Bishop 03/11/2015 CCG Board Associate Lay Member CCG GP Confederation Oversight Group Member CCG Local GP Provider Contracts Committee Chair Jaime Bishop 03/11/2015 CCG Board Associate Lay Member CCG GP Confederation Oversight Group Member CCG Local GP Provider Contracts Committee Chair Jaime Bishop 03/11/2015 CCG Board Associate Lay Member CCG GP Confederation Oversight Group Member CCG Local GP Provider Contracts Committee Chair Pattern Investments Ltd Labour Party Barretts Grove Practice Director Member Patient at a Hackney General Practice, Barretts Grove. Christine Blanshard 25/02/2016 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. Siobhan Clarke 04/03/2016 CCG Board Registered Nurse Your Healthcare CIC Managing Director Siobhan Clarke 04/03/2016 CCG Board Registered Nurse Albion Care Alliance CIC Director Siobhan Clarke 04/03/2016 CCG Board Registered Nurse Albion Healthcare Alliance LTD Director Siobhan Clarke 04/03/2016 CCG Board Registered Nurse Albion Outlook LTD Director Siobhan Clarke 04/03/2016 CCG Board Registered Nurse Transform Research Alliance CIO Trustee Mariette Davis 24/11/2015 CCG Board Governance Lay Member Tower Hamlets CCG Lay Member for Governance for Tower Hamlets CCG Audit Committee Chair Remuneration Committee Chair Mariette Davis 24/11/2015 CCG Board Governance Lay Member Acanthus Capital Limited Advisor Audit Committee Chair Remuneration Committee Chair Paul Fleming 25/02/2016 Healthwatch Hackney Chair Positive East Director of Fundraising and Communications Page 20 of 235

21 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Paul Fleming 25/02/2016 Healthwatch Hackney Chair Healthwatch Hackney Chair Paul Haigh 25/02/2016 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR and Organisational Development, NHS England (London Region) Paul Haigh 25/02/2016 CCG Chief Officer Healthy London Partnerships SRO (senior responsible officer) for the Cancer Programme funded by the Healthy London partnership (HLP is funded by all London CCGs and NHSE). Paul Haigh 25/02/2016 CCG Chief Officer London Borough of Hackney Member of the LBH Health & Wellbeing Board Paul Haigh 25/02/2016 CCG Chief Officer City of London Corporation Member of the CoL Health & Wellbeing Board Leah Herridge 01/03/2016 CCG Integrated Care Programme Manager Declared they have no Interest Declared they have no Interest Clare Highton 10/11/2015 CCG Chair Lower Clapton Group Practice (CCG Member Practice) GP Principal Lower Clapton. Practice provides GMS and APMS at Sorsby. Provides full range of CCG contracts and local GPwSI and consultant ENT services and provides a Heart Failure nurse service. We are a research, teaching and training practice. Practice is an associate research practice. We do not hold grants but participate in research and under/postgraduate teaching. Clare Highton 10/11/2015 CCG Chair Tavistock and Portman NHS Trust Husband is Medical Director of Tavistock and Portman NHS FT. Clare Highton 10/11/2015 CCG Chair Daughter is a trainee Psychiatrist in East London Clare Highton 10/11/2015 CCG Chair CHUHSE Practice is a member Clare Highton 10/11/2015 CCG Chair GP Confederation Practice is a member, and a shareholder Clare Highton 10/11/2015 CCG Chair LMC Practice partner is a member of LMC Clare Highton 10/11/2015 CCG Chair Body and Soul, HIV Charity Daughter in Law works for Clare Highton 10/11/2015 CCG Chair Extended Family live locally, and use local services Matthew Knell 09/11/2015 CCG Business Co-ordinator Somerford Grove Practice (CCG Member Practice) Patient at Somerford Grove Practice, a CCG member practice. Glyn Kyle 03/11/2015 City of London HealthWatch Chair Orbit South Housing Association Independent Board member at Orbit South and Chair of East and South Operations Committee Glyn Kyle 03/11/2015 City of London HealthWatch Chair Swan Housing Association Committee Member at Swan Housing Glyn Kyle 03/11/2015 City of London HealthWatch Chair London Travel Watch Board Member at London Travel Watch Glyn Kyle 03/11/2015 City of London HealthWatch Chair Age UK East London Trustee at Age UK East London Glyn Kyle 03/11/2015 City of London HealthWatch Chair City of London Health Watch Chair at City of London Health Watch Glyn Kyle 03/11/2015 City of London HealthWatch Chair GLA Strategic Access Panel Panel Chair at GLA Strategic Access Panel Philippa Lowe 26/04/2016 CCG Chief Financial Officer PIQAS Ltd Director at PIQAS Ltd, dormant company. Page 21 of 235

22 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Philippa Lowe 26/04/2016 CCG Chief Financial Officer GreenSquare Group Board Member, Group Audit Chair and Development 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 arrangements under a Power of Attorney. Philippa Lowe 26/04/2016 CCG Chief Financial Officer NHS Oxford Radcliffe Hospital Member of this Foundation Trust Catherine Macadam 23/03/2016 CCG Lay Member for PPI British Medical Association Chair of the British Medical Association Patient Liasison Group and Council Member (until 30/06/2016) Catherine Macadam 23/03/2016 CCG Lay Member for PPI Catherine Macadam, Coaching/Mentoring and Consulting Owner/Sole Trader Catherine Macadam 23/03/2016 CCG Lay Member for PPI Nightingale Practice (CCG Member Practice) Self and family are patients at the Nightingale Practice Catherine Macadam 23/03/2016 CCG Lay Member for PPI People Opportunities Ltd Deborah West, close friend, part owner of People Opportunities Ltd Catherine Macadam 23/03/2016 CCG Lay Member for PPI Ann Sanders Consultancy Services Ann Sanders, close friend, owner of Ann Sanders Consultancy Services Catherine Macadam 23/03/2016 CCG Lay Member for PPI City and Hackney Carers Centre Volunteer and occasional sessional worker at City and Hackney Carers Centre Catherine Macadam 23/03/2016 CCG Lay Member for PPI People Opportunities Ltd Associate Consultant for People Opportunities Ltd Catherine Macadam 23/03/2016 CCG Lay Member for PPI Volunteer Centre Hackney Contractor for Volunteer Centre Hackney David Maher 22/11/2015 Mental Health and Medicines Programme Director, City and Hackney CCG. Commissioning and Social Value Advisor, NHS England Beyond Profit a social enterprise working across the University of Cambridge. Advisor Gary Marlowe 24/11/2015 CCG Board GP De Beauvoir Surgery Lead GP at De Beauvoir Surgery Planned Care Programme Board Clinical Lead GP Gary Marlowe 24/11/2015 CCG Board GP Planned Care Programme Board Clinical Lead GP City and Hackney Urgent Health Care Social Enterprise Member of City and Hackney Urgent Health Care Social Enterprise (CHUHSE) Gary Marlowe 24/11/2015 CCG Board GP Planned Care Programme Board Clinical Lead GP British Medical Association British Medical Association London Regional Council Chair Gary Marlowe 24/11/2015 CCG Board GP GP Confederation Practice is a member Planned Care Programme Board Clinical Lead GP Gary Marlowe 24/11/2015 CCG Board GP CHUHSE Member Planned Care Programme Board Clinical Lead GP Jonathan McShane 08/12/2014 London Borough of Hackney Councillor Shoreditch Town Hall Trust Director Jonathan McShane 08/12/2014 London Borough of Hackney Councillor Health, Social Care and Culture, Hackney Health and Well Cabinet Member Being Board Jonathan McShane 08/12/2014 London Borough of Hackney Councillor LBH, Hackney Health and Wellbeing Board Chair Page 22 of 235

23 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network GP Confederation Practice is a member of the GPC Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network Latimer PMS Plus Practice (CCG Member Practice) Senior GP at this practice Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network Pharmacy in Brent (outside of Hackney) Joint Director of Pharmacy in Brent with other family members Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network North East London Medicine Management Committee Member and Chair of North East London Medicine Management Committee Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network City & Hackney Local Medical Committee Member of City & Hackney Local Medical Committee Haren Patel 07/03/2016 CCG Clinical Vice Chair CCG Governing Body Member CCG Prescribing Clinical Lead GP Chair North East London Medicine Management Network Acorn Lodge Nursing Home Practice holds contract for this nursing home Honor Rhodes 03/11/2015 CCG Associate Lay Member Barton House Practice I, partner and one child are patients at Barton House Practice (CCG Member Practice) Honor Rhodes 03/11/2015 CCG Associate Lay Member Tavistock Relationships Employed as Director at Tavistock Centre for Couple Relationships Honor Rhodes 03/11/2015 CCG Associate Lay Member Early Intervention Foundation Trustee and Company Secretary of Early Intervention Foundation Honor Rhodes 03/11/2015 CCG Associate Lay Member The Institute of Wellbeing Mentor to CEO of The Institute of Wellbeing Honor Rhodes 03/11/2015 CCG Associate Lay Member Oxleas CAMHS Partner is Consultant Family Therapist at Oxleas CAMHS Honor Rhodes 22/07/2016 CCG Associate Lay Member The School & Family Works Special advisor (paid) to this charity Mark Scott 09/12/2015 CCG Urgent Care and Integrated Care Programme Director Declared they have no Interest Declared they have no Interest Page 23 of 235

24 Forename Surname Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Lee Walker 11/03/2016 CCG Senior Contract Manager Declared they have no Interest Declared they have no Interest Jonathan Gruffydh Williams 27/02/2016 Healthwatch Hackney Director Healthwatch Hackney Director of Healthwatch Hackney, lead organisation, responsible for strategy and operational management and fundraising Page 24 of 235

25 Full Board Assurance Framework and CCG Risk Management Report to the October 2016 Governing Body Page 25 of 235

26 Introduction The Governing Body (GB) is asked to consider the updated version of the Board Assurance Framework (BA), to confirm that it is satisfied that it accurately reflects the current risk position of the CCG and to give feedback on specific items of risk and issues raised. This iteration of the BAF was reviewed by the Audit Committee on 13 October, and the Audit Committee has begun a rolling programme of scrutiny, reviewing in detail selected risks to the CCG and considering controls in place and actions to be taken to reduce the likelihood and impact of risks identified. On 13 October the committee discussed the following risks in detail: UC01 - 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. PB05 - Lack of clarity/ systemisation of reporting of prescribing / Medicines related Incidents & Near misses by primary care providers. Missed opportunity for health system learning to prevent further incidents, improve patient safety & reduce possible financial risk through litigation. PB06 - Service redesign decisions being taken without appropriate consultation with PPB leads to financial risk on primary care prescribing budgets Since the last Governing Body report, the following changes have been made to the BAF: 1 new risk has been added. 2 risks have increased in score. 4 risks have decreased in score. All other risks remain unchanged. In terms of residual versus tolerance scores, of the 19 risks escalated to the Committee, four risks are currently returning scores equal to or below the agreed tolerance (PC02, PB01, CR02, CR04) and the remaining fifteen are currently scoring above the agreed tolerances. Page 26 of 235

27 New Risks Since the last meeting of the Governing Body, one new risk has been added (CH16) following discussions by the Children s Programme Board: o Unavailability of designated doctor for safeguarding leading to lack of 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 damage, as well as the CCG not being in accordance with NHSE Accountability and Assurance Framework or Working Together statutory guidance. This risk, which is rated 4 for impact and likelihood, was agreed at the September meeting of the Children s Programme Board and is flagged as new in the summary. A number of controls are in place but they give only limited assurance regarding the mitigation of this risk. The CCG Chair is in discussions with NHS England regarding this matter. Page 27 of 235

28 Areas of Increased Risk Two risks have increased since last reported: o o M06 There have been 5 maternal deaths in a 2 year timeframe at HuH which is unusual and very concerning. There may be a heightened risk of further deaths which must be mitigated and there is also a possible impact on womens perception of safety at the Homerton. The CCG's reputation may also be impacted on negatively. There is also the risk that greater and continued scrutiny unearths further quality, clinical, safety, staffing and other issues that will require swift resolution. There has been a further maternal death in July 2016 taking the total to 6 over a three-year period. This was discussed by the CCG Governing Body in September. Any learning and recommendations will come from the formal review of the death, which took place on 16 September and included external clinical input. Significant work has been undertaken by the Homerton to improve the safety of their maternity service, reflected by the latest maternity combined action plan which has closed down 27 of 53 items, with a further 23 items subject to on-going audit and training monitoring & scrutiny. But in light of this further death and in the context of awaiting clarity on what happened to cause this tragic event, the risk remains on the BAF with a score of 20 for quarter 2. UC01 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. There have been increases in A&E activity (2%) from 2015/16 to 2016/17, driven primarily by over-performance and the Homerton and Barts Health, and an increase in paediatric attendances, while emergency admissions are projected to increase by 8%. Across paediatrics there are increasing admissions, bad days and excess bed days; whereas in adult services, although admissions are increasing, bed days and excess bed days have reduced. The Urgent Care Programme Board is implementing a range of measures to improve primary and community urgent care responses, but in light of activity, the risk score has increased from 8 to 12, reflecting an increase to likelihood. 4 Page 28 of 235

29 Areas of Decreased Risk Four risk scores have been reduced due to mitigating controls and actions in place: CR06 On-going difficulties in recruiting staff within OOH, A&E and Primary Care will lead to difficulties in covering rotas, increases in waiting time, and inability to deliver enhanced services. This impact on primary care capacity will place further strain on A&E through increased attendance. (Previous Score 20; Current Score 16) The likelihood of this risk has been reduced in Q2 from 5 to 4 to reflect controls in place. 700k has been agreed specifically to fund workforce issues in primary and community services: by funding Integrated Nursing Teams, Generic HCA roles working across primary and community nursing and Nursing Teams working under GP supervision. PC02 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 (Previous Score 15; Current Score 10) The likelihood of this risk has been reduced from 4 to 2 to reflect controls in place and performance to date. The CCG has met targets on waiting times (18 weeks, RTT, etc.) throughout the financial year to date, and performance is regularly monitored. M04 Vulnerable Women s Pathway. A clear pathway is now in place however there are threats to funding for various services for vulnerable pregnant women because of Local Authority cuts. This includes Substance Misuse and Public Health midwifery services and community services including Bump Buddies. Short term CCG funding may also mean further services for vulnerable women may reduce from 2016 or The impact of reduced services for vulnerable women could directly results in worse health outcomes for women and children. (Previous Score 16; Current Score 12) The likelihood of this risk has been reduced in Q2 from 4 to 3 to reflect controls in place. 7 community midwifery teams are now operating with the team leader holding the former Public Health Midwife role. The CCG is funding targeted Antenatal classes / programmes for vulnerable women and funding has been secured for 2017/18. 5 Page 29 of 235

30 Areas of Decreased Risk (Contd.) CR02 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. (Previous Score 16; Current Score 12) The likelihood of this risk has been reduced from 4 to 3 to reflect controls in place. A workplan has been agreed and improved care pathways are being developed. There is an ongoing review of secondary care service opportunities for development and implementation, and plans are due to be discussed at the Planned Care Programme Board in December Plans for Teledermatology, MECS and ENT are in final stages of development and will be implemented in Q4 of 2016/17. 6 Page 30 of 235

31 BOARD ASSURANCE FRAMEWORK SUMMARY Residual Risk Score Inherent Risk Risk 2015/ /17 Risk Ref Description Score Tolerance Q3 Q4 Q1 Q2 Objective 1 Reduce Premature Mortality Risk Movement M06 Maternal deaths. There have been 5 maternal deaths in a 2 year timeframe at HuH which is unusual and very concerning. There may be a heightened risk of further deaths which must be mitigated and there is also a possible impact on womens perception of safety at the Homerton. The CCG's reputation may also be impacted on negatively. There is also the risk that greater and continued scrutiny unearths further quality, clinical, safety, staffing and other issues that will require swift resolution. There has been a further maternal death in July 2016 taking the total to 6 over a three-year period. This has been discussed at the CCG Governing Body ( ). Any learning and recommendations will come from the formal review of the death. This process includes external clinical input, and the review meeting took place on Significant work has been undertaken by the Homerton to improve the safety of their maternity service, reflected by the latest maternity combined action plan which has closed down 27 of 53 items, with a further 23 items related to ongoing audit and training monitoring & scrutiny. But in light of this further death and in the context of awaiting clarity on what happened to cause this tragic event, it is suggested that the risk remains on the CCG register and that it is kept at a scoring of 20 for quarter Objective 2 UC01 UC08 CR06 Objective 3 PC02 M04 PB01 PB02 Manage Demand 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. Homerton achieved the A&E 4 hour target during 2015/16, but it did not meet the target during Q4 (Winter). Risk that Homerton A&E will not maintain delivery against 4 hour standard for 2016/17 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. Develop Primary Care and Community Services 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 Vulnerable women's pathway. A clear pathway is now in place however there are threats to funding for various services for vulnerable pregnant women because of Local Authority cuts. This includes Substance Misuse and Public Health midwifery services and community services including Bump Buddies. Short term CCG funding may also mean further services for vulnerable women may reduce from 2016 or The impact of reduced services for vulnerable women could directly results in worse health outcomes for women and children. 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 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 Page 31 of 235

32 Inherent Risk Risk 2015/ /17 Risk Ref Description Score Tolerance Q3 Q4 Q1 Q2 Objective 4 Support the Provision of Safe, High Quality Hospital Services CR01 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 Risk Movement CR02 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 CH16 Objective 5 MH17 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 damage, as well as the CCG not being in accordance with NHSE Accountability and Assurance Framework or Working Together statutory guidance To Address Mental Health Needs 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 timely manner leading to a breakdown in referrals to the service and continued failure to meet waiting list targets NEW Objective 6 CR03 Meet all Statutory and Legal Responsibilities 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 CR04 A possible over-performance on acute contracts could lead to a financial overspend potentially impacting on the CCG financial position CR05 CH10 CR07 CR08 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 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 The Devolution pilot fails to progress as proposed which may lead to funding being redistributed elswhere as part of a bigger system and may include the local Trust services being reconfigured as part of that system. 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 PB04 Controlled Drugs (CDs) - assurance of appropriate prescribing & access Page 32 of 235

33 Objective 1 Reduce Premature Mortality Date Risk Added: 1/1/15 Risk: Risk Owner Maternal deaths. There have been 5 maternal deaths in a 2 year timeframe at HuH which is unusual and very concerning. There may be a heightened risk of further deaths which must be mitigated and there is also a possible impact on Chief Officer Risk Lead Clinical Lead Maternity Programme Board womens perception of safety at the Homerton. The CCG's reputation may also be impacted on negatively. There is also the risk that greater and continued scrutiny unearths further quality, clinical, safety, staffing and other issues that will require swift resolution. Inherent risk score Residual Risk score Risk Tolerance Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total BAF Ref: M06 There has been a further maternal death in July 2016 taking the total to 6 over a three-year period. This has been discussed at the CCG Governing Body ( ). Any learning and recommendations will come from the formal review of the death. This process includes external clinical input, and the review meeting took place on Significant work has been undertaken by the Homerton to improve the safety of their maternity service, reflected by the latest maternity combined action plan which has closed down 27 of 53 items, with a further 23 items related to ongoing audit and training monitoring & scrutiny. But in light of this further death and in the context of awaiting clarity on what happened to cause this tragic event, it is suggested that the risk remains on the CCG register and that it is kept at a scoring of 20 for quarter 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 Enhanced scrutiny of performance including review actions, at Maternity Review (Jan 15) Significant amount of evidence Quality and Risk Summits (held in March, May, July & Gateway Review (Jan 15) received from HUH to show change C1 3 Various 3 External September 2015 and February 2016) Maternity summit meeting minutes x 4 in practices. Summarised on Risk summit meeting minutes combined action plan Page 33 of 235

34 A mtg on 19th Nov 16 took place to review evidence and gain assurance that actions have been progressed and positive change realised. This also helped Combined action plan (version 10) C2 identify any residual areas of work that needed more focus. Progress has been Development of a combined action plan to monitor actions 2 good for the vast majority of actions. and progress and identify themes for improvement. Minutes to various maternity Feb-16 2 Internal Following the February maternity summit (23rd Feb) the action plan will be updated to reflect the CQC report and any updated items. programme board dashboard discussions. CQC report now received and safety domain has improved from inadequate to requires improvement. This is positive, though there is of course still work to be C3 done and monitored to ensure change is embedded. The main issues CQC re-visit (October 2015) to measure progress since March 3 outstanding pertained to: inspection - neonatal observations CQC investigation report. Feb-16 3 External - governance - consistency of cleaning and equipment checks Agreement in principle to undertake a staffing review is captured in CQRM HUHT has been requested to undertake a maternity staffing minutes of 9 August Further discussions required with the Trust to agree C4 review to provide assurance that current staffing levels are 2 Sep-16 2 Internal an approach. sufficient given the reported increase in acuity of deliveries. While Birthrate plus may take several months to complete a real time staffing Page 34 of 235

35 Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance C1 * At February 2016 Maternity summit it was agreed that ongoing scrutiny of quality of HuH maternity service, including of combined actions plan, via Maternity programme board, CCG board, CQRM and CEC * Peer review by London SCN (likely September 2016) Assurance Programme Director Maternity Review Committee Maternity Programme Board Date Payment systems (tariff) for maternity services means there is little scope to increase staffing levels to best practice standards locally. However the CCG can monitor minimum standards (1:30 midwifery ratio and 98hr labour ward cover) as KPIs in 16/17 to ensure the service meets these measures. 30-Sep-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 35 of 235

36 Objective 2 Manage Demand Date Risk Added: 10/5/15 BAF Ref: UC01 Risk: Risk Owner Risk Tolerance Inherent risk score Residual Risk score before we consider any mitigation Risk after consideration of controls 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. Chief Officer Risk Lead Urgent Care Programme Director The level of risk the CCG will tolerate in line with the risk appetite 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 Urgent Care and Integrated Care Programme Board delivery C1 plans developed with a specifc focus on demand management 2 Incremental activity increases Bi-monthly 1 Internal UC Programme Board through commissioning new services meeting papers C3 The Finance and Activity Duty Doc service providing C&H residents with advise on the 3 Incremental activity increases report is presented and appropriate course of action to take, reducing demand on A&E. reviewed at the FPC Bi-monthly 1 Internal The Paradoc Service works to reduce the number of Performance data from CHUHSE shows the number of probable Evidence presented C4 inapprorpaite attendances in ED and unplanned admissions to 3 avoidable admissions and ED attendances the service has achieved CHUHSE Quality and Bi-monthly 2 Internal hospital. each month. Performance Meeting and Date Strength 1=red 2=amber 3=green Internal / External C5 Comissioning of Enhanced Access service to increase access to GP services offering a wider choice of appointment times July - March service specification requires 100% population coverage. 1 Current population coverage from the Enhanced access service is 48%. When Extended Hours Service, the National DES and APMS / PMS KPIs are considered 38 practices (89% of the registered population) offer extended hours. Performance data presented to each UC Programme Board meeting Bi-monthly 2 Internal Development of Single Point of Access to mitgigate growth in LAS Clinical Working Group to undertake initial design of model SPA will report into the C6 2 Bi-monthly 2 Internal Conveyances, A&E attendances and hospital admissions August/September 2016 UCPB Proposal to be developed for crisis and out of hospital services C7 2 two workshops planned Bi-monthly 2 Internal for 2017/18 Page 36 of 235

37 Objective 2 Manage Demand Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance C1 Not stated Control Not stated Review Committee Committee Chair Feedback Urgent Care Programme Board Date 30-Sep-16 There have been increases in A&E and Emergency Admission activity in Months 1-4 for City and Hackney registered patients and so the Programme Board has agreed to increase the risk likelihood score from 2 to 3. Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 37 of 235

38 Objective 2 Manage Demand Page 38 of 235

39 Objective 2 Manage Demand Date Risk Added: 14/7/14 BAF Ref: UC08 Risk: Risk Owner Homerton achieved the A&E Four Hour during 15/16 it did not meet the target during Q4 (Winter). Risk Chief Officer that Homerton A&E will not maintain delivery against four hour standard for 16/17 Risk Lead Urgent Care 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 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 System Resilience Funding part of a wider investment and transformation plan has been signed off by UCPB. 1.Additional C1 Clinical Capacity 2.Maintaining Flow 2 3.Additional Bed Capacity 4.Demand management and community pathways The Homerton underperformed against the monthly A&E standard during Apr16 (94.1%), May16 (93.3%) and Jun16 (92.8%). The previous year, the Homerton achieved during the standard during each of the three months. Weekly CSU performance. Performance Dashboard presented at UCPB and FPC bimonthly/mo nthly 2 Internal Divert ambulance activity: C2 Maintain ParaDocModel and further integrate, diverting activity 2 2 from London Ambulance Reduce Delayed Transfer of Care C3 Further financial support in place to reduce DTOCs via joint 2 2 health and social care plans key local risk area Review Committee Urgent Care Programme Board Date 30-Sep-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 39 of 235

40 Objective 2 Manage Demand Page 40 of 235

41 Objective 2 Date Risk Added: 6/5/16 Risk Ref: CR06 Risk: Manage Demand Risk Owner Ongoing difficulties in recruiting staff within OOH, A&E and Primary Care will lead to : Chief Officer - difficulties in covering rotas (OOH) Risk Lead - increases in waiting time (A&E) Urgent Care Programme - inability to deliver enhanced services (Primary Care) Director This impact on primary care capacity will place further strain on A&E through increased attendance. 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 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 Section 256 agreement signed between C&H CCG and LBH Social Contract was signed on 23/3/2016 and details the basis of funding C1 3 Copy of signed contract Mar-16 3 External Services to address provider workforce development. agreed. held. 700k agreed specifically to fund workfirce issues in primary and community services: CEPN Workforce Development Proposal April 2016 has proposed 4 -address the GP Confed issues in the report "Primary Care specific work streams to deliver the requirements in the contract: workforce and buildings timebomb" 1) Place based Integrated Nursing Model Copy of Proposal that went C2 -Piloting ideas from the community nursing workshop (Jan 16) 2 May-16 2 to the C&H CEC May 2016 i) Integrated Nurisng Teams ii) Generic HCA roles working across primary and community nursing iii) Nursing Teams working under GP supervision 2) Workforce Integration (new ways of working and skill mix) 3) Capacity & Capability in Primary Care, OOH and A&E 4) C&H Integrated System Leadership Programme LGPPCC Papers April 2016 Maximum 150k to be spent on feasibility study and options An initial proposal for 25k for consultancy review of the options Governing Body C3 appraisal to the operation of back office functions between local 2 available was recommended by the LGPPCC and subsequently signed Apr-16 2 Internal recommendation paper partner organisations. off by the Governing Body on 29th April April 2016 Date Strength 1=red 2=amber 3=green Internal / External Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Not stated Not stated Review Committee Clinical Executive Committee Date 08-Jun-16 Page 41 of 235

42 Objective 2 Manage Demand Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 42 of 235

43 Objective 3 Develop Primary Care and Community Services Date Risk Added: 12/8/14 BAF Ref: PC02 Risk: 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 Risk Owner Clinical Lead Planned Care Risk Lead Planned Care 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 risk appetite 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 Programme Board meet bi monthly to discuss waiting time PB Performance reports & C1 2 Minutes of PB meetings 2 Internal performance. minutes FPC meeting papers C2 FPC meet monthly and discuss provider service performance. 2 FPC Minutes and Paper Sep-15 2 Internal monthly C3 Programme Director reviews provider performance targets on a monthly basis. 2 F&A Report produced monthly FPC papers Monthly 2 Internal C4 Contracts Team meet monthly with Providers to discuss performance 2 Minutes and papers of meetings held Meeting Minutes Monthly 2 Internal Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance No actions identified for this risk None stated Review Committee Finance and Performance Committee Date 27-Jul-16 Planned Care Programme Director Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 43 of 235

44 Objective 3 Date Risk Added: 1/11/15 BAF Ref: M04 Risk: Develop Primary Care and Community Services Vulnerable women's pathway. A clear pathway is now in place however there are threats to funding for various services for vulnerable pregnant women because of Local Authority cuts. This includes Substance Misuse and Public Health midwifery services and community services including Bump Buddies. Short term CCG funding may also mean further services for vulnerable women may reduce from 2016 or The impact of reduced services for vulnerable women could directly result in worse health outcomes for women and children (and the outcomes could already be locally improved). Risk Owner Clinical Lead Planned Care Risk Lead Maternity 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 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 Maternity programme board are submitting proposals for new *Proposals relevant to the pathway were submitted for January 2016 short term funding and extensions to funding for these at risk PIC. Only 1 bid was successful (targeted antenatal classes). services. However there is a risk these proposals are not *HUH have taken steps to mitigate risks of funding cuts to midwifery prioritised or seen as part of tariff and therefore not funded servcies which is positive. But funding cuts to voluntary sector C6 past March The bids included: services are much more difficult for them to mitigate short to long NRF reports to Maternity - Bump buddies (PH funded peer support in pregnancy) 1 term. PB & minutes to PB Jan-16 2 Internal - Bonding with baby (CCG funded postnatal support) - Specialist midwifery posts for vulnerable women (PH and LA funded) - Targeted antenatal classes (CCG funded) - CO screening (new bid) *Lastly 2 Orthodox Jewish projects (one CCG funded one PH funded) have also not had funded extended and relationships with the community organisations (including Interlink) are at risk of deteriorating. N25 NRF bids sent to Jan 16 PIC Assurance to be received through examination of HUH plans - this The programme board are also in discussion with HUH about has now happened: HUH updated the Maternity Programme Board their plans to address funding cuts to specialist midwifery in January 2016 of their plans to restructure their community HuH plans to address C7 services. These discussions also include consideration of 3 midwifery offer. No posts will be lost, some will be downgraded from Jan-16 3 Internal possible cuts contractual levers and mechanisms that could be utilised to B7 to B6. A formal staff consultation is underway.dependent on the mitigate these risks, such as CQUINs. outcome of the consultation, this risk does appear to have been largely mitigated by HUH. Page 44 of 235

45 Objective 3 Develop Primary Care and Community Services 7 community midwfiery teams operating with the team leader holding the former public health midwife role. An update on the community midwifery team restructure provided C8 The CCG is funding targetted Antenatal classes / programmes 3 at the Programme Board in July. Funding confirmed for targetted Oct-16 3 Internal for vulnerable women and funding has been secured for Antenatal classes in 2017/ /18. Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance The Programme Board is working with providers to try to support them to identify other funding streams for services. However this is not our area of expertise and so is limited. The residual risk has now increased as the controls put in place have been partly ineffective. Control 2016/17 Programme Director Maternity There is now confirmation that funding has not been secured and services for vulnerable pregnant women will reduce in scope. This is likely to lead to worse maternal and infant outcomes. Locally it has been identified that our infant mortality and morbidity outcomes can and should be improved and this can be achieved via better pregnany and postnatal support for vulnerable women who are at greater risk of poorer outcomes and health inequalities. Review Committee Maternity Programme Board Date 29-Jul-16 Committee Chair / Clinical Lead Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. 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 Date Risk Risk: Risk Owner Added: Impact of less robust Repeat prescribing / 01/06/201 Chief Officer Prescription reordering processes at Practice and 6 Community pharmacy settings on Budgetary Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total control of Primary Care Prescribing Budget & BAF Ref: Risk Lead Potential Patient Safety PB01 Clinical Lead Maternity Programme Board 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 Page 45 of 235

46 Objective 3 Develop Primary Care and Community Services Assurance that staff in GP Practices & community pharmacies 1 have adequate systems to ensure that what medicines are Community Pharmacies policy for ordering prescriptions developed ordered by & on behalf of patients. Medication review by 2 by PPB with input & endorsement from Local Pharmaceutical CCG p/cists has identified overordering by healthcare Committee & made available to community pharmacists & practices professionals & requirements re:- patients knowledge on Policy Feb-16 2 Internal repeat prescribing processes Training package is being developed by MMT for delivery - (face to Training package (face to face)for administrative staff being Training package in 2 2 face training) to practice admin staff involved in generating repeat Sep-16 2 Internal developed development prescriptions Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Continue to work with practices and LPC to encourage improved systems for prescribing. Work with NHSE - as commissioner of community pharmacies ongoing Inappropriate ordering of prescriptions [e.g. where no attempt made to confirm if patient needs medicines being ordered] esp by some community pharmacies is an increasingly significant issue not just locally but also nationally 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 provision (ie minimising risks of overordering by community pharmacies & providing pharmacy technician Review Committee Prescribing Programme Board Date 13-Jun-16 Committee Chair Feedback Risk Conclusion Date Risk Added: 07/06/201 6 Risk: 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 Risk Owner Prescribing 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 Page 46 of 235

47 Objective 3 Develop Primary Care and Community Services Primary Care Anticoagulation Contract was Risk Lead reviewed and updated to reflect National CCG Anticoagulation Guidance only with no material change. This Clinical Lead Contract has been issued to GP Practices in the BAF Ref: Standard NHS Contract form. As this is a PB02 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. 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 Practices submit activity data (i.e. the number of patients treated by the practice and the number of home visits carried out) and a point prevalence report for the Quarter using INR star, a Computerised Decision Support Software (CDSS). The requirement of the Contract is that the point prevalence figure should be at least 60%. C1 WEQAS is the service provider for external quality assurance of the near patient testing (NPT) equipment. WEQAS monitors 3 the performance of anticoagulation machines every two months and practices are required to submit their quality assurance results to WEQAS on time and results should be in range and this is a requirement of running the anticoagulation service as per the Contract. WEQAS end of cycle reports are received every 2 months from WEQAS and INR STAR reports are received at the end of each Quarter from Practices providing the service. The Clinical lead provides clinical oversight to service providers. The Prescribing Programme Board are kept advised of both the activity and quality assurance data as stated above as part of the process for approving payments to member practices. Latest reports: Q4 2015/16 recommendations of payments to Practices providing the service presented to PPB on 9th May 2016 and due to be presented at Contracts Committee on 24th June PPB: 9th May 2016 Contracts Committee:24t h June External C2 Clinical and management oversight to be established 2 TBC: No formal process in place. TBC 1 Internal TBC: No plans in place for standardised clinical Standardised clinical governance/performance management governance/performance management visits and support to be C3 visits and support to be carried out by suitable competent 1 TBC 1 Internal carried out by suitable competent clinicians to all practices providing clinicians to all practices the service Page 47 of 235

48 Objective 3 Develop Primary Care and Community Services Training and educational events to re-commence in 2016/17. C4 All appropriate clinical staff working in those practices that Training and educational sessions to be provided by the CCG in 2 currently offer the service must have undertaken relevant 2016/17 - to be organised and implemented TBC 1 Internal training and show evidence of continued professional development. Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances Type Delivery Date Owner Ref: TBC Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Prescribing Programme Board Date 13-Jun-16 Committee Chair Feedback Risk Conclusion Page 48 of 235

49 Objective 4 Support the provision of Safe, High Quality Hospital Services Date Risk Added: BAF Ref: CR01 Risk: 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 Risk Owner Chief Officer Risk Lead Head of Quality 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 risk appetite 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 Quarterly quality reports to Monthly CQRM meetings with HUH and ELFT to discuss Dates of meetings CEC and GB and monthly C1 quality concerns, and monitor key areas. Bimonhtly or 3 Quarterly 3 Internal CQRM reports quality reports to quarterly CQRMs with CHUHSE, Tavistock ns St Josephs. programme Boards Monthly FPC meeting Prog Board commissioning intentions and clinical ambitions minutes and papers C2 focus on plans to improve capacity & outcomes reviewed on a 2 Reporting to CEC and the FPC on a cyclical programme 2 Internal Monthly CEC papers and quarterly basis minutes C3 Quality reports to CEC & Board every 3 months 2 Assurances Reports/information received that confirms controls listed are working effectively Quality Reports to GB in March, July, November and January and reporting to CEC the month after Evidence what was received and where was it presented Papers and minutes of GB and CEC Date Dec 2015 GB Jan 2016 Strength 1=red 2=amber 3=green Internal / External 3 Internal Performance reports Report on outcome performance to Prog Boards and to CCG Quarterly Performance reports provided by the CCG Head of C4 2 received by FPC, CEC and Quarterly 2 Internal Board Outcomes to CEC and GB and FPC GB Agreed Prog Board clinical audit programme as part of Audit programme has been built in to the Homerton contract. C5 2 Audit Programme 2 Internal Homerton contract Minutes from CQRM meetings confirm this. Duty of Candour reports (6) Duty of Candour from practices discussed at CEC & Prog C6 2 Quarterly board report on quality and all commissioned providers CEC minutes and papers Monthly 2 Internal Boards and reported to HUHFT via the Programme Boards includes benchmarked information and Duty of Candour themes. Bi-monthly serious incidents panels to review all SIs reported C7 3 by main providers (HUH, ELFT). Incident reporting by CHUHSE. Six monthly report to CEC. SI reports are included in the monthly quality report. CEC minutes and papers. Monthly quality report Monthly/S ix monthy 3 Internal Page 49 of 235

50 Objective 4 Support the provision of Safe, High Quality Hospital Services Cross Ref: Actions actions taken to directly improve the effectiveness of controls or assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Maternity summits & regular monitoring of actions plans in CQRMs and PBs C1 Mary Secole CQC report "requires improvement" Maternity CQC report "requires improvement" No regular CQRMs with Confederation, care homes or smaller providers and no quality reporting of these Review Committee Planned Care Programme Board Date 20-Jun-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 50 of 235

51 Objective 4 Support the provision of Safe, High Quality Hospital Services Date Risk Added: BAF Ref: CR02 Risk: 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 Risk Lead Planned Care 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 risk appetite 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 1. Clinical Leads across different specialities identified in CCG C1 2 2 Internal and secondary care provider 1. Audit work plan (1, 2) TBC 2. Workplan agreed and have commenced audit of outpatient C2 2 2 Internal activity 2. Audit results (2) TBC C3 3. Workplan agreed and review and development of 2 pathways of care underway 3. Written pathways of care - new and updated existing (3) TBC 2 Internal C4 4. Minutes of meetings (4) 4. Ongoing review of secondary care service opportunities for 5. Consortia Review & GP visits: 7 Practices that are 2 standard development and implementation in 17/18. Initial plans to be 2 deviations above the mean for referrals will receive visits in February discussed at Programme Board in December & March TBC 2 Internal Date Strength 1=red 2=amber 3=green Internal / External Cross Ref: C1 C2 Actions actions taken to directly improve the effectiveness of controls or assurances Delivery Type Date Owner Ref: PC Referral audits have been arranged for February & March Programme Control Director None stated PC Plans for Teledermatology, MECS, ENT in final development Programme and to be implemented by Q4 2016/17 Control Director None stated Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Planned Care Programme Board Date 20-Jun-16 Committee Chair Feedback Risk Conclusion The risk is being managed within defined appetite levels. Page 51 of 235

52 Objective 4 Date Risk Added: 4/10/2016 BAF Ref: CH16 Risk: Support the provision of Safe, High Quality Hospital Services 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 damage, as well as the CCG not being in accordance with NHSE Accountability and Assurance Framework or Working Together statutory guidance Risk Owner Chief Officer Risk Lead Carol McLoughlin - Programme Director Children's Services 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 Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total TBD TBD TBD Strength Strength Controls 1=red Assurances Evidence 1=red Control Specific tasks and measure implemented to mitigate the effect of the 2=amber Reports/information received that confirms controls listed are working effectively what was received and where 2=amber Internal / pricipal risks. Ref: 3=green was it presented Date 3=green External Written correspondance 1. NHSE Informed of the situation and ongoing liaison with C1 2 n/a n/a 1 Internal Tavistock Institute requesting provision of service locally. 2. Liaison with London network to enquire if any other C2 Designated Doctors may be able to fill the position as interim Local Health Safeguarding Forum set up for support - latest 2 6 September Internal message sent out on 6 September 2016 This arrangement is in place, but update is poor, owing to the C3 City & Hackney CCG have agreed to fund supervision through the Tavistock in lieu of a Designated Doctor appointment 1 distance to the Tavistock. n/a n/a 1 Internal 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: C1 Actions actions taken to directly improve the effectiveness of controls or assurances CCG Chair in discussion with NHSE regarding the management of risk. Type Control 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 Page 52 of 235

53 Objective 4 Support the provision of Safe, High Quality Hospital Services Committee Chair Feedback Risk Conclusion At the meeting on 16 September, the Programme Board agreed this risk was significant and should be added to the Board Assurance Framework. Further mitigation of risk is required to bring In line with the defined risk appetite. Page 53 of 235

54 Objective 5 Date Risk Added: BAF Ref: MH17 Risk: To Address Mental Health Needs 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 timely manner leading to a breakdown in referrals to the service and continued failure to meet waiting list targets. Risk Owner Chief Officer Risk Lead Programme Director Mental Health 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 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 Proposed investment c 582,660 to reduce backlog through Progress tracked in monthly meetings with HUH and the CCG. Provider meeting minutes C1 agency staff; payment in instalments based on monitored 3 Monthly 2 Internal and papers results. Psychological therapies alliance agree transfer of some Psychological therapies alliance have started triaging patients and C2 2 patients into other services. referring them on to other services CQUIN to incentivise progress. C3 2 1 Page 54 of 235

55 Objective 5 To Address Mental Health Needs Actions actions taken to directly improve the effectiveness of controls or assurances Cross Ref: received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance C1 Action 1 Evidence of increased capacity from agency staff Action 2 - Payments to be made in instalments with gateways to be passed through when backlog is reduced. Action 3 CQUIN: IAPT pulse check a dashboard that monitors demand, capacity, waiting times and experience measured reported at a high frequency. Control Prog Dir Mental Health C2 Action 1 Review waiting list by telephoning patients 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 Control Prog Dir Mental Health C2 Action 1: Alliance organisations asked to produce 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. Control Prog Dir Mental Health C3 Action 1: Submit CQUIN to Quality lead for approval Control Prog Dir Mental Health Review Committee Mental Health Programme Board Date 20-Jun-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 55 of 235

56 Objective 6 Meet all Statutory and Legal Responsibilities Date Risk Added: BAF Ref: CR03 Risk: 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 Risk Owner Chief Officer Risk Lead Head of Corporate Services 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 risk appetite Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total Strength Strength Controls 1=red Assurances 1=red Control Specific tasks and measure implemented to mitigate the effect of the 2=amber Reports/information received that confirms controls listed are working effectively Evidence 2=amber Internal / pricipal risks. Ref: 3=green what was received and where was it presented Date 3=green External Corporate Calendar Learning by Doing Workshops held as required to address C1 3 Quarterly 3 Internal emerging issues where need to consider CCG response Records of dcevelopment sessions Programme of Board development sessions held throughout the year held C2 All GB members have PDPs 2 Annually 2 Internal Records of PDPs completed and objectives set retained Board Workplan Annual Board Member appraisal process on both individuals C3 2 Record of output from development Quarterly 2 Internal and collective Governing Body performance Board effectiveness development session held session Annual engagement with practices and other stakeholders C4 through a 360 degree survey to obtain data on performance 3 Annually 3 Internal to aid organisational development. 360 degree survey was completed for Record of feedback received NHSE review produced a rating of 'Good' for the CCG C5 Governing Body performance review undertaken 3 3 External Board effectiveness development session held Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: NHSE feedback report Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Original advert failed to attract suitable candidates so the criteria has been relaxed to include indiviudals outside of the area. A second advert is due to be placed. C5 C2 Additional Lay member with financial expertise is required as part the succession planning process for the Audit Chair role. Induction programmes are required for new Governing Body members C7 Control C3 The CCG needs to implement an appropriate succession planning process for the entire Governing Body Review Committee Audit Committee Date 22-Jul-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 56 of 235

57 Objective 6 Meet all Statutory and Legal Responsibilities Date Risk Added: BAF Ref: CR04 Risk: A possible over-performance on acute contracts could lead to a financial overspend Risk Owner Chief Finance Officer Risk Lead Deputy CFO 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 risk appetite 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 C6 1.Formal contracts in place with provider 3 Contracts held for each provider organisation Contracts office hold a copy of the acute contract Annually 3 Internal C7 2.Regular review of performance data 2 The 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 and papers of the FPC held Monthly 2 Internal C8 3.Regular performance monitoring meetings held 3 Contract review meetings held with providers Notes are retained of meetings held but no formal minutes Weekly 2 Internal C9 4. Risk share in place with WELC CCGs, includes provision for return of funds drawn in 2013/14 and 2014/15. 2 N/A 1 Internal C10 5. Acute Risk reserve and contingency held 3 Finance reports to the Governing Body and to CEC and FPC demonstrate the position in terms of risk reserves held TBC Monthly 2 Internal C11 6. SPRG meetings with providers 3 Records of meetings demonstrate scrutiny of performance Minutes of SPRG meetings Monthly 3 Internal Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: C6 Whilst the risk can be mitigated to some extent through various initiatives and contract negotiations regarding volumes, some over performance may be inevitable particularly on non-elective care Control 28/08/2014 Head of Contracts Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance None stated Review Committee Finance & Performance Committee Date 27-Jul-16 Committee Chair Feedback Risk Conclusion The risk is being managed within defined appetite levels. Page 57 of 235

58 Objective 6 Meet all Statutory and Legal Responsibilities Date Risk Added: BAF Ref: CR05 Risk: 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 Risk Owner Prog Director Prescribing Risk Lead Head of Medicines Management 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 risk appetite 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 PSP time provided to support practices to review, 'Specials' & C Regular feedback from practices discussed at monthly PPB meeting Programme Board meeting minutes 2 Internal Hospital only drugs as part of the 2015/16 CCE contracts [C1,C2,C3] and reports C3 PSPs have been assigned QIPP areas (which include prescribing areas of higher financial risk identified nationally or by MMT) to review which are separate to those QIPP areas in CCE contract workplan Assurances Reports/information received that confirms controls listed are working effectively Evidence what was received and where was it presented Frequent updates to Prescribers with recommendations on quality, safety as well as cost effectiveness of prescribing. C1 This includes via: minimum 4 face to face practice level 3 1. Post visit Letters to MMT, Newsletters (archived on Intranet) [C1] 2 meetings, GP Education events, minimum 10 Newsletters per Minutes of meetings;' Education / annum Forum Presentations Date Strength 1=red 2=amber 3=green Internal / External 2 Dashboard reports to PPB & archived 2 Internal 3. Monthly QiPP dashboard [C2,C3,C4] on Intranet LPP Dashboards published on LPP 2 4.London Procurement Partnership Dashboards [C2,C3,C4] secure site for all London NHS 3 External organisations 3. PSPs required to report regularly on qualitative as well as C4 quantitative interventions - medication reviews- that are 2 1 Internal Programme Board meeting minutes being made as part of the PSP workplans 5. Fortnightly & monthly reports produced by PSPs [C2,C3,C4] and reports Monthly Primary Care Budget monitoring - by practice & C5 3 3 Internal identification of areas of financial pressure 6. Budget statements produced for monthly Prescribing Board mtg and FPC Dashboard reports to PPB & archived based on NHSBSA forecasts of spend [C5] on Intranet C6 Dedicated Joint Formulary Pharmacist supporting JPG agenda s 2 7. Updated ebnf available to all Practices (& HUHFT) in City & Hackney [C6] ebnf 3 External Internal C7 Development of appropriate policy in respect to fraud, bribery and corruption 1 Increased interaction and support provided by BT experts. Fraud,Bribery and Corruption is covered in the CoIs policy and we do have an stand-alone policy in place. A 'working with the Pharma industry' policy is currently in draft. TBC 1 Internal Type Delivery Date Owner Ref: TBC Cross Ref: Actions None stated Gaps In Control / Assurance None stated Page 58 of 235

59 Objective 6 Meet all Statutory and Legal Responsibilities Committee Chair Feedback Risk Conclusion The risk is being managed within defined appetite levels. Page 59 of 235

60 Objective 6 Meet all Statutory and Legal Responsibilities 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 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 risk appetite 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 C3 1. Monthly joint commissioning task group Records of joint commissioning taks group meetings demonstrate robustness Minutes from joint commissioning 2 2 Internal of process task groups (1) C4 2. All arrangements to be approved via Children's Programme Programme Board and CCG Board 1 Board papers (2 & 3) Records of programme board approval received. 2 Internal 3. All joint commissioning agreements must be agreed via C5 CCG governance arrangements Meeting arranged in January 2015 to agree content and financial sign off of Record of meeting held showing sign 1 Education and Health Care Plans off of plans 3 Internal Date Strength 1=red 2=amber 3=green Internal / External Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance C1 None stated None stated Review Committee Children's Programme Board Date 15-Jun-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 60 of 235

61 Objective 6 Meet all Statutory and Legal Responsibilities Date Risk Added: BAF Ref: CR07 Risk: The Devolution pilot fails to progress as proposed which may lead to funding being redistributed elswhere as part of a bigger system and may include the local Trust services being reconfigured as part of the system. Risk Owner Chief Officer Deputy Chief Officer Risk Tolerance Inherent risk score Residual Risk score The level of risk the CCG will tolerate in line with before we consider any mitigation Risk after consideration of controls the risk appetite 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 C3 Transformation Board driving forward the Devolution agenda. 3 Meetings are held every three weeks. Minutes of meetings 3 External Enabler groups being set up to drive forward elements of the C4 agenda (Finance & Commissioning, Estates, Communications, 2 Minutes will be available. 2 Internal patient Involvement, IT, Workforce/Organsational Design) First Finance meeting set for 10/5/2016. C5 Local transformational project is part of the 5 year STP plan. 2 Governing Body papers will be The plan is currently in draft and will go to the May Governing Body for available for the May meeting online. approval. Meeting minutes avaialble online. 1 Internal Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance C1 None stated No Transformational Director currently in post Devolution plans not yet in place. Review Committee Clinical Executive Committee Date 08-Jun-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Page 61 of 235

62 Objective 6 Date Risk Added: BAF Ref: CR08 Risk: Meet all Statutory and Legal Responsibilities 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. Risk Owner Chief Finance Officer Risk Lead Deputy Chief Finance Officer 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 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 C3 Changes to the CHC structure including the introduction of the MDT and Action agreed as a result of the February 2016 FPC meeting 3 improvements to care packages and financial forecasting reflect work attended by CHC Team. undertaken. The CHC activity and finance report element of the F&A report CHC report to LTC PB (13/5/16) To be received 1 Internal will now be taken to the LTC PB for scrutiny (next meeting 13/5/2016) C4 F&A reports now include section on CHC activity and finance 2 status The F&A reports are produced in full each month. F&A reports Monthly 2 Internal Multidisciplinary Team in places to review care packages, provide trend analysis and review forecasting. Team consists of: Long Term Condition programme 2 Health Economists Forecast Planning has improved with a more refined process in place. There board Bi Monthly 2 Internal Contract Management has been a slight financial impact on the CCG as a result of the refined Finance Management forecasting but the process is now more accurate. A Summary position is reported to the FPC each month that includes CHC C5 FPC meetings brief on latest CHC position. 2 risk status. The full F&A report is reviewed on a quarterly basis by the FPC. NELCSU is due to report to the FPC on actions carried out to manage the FPC papers Monthly 3 Internal position in October Actions actions taken to directly improve the effectiveness of controls or Cross Ref: assurances received Type Delivery Date Owner Ref: C1 None stated Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance None stated Review Committee Finance & Performance Committee Date 22-Jun-16 Committee Chair Feedback Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite. Date Risk Added: 01/06/2016 Risk: 3a The list of Non Medical Prescribers(NMPs) held by the NHSBSA and CCG is not up to date. NMPs are often not registered correctly by the Risk Owner Prescribing Programme Board 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 Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total Page 62 of 235

63 Objective 6 Meet all Statutory and Legal Responsibilities NMPs are often not registered correctly by the practices, resulting in incorrect allocation of Risk Lead prescribing spend ('unidentified doctors' ) by the Head of Medicines NHSBSA to GP practices. Management 3b C&H GPs & nurses working in other CCGs who have not been registered properly on practice systems nor registering a move from / to another BAF Ref: PB03 CCG with NHSBSA causing financial risk as either our budget is being utilised elsewhere or late in financial year we are presented with bill from another CCG. In last 12months C&H CCG have settled > 100K to other GPs for latter scenarion & possibly incurred similar or more costs for inadvertently paying other CCGs' prescribing costs 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 Reminders to practices to inform MMT & NHSBSA of changes 1 1 this is undertaken periodically through newsletter but not effective Newsletters 1 Internal in their staff who have prescribing responsibility Access to regular dedicated prescribing data analyst (as per 2 other CCGs) - to build & regularly update database of presscribers & identify any out of area / unusual presacribing/ 2 Current access to data analysis is insufficient NIL 1 Internal dispensing Date Strength 1=red 2=amber 3=green Internal / External Actions Cross Ref: actions taken to directly improve the effectiveness of controls or Type Delivery Date Owner Ref: Need to recruit to at least part time dedicated data analyst [previous postholder provided by CSU not replaced] HoMM Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Committee Chair Feedback Date Risk Added: 01/06/2016 Review Committee Prescribing Programme Board Date 13-Jun-16 Risk Conclusion Risk: Risk Owner Chief Officer 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 Controlled Drugs (CDs) - assurance of appropriate prescribing & access Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total BAF Ref: PB04 Risk Lead Clinical Lead Maternity Programme Board Page 63 of 235

64 Objective 6 Meet all Statutory and Legal Responsibilities Control Ref: Strength 1=red 2=amber 3=green The Controlled Drugs (Supervision of Management & Use) Functions provided by LAT as Office of the CD Accountable Officer are top Regulations 2013 that came into force 1st April 2013, set out a level & do not give sufficiently robust processes for early detection of E single operating model with NHSE as the responsible body for inappropriate activity relating to the prescribing of CDs as evidenced by a CDs. recent incident - Dec2015 currently:- Annual data analysis for 2 Proactive & regular data analysis of prescribing activity individual practice visits rather than 2 Regular & planned review of CD prescribing patterns not in place currently relating to Controlled Drugs to feed into PPB / London CDAO regular review of patterns across all of 1 Internal CCG Cross Ref: actions taken to directly improve the effectiveness of controls or Type Delivery Date Owner Ref: C1 Controls Specific tasks and measure implemented to mitigate the effect of the pricipal risks. Actions Access to regular & dedicated data analyst would enable early identification of any untoward activities- would require recruitment to role 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 Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Internal / External Review Committee Prescribing Programme Board Date 13-Jun-16 Committee Chair Feedback Risk Conclusion Date Risk Added: 01/06/2016 Risk: Risk Owner 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 Lack of clarity/ systemisation of reporting of prescribing / Medicines related Incidents & Near PPB Director misses by primary care providers. Missed Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total opportunity for health system learning to Risk Lead BAF Ref: PB05 prevent further incidents, improve patient safety & reduce possible financial risk through litigation. Head of Medicines Management (HoMM) 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 Page 64 of 235

65 Objective 6 Meet all Statutory and Legal Responsibilities NHSE require all CCGs - from to have a named Medication Safety Officer (MSO) "...& their contact details the CAS team & who would be a member of the national medication safety network to support reporting & learning & take local actions to improve medication safety. The MSO can also use learning to influence policy, planning & commissioning as part of clinical governance in the commissioning organisation; and regularly review information from the NRLS & the MHRA to support improvements in reporting & learning & to take local action to improve medication safety..." the MMT is working to > maximum capacity & we currently have no MSO 2 role appointed or MSO functions stipulated in current JD's. We would have to review current roles & funtions of team in order to build capacity to NIL undertake these functions Internal / External Named pharmacist whose role would be to support practices on Reporting of prescribing / Medicines related Incidents & Near misses. NHSE measure CCG's on "Proportion of GP practices in the CCG who have access to software that supports safety audits - data derived from the PRIMIS PINCER (a pharmacist-led information technology intervention for medication errors) toolkit"- C&H is currently v low on this measure 6.98% vs LDN av of 18.29% & Engl av of 28.61% 3 NHSE Medicines Optimisation Dashboard (?quartely) available - measuring this & showing suboptimal achievement for the CCG NHSE MO dashboards May 2016 & quarterly updates of NHSE MO Dashboards 1 External Actions Cross Ref: actions taken to directly improve the effectiveness of controls or Type Delivery Date Owner Ref: Need to appoint role - pharmacist to co-ordinate medication safety activities in line with MHRA-NHSE Patient Safety Alert of HoMM Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance No MSO role in place to co-ordinate these activities Review Committee Prescribing Programme Board Date 13-Jun-16 Committee Chair Feedback Risk Conclusion 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 Date Risk Risk: Risk Owner Added: 01/06/2016 Service redesign decisions being taken without Chief Officer appropriate consultation with PPB leads to Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total BAF Ref: financial risk on primary care prescribing budgets Risk Lead PB06 Clinical Lead Maternity Programme Board Page 65 of 235

66 Control Ref: Objective 6 Meet all Statutory and Legal Responsibilities 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 Programme Boards & HUHFT to continue to be encouraged to No robust process in place however ogver last 2years, generally 1 engage with PPB with details of planned changes & what 1 improvement in communication from some Boards when planning service NIL 2 Internal changes in responsibility of prescribing may be envisaged redesign - however earlier engagement of PPB is still a gap Link pharmacists to programme boards & Regualar all CCG 2 staff updates as efficient way of having notification of 2 All Boards have named pharmacist in the MMT Named pharmacists list 2 Internal planned services Date Strength 1=red 2=amber 3=green Internal / External Actions Cross Ref: actions taken to directly improve the effectiveness of controls or Type Delivery Date Owner Ref: C1 Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Prescribing Programme Board Date 13-Jun-16 Committee Chair Feedback Risk Conclusion Page 66 of 235

67 RISKS REMOVED OR CLOSED FROM THE BAF No risks have been removed from the BAF since the previous Audit Committee meeting in March 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. Risk Owner Chief Officer Risk Lead Programme Director Mental Health Inherent risk score Residual Risk score Risk Tolerance 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 Negotiations now complete for a re-designed urgent response pathway with efficiency Clinical Working Groups and Financial Working Groups have been established C1 savings through a Clinical Working Group and a Financial Working Group, which report to the 3 Commissioning negotiations process. 400k has been released. Clinical and financial models produced and signed off by groups and contract Working group papers and minutes 3 Internal negotiating process. Underspend in the urgent care pathway is used to create a further year s top up funding to C2 bridge any shortfall. 2 As above As above 2 Internal 400k identified. Actions Type Gaps In Control / Assurance Cross Ref: Delivery Date Owner Ref: C1 Action 3 Sign off the implementation plan (mid March) Action 4 Sign off service specifications and KPIs in HOT (end March) Action 5 Monitor implementation (April May) Control Prog Dir Mental Health C2 Actions completed. Control Prog Dir Mental Health Evidence what was received and where was it presented 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. Date Strength 1=red 2=amber 3=green Internal / External Date Risk Added: 29/5/15 Risk Ref: UC11 Risk: Risk Owner Non-recurrent funding for primary care initiatives may not be approved beyond Chief Officer 16/17 This will have an impact on Urgent Care systems, potentially increasing A&E attendances & admissions. Risk Lead Urgent Care 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 risk appetite 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 C1 Proposal to be developed for crisis and out of hospital services for 2017/18 2 two workshops planned 2 Internal Page 67 of 235

68 Revised service specifications for include more robust performance indictaors to C2 2 performance data presented to UCPB UCPB Minutes 2 Internal better evidence the value of the service Non-recurrent service specifications include review dates for overall evaluation of nonrecurrent C3 2 Review of service to be presented at UCPB UCPB Minutes 2 Internal investment. Actions actions taken to directly improve the effectiveness of controls or assurances received Cross Ref: Type Delivery Date Owner Ref: Gaps In Control / Assurance Aread requiring improvement where we lack control or assurance Review Committee Non-recurrent funding of projects Urgent in 2016/17 Care Programme became recurrent Board for those projects continuing into 2017/18 Date in September 2016 following 30-Sep-16 the agreement of Committee Feedback the CCG Prioritisation and Investment Committee and the Local GP Provider Contracts Committee. Risk Conclusion Page 68 of 235

69 BAF Glossary of Terms Inherent Risk Residual Risk Risk Ref RTT KPIs CCG CH LBH HUHFT LAS LGPPCC Risk Owner Risk Lead Risk Tolerance Control Assurances Evidence Actions GP COG CEC GB CHUHSE FPC OOH CQRM CSU ELFT The amount of risk the organisation is exposed to before consideration of any control or mitigating action The amount of risk exposure left after current controls and mitigating actions have been considered This is the reference given to each risk within the individual risk registers Return to Treatment Key Performance Indicators Clinical Commissioning Group City & Hackney London Borough of Hackney Homerton University Hospitals NHS Foundation Trust London Ambulance Service Local GP Provider Contracts Committee This is the accountable officer for that risk The officer responsible for the operational management of the risk The amount of risk the organisation is prepared to accept in the persuit of targets and objectives A deliberate action designed to achieve a specific outcome A report or feedback that provides confidence that controls in place are operating effectively Documented record of an assurance received Tasks designed to enhance the level of control or assurance in place specifcally to reduce the level of risk exposure GP Confederation Oversight Group Clinical Executive Group Governing Body City and Hackney Urgent Healthcare Social Enterprise Finance and Performance Committee Out of Hours Clinical Quality Review Meeting Commissioning Support Unit East London Foundation Trust Page 69 of 235

70 DEVOLUTION AND INTEGRATION UPDATE GOVERNING BODY MEETING OCTOBER 2016 Page 70 of 235

71 INTRODUCTION This paper provides An update to the GB on the current devolution programme page 72 which also includes plans to explore a fully integrated commissioning model with London Borough of Hackney and the Corporation of the City of London An update to the GB on the crisis workstream which provides information on service provision integration plans and an new approach to contract performance page 89 An update to the GB on key headlines from the Planning Guidance page 108 The GB is invited to debate these items Page 71 of 235

72 DEVOLUTION UPDATE Local devo plan must show how it delivers the STP Very few formal devolution asks Prevention and LA licensing powers Estates ownership but London model unclear.?screening and immunisations delegation of commissioning but probably not before 2018 Next iteration of the business case for devo to be submitted early November Local plans are focusing on Integrated commissioning with each Local Authority Full pooling of CCG, Public Health and social care budgets with new joint governance Integration of services/crisis care Quadrant working and Single Point of Coordination Page 72 of 235

73 Hackney Devo Pilot proposed Public Health powers This paper outlines the case for requesting Public Health (PH) devo powers for Hackney. These asks are in line with those of the one Prevention Devo Pilot in London, Haringey. It is recommended that local decisions on the detail of the requested Hackney PH devo powers are taken once the outcomes of a more detailed analysis of insight and evidence, along side the deep dive exercise being undertaken by Haringey, are known. Page 73 of 235

74 Planning powers Why is this an issue for Hackney? What are we already doing? What is the devo ask? Obesity is a major public health problem in Hackney: contributes to 1 in 10 deaths; almost 40,000 adults and 25% of year olds are obese (amongst the highest rates of child obesity in the country) Significant costs associated with obesity annual costs to the NHS in Hackney are 95m; obese adults 3x as likely to need social care Obesity is strongly linked to deprivation and so acts to widen inequalities We live in an obesogenic environment where unhealthy choices are the norm Higher concentrations of fast food outlets are associated with higher levels of obesity - there are over 200 fast food outlets in Hackney Page 74 of 235 Whole systems approach to obesity led by Hackney Obesity Strategic Partnership (chaired by LBH Chief Exec) membership drawn from across council services and NHS to address wider determinants of obesity Relevant workstreams include: healthier catering commitment award for hot food takeaways; research to develop a model for healthier retail offer in corner shops; Public Health input to relevant planning applications in line with DM Policies Power to amend Use Class Order to better distinguish between unhealthy and healthier uses (e.g. Class A5 hot food takeaways)

75 Health as an alcohol licensing objective Why is this an issue for Hackney? It is estimated that almost 10,000 people in Hackney are dependent drinkers, and these numbers are expected to rise Alcohol-related health harms are more prevalent in Hackney than nationally - hospital admissions for alcohol-related problems and alcoholic liver disease are both more common in the local population Levels of alcohol-related violent crime and sexual assault are also higher locally than the London and England averages linked to a vibrant nighteconomy as well as a relatively young population What are we already doing? Proactive alcohol identification and brief advice in General Practice A new drug and alcohol treatment service has been commissioned, responsive to the needs of the local community Public Health input to licensing decisions using bulls-eye tool to help identify high areas of crime and where there are numerous licensed premises What is the devo ask? Power to extend the four Licensing objectives under the 2003 Licensing Act to include health to enable LB Hackney to take wider health related harms into account in licensing decisions Possible further powers: restrict sale of alcohol in offlicenses located near schools Page 75 of 235

76 Tobacco licensing Why is this an issue for Hackney? Smoking contributes to almost 1 in 5 deaths in Hackney; and is a major cause of health inequalities - accounts for half the difference in mortality between rich and poor areas Local smoking prevalence (20.5%) is significantly higher than the national average over 40,000 adults in Hackney currently smoke Smoking is costly to Hackney s public services (annual cost to the NHS= 7.4m; annual social care costs= 2.9m) and to society as a whole (total annual costs= 65.1m) Availability of cheap/illegal tobacco makes it harder for smokers to quit and easier for young people to start Half of Hackney smokers in a recent survey had been offered cheap tobacco Page 76 of almost 2/3 of these took up the offer What are we already doing? A comprehensive multi-agency tobacco control action plan has been developed in partnership with a broad spectrum of local stakeholders - responsibility for delivery of the action plan lies with Hackney Public Health, accountable directly to Hackney HWB Board Relevant actions in the plan include: various activities implemented through a collaborative arrangement with neighbouring NE/NC London boroughs to improve reporting and reduce the supply of cheap/illegal tobacco across the patch (working with enforcement colleagues) What is the devo ask? Powers to establish a positive tobacco licensing scheme to cover all commercial entities involved in the tobacco supply chain (i.e. retailer and wholesalers) - fines and deprivation of licenses to be administered by the responsible enforcement authorities [NB: this ask is subject to the outcome of the HMRC consultation, Tobacco Illicit Trade Protocol licensing of equipment and the supply chain] Smokefree outdoor spaces in cafes, restaurants and bars

77 Tackling problem gambling Why is this an issue for Hackney? Around one in 10 people in the UK participate in over-the-counter betting in bookmakers a small % of these are problem gamblers Gambling exacerbates financial vulnerability and worsens mental health problems through addictive behaviour problem gamblers have the poorest health outcomes and tend to live in more deprived areas Fixed Odds Betting Terminal (FOBT) use by young people is a growing problem There is a strong link between the availability of venues and the number of regular/problem gamblers in a local area There are 56 betting shops in Hackney, with the highest concentrations in Haggerston and Dalston Page 77 of 235 What are we already doing? Local licensing decisions for betting shops are decided on the basis of principles set out in the Council s Gambling Policy, including a requirement to protect children and other vulnerable persons from being harmed or exploited by gambling Hackney Council has lobbied successive governments calling for councils to have more powers over betting shops, including a proposal to give betting shops their own planning class Following a public consultation in 2014, the Government amended the General Permitted Development Order to give bookmakers their own planning use class, giving greater control to licensing authorities to control their proliferation What is the devo ask? Local licensing powers over gambling premises and Fixed Odds Betting Terminals (FOBTs) to: influence the location of betting shops (to prevent overconcentration and reduce saturation) limit the hours of operation restrict the number of FOBTs in each betting shop set limits on maximum stakes accepted by FOBTs

78 INTEGRATED COMMISSIONING With our 2 LAs we have agreed to explore what a local place based integrated commissioning model would look like by 1 April 2017 We have had discussions with Tameside and Glossop who introduced such a model in April 2016 and we have had discussions with national partners We are already through our 5 year planning work working across the 2 LA social care commissioners, Public Health commissioners and CCG to Understand current performance against metrics and outcomes What plans we each have to secure improvements and are there opportunities for greater alignment in our planning What contracts do we each hold Page 78 of 235

79 MODEL Current legislation doesn t allow full pooling of all CCG functions with LAs under s75 arrangements There are national plans to change legislation to allow this possibly by April 2017 and this is a key devolution ask As part of these changes there could be some streamlining of powers around delegation London was excluded from the last delegation act which limits the delegation opportunities to CCGs and LAs both individually and collectively The model we are currently exploring for April is outlined on the next pages Page 79 of 235

80 INTEGRATED COMMISSIONING BOARD Each LA (LBH and COL) and CCG could formally establish an Integrated Commissioning Board (ICB) as a Joint Committee The ICB could be made up of 3 Councillors/Cabinet members 2 CCG GPs 1 CCG lay member Chief Officers of LA and CCG Others in attendance (eg DOF [Pooled Fund Manager]; Healthwatch) The Board would represent the interests of both the LA and CCG in improving the local health and social care system ICB members will have equal voting rights and an equal stake in securing better outcomes It would have delegated decision making authority from CCG and LA to make decisions binding on both parties on use of the pooled fund (Integrated Commissioning Fund) created via a s75 agreement The pooled fund would cover all CCG budgets, Public Health and Social Care budgets which are within scope and can be legally pooled (see next slide) The Board would agree how best to use the fund to secure local improvements and deliver the locality plan and will be accountable for the use of the fund There would be a clear financial framework outlining how the partners develop and manage the fund each year the framework would be agreed by the LA and CCG GB There would be a Pooled Fund Manager will responsibility for day to day management of the fund and reporting on performance The Board would make recommendations to the CCG Governing Body and LA for aligned fund services budgets for services which can t legally be pooled via a s75 agreement (see next slide) Page 80 of 235

81 ALIGNED FUND SERVICES Services commissioned only by CCG (on recommendation of ICB) Surgery Radiotherapy Termination of Pregnancies Endoscopy Laser Treatment Emergency Ambulance Services Services commissioned only by the LA Subject to what is in scope but formal list is Adoption services Appointment of Mental Health Professional MHP powers of entry Safeguarding children in care homes Appointment of DSS Page 81 of 235

82 Operating model Each year a locality plan is developed for City and for Hackney outlining What we want to achieve over next 2 years Our local contribution to NEL STP Improvements we expect to achieve in outcomes and performance Outcome improvement plan is signed off by the HWBB to ensure fit with JSNA HWBB monitors delivery improvements across the system Page 82 of 235

83 TRANSFORMATION BOARD The ICB would take its recommendations from the Transformation Board who are charged with developing and implementing the locality plan There are 4 workstreams to support the priority areas agreed to date Early Years Prevention Planned Care Crisis Care And discussions are in place about a 5 th workstream focusing on delivery, provider OD and enablers The Transformation Board is made up of CEO/Medical Directors of Homerton ELFT GP Confederation CHUHSE CCG Director of Public Health Group Director of Childrens, Adults & Community Health (LA) Healthwatch HCVS representative Pooled Fund Manager CCG Lay member for PPI Pharmaceutical Committee Chair Page 83 of 235

84 REDESIGN WORKSTREAMS Each of the current 4 workstreams is led by an SRO from the Transformation Board, a clinician and a patient representative They are supported by a manager who has responsibility for all the contractual arrangements to secure delivery of outcomes agreed for that workstream and undertake performance management the contractual arrangements will focus on delivery of system metrics and integration across providers Each workstream will be made up of a number of work programmes each will have clear leadership arrangements, outcomes expected to be delivered and aligned budget/contracts Page 84 of 235

85 PRIMARY CARE CONTRACTS COMMITTEE CCG would retain a formal Primary Care Contracts Sub Committee it provides additional oversight and scrutiny of all contracts with primary care free from any conflicts of interest It would take recommendations from the Transformation Board and provide assurance to the ICB (on services will be funded from the pooled budget) This Committee could also undertake primary care commissioning should this be delegated to the locality Separate governance arrangements may need to be established for any functions delegated to the locality as part of the devolution programme the Transformation Board would still make the recommendations Page 85 of 235

86 OTHER CCG ARRANGEMENTS CCG would continue to consult with members via CCF and Localities on plans Current CCG Clinical Executive would meet 2-3 monthly as a forum to share ideas and issues from the workstreams CCG Programme Boards would continue to have responsibility for operational performance and contract management until this can transfer to the new workstream arrangements The CCG GB would need to keep oversight of the ICB and ensuring it is delivering the statutory responsibilities of the CCG and acting in line with the scheme of delegation Page 86 of 235

87 Proposed Governance Structure for Integrated Commissioning Redesign Workstreams Early Years Prevention Planned Care Crisis Care?delivery arrangements Recommendation Primary Care Contracts Committee CCG Recommendations for aligned fund services Transformation Board Recommendation and advice Implementation of decisions Integrated Commissioning Board Delegated decision making for pooled budget Local Authority Agrees outcome improvements and progress across system Health and Wellbeing Board Page 87 of 235

88 NEXT STEPS We are now meeting with the 2 LAs to develop this model in more detail and begin discussions with partners We plan to establish a set of principles to guide the development of the model and establish a series of gateways which would be stop/go points I propose to report regularly on progress to the CCG Audit Committee and Governing Body, particularly once we have a more defined governance model Page 88 of 235

89 Page 89 of 235 CRISIS CARE WORKSTREAM

90 BACKGROUND Our devolution strategic outline case detailed 2 specific initiatives to take forward our objectives The development of a quadrant model for delivery of community/out of hospital services The introduction of a single point of access/coordination to organise crisis services Two workshops have been held in September with wide representation from the following organisations to debate our objectives and reach consensus on the models for each LBH; COL; Homerton; ELFT; GP Confederation; CHUHSE Page 90 of 235

91 QUADRANT WORKING Based on the learning from One Hackney the core quadrant team will consist of Mental heath/cpn (ELFT) Voluntary sector navigator (HCVS) Community Matron (Homerton/GP practices) Geriatrician (Homerton) Social Worker (LA) GP lead Team leader They will work with each GP practice and the wider range of community services to support the management of high risk patients Top 5% at risk of admission to hospital Housebound Frequently admitted End of life Other highly complex With the aim of reducing avoidable A&E attendances and admissions and enabling people to stay at home Page 91 of 235

92 SINGLE POINT OF ACCESS Initially bring together IIT (Homerton and SS) and Paradoc (CHUHSE) to offer a crisis response service (24/7) for community practitioners, nursing homes, LAS which will avoid a LAS call and subsequent conveyance to hospital Using one referral and triage process Linking with CHUHSE and the Confederation for out of hours and in hours primary care The service could be expanded to offer one point of access to at risk patients/carers/relatives in the community and become the gateway into other crisis services Page 92 of 235

93 Running through both initiatives are The services contributing to admission avoidance Multi practitioner and multi provider team working and streamlining of processes The potential for the services to support hospital discharge We are holding a 3 rd workshop to focus on discharge/dtocs in November Potential for the initiatives to grow (eg quadrants beyond at risk patients; SPA into access to all crisis services) once the building blocks are secure Page 93 of 235

94 IMPLEMENTATION A wrap up workshop was held at the end of September It was agreed that Dylan Jones (Homerton) would lead the SPOC initiative Jennifer Walker (One Hackney) would lead the quadrant model But with active commitment from all local partners A set of gateways/milestones were proposed attached to steer the development and implementation of these initiatives Dylan and Jennifer have been asked to Review the ordering of the milestones Develop project plans and PMO arrangements (the devo PMO is supporting the initial workplan) funding will be met by CCG Whilst there is some non recurrent funding available to support double running of new arrangements, these initiatives will need to deliver recurrent savings if they are to continue Page 94 of 235

95 GOVERNANCE 1. We have asked senior leaders to endorse these initiatives and commit to their importance as key initiatives to deliver new integrated delivery models 2. Progress reports will go to the Transformation Board with more formal review mechanisms in place to review each gateway, and in particular the December gateway 3. The devo OD workstream will be asked to assess implications for cross organisation working arising from the delivery model Page 95 of 235

96 OVERSIGHT OF THE MONEY At present we commission a range of services across organisations which support crisis care the CCG also pays PBR (payment by results for A&E attendances and emergency hospital admissions) The total spend in 16/17 is c 150m As a system we don t benchmark well compared to other areas PBR spend is increasing year on year A&E attendance rates/1000 are high Emergency admission rates/1000 are high and rising Whilst the NHS will contract on the same basis for 17/18 (given contracts have to be agreed by Christmas) these 2 initiatives and cross organisation working may lead to different contractual arrangements/different delivery models Page 96 of 235

97 It is proposed that from 1 December on a monthly basis a group of senior leaders across the partnership meet to Review monthly finance and performance information Debate and agree collectively what mitigating actions to put in place should PBR spend increase and risk overall financial balance eg reduce spend in other areas; cut nonrecurrently funded services Discussions are taking place about the inclusion of social care budgets focused on crisis care Whilst not a formal contractual alliance at this stage this could emerge over the next few months Under this model the current Integrated Care Programme Board will cease and the Urgent Care Board will continue for now with oversight of A&E delivery during the winter and providing a forum for practitioner/clinician debate Discussions are ongoing about whether this group should be the current Transformation Board Page 97 of 235

98 Single point of access / co-ordination Gateways Led by Dylan Jones Gateway 1 - End October 2016 Offer to primary care and nursing homes of a consistent in hours response, seamless service with one triage and assessment process across IIT and Paradoc - both adults and children. Gateway 2 - Mid December 2016 Offer on how the service could support primary care over winter and in particular Homerton A&E during winter surge and ensure an agreed escalation process for surge response (use the model to agree a surge plan for other times) Offer ready to discuss with LAS to formalise alternative to ambulance despatch for 999 calls - particularly to support winter surge Offer to non C&H registered patients resident in the Borough/City picked up via LAS Outline the operating model with CHUHSE for the out of hours period which is consistent with delivery of terms of CHUHSE contract Proposals to CCG on any changes needed to Duty doctor and/or FHV contract specifications for 17/18 to support delivery model Outline to CCG any changes needed in Paradoc, IIT and Chuhse contract specifications for 17/18 to support delivery model Page 98 of 235

99 Single point of access / co-ordination Gateways Gateway 2 - Mid December 2016 (continued) Proposals for particular pathways where service could respond rather than use A&E Outline the model for feedback to GPs/referrers following all patient interactions Formal pathway agreed with Homerton to increase use of duty doctor service to support admission avoidance, protocol agreed for when Paradoc could offer a stepin/holding service and formal system in place to report and address access problems with duty doctor Governance model agreed across providers Test of fit of model against 111 and NEL urgent care plan Contingency plan if service cannot be maintained Immediate plans to support improvement in discharge following the discharge workshop Page 99 of 235

100 Single point of access / co-ordination Gateways Gateway 3 - End January 2017 Offer to relatives/carers/patients for crisis response as an alternative to agreement with GP Confederation and Chuhse on who is first point of contact and arrangements to ensure contact details included in all care plans (to tie in with new contract to transfer all care plans to Cmc by 31/3) offer ready to be tested with PPI for April mobilisation Outline the care record system and interface with coordinate my care to ensure the latter can be accessed in "call centre" and in the community on home visits and meet IG requirements Outline integrated pathway with social care and mental health crisis Proposals to CEPN and to IT enabler group for investment required to support delivery model OD plan to support service development Operating model for hot referrals to acute providers Page 100 of 235

101 Single point of access / co-ordination Gateways Gateway 4 - End February 2017 Offer to Barts Health and UCLH to support alternative to admission Assure the model will also work for City patients Gateway 5 - End March 2017 Offer which makes the service the route into other crisis services using one single assessment process (eg ACERs, Heart Failure) Formal KPIs to evaluate the service proposed along with triggers for audit/case review Review of plans and model with PPI Page 101 of 235

102 Single point of access / co-ordination Gateways April 2017 Stocktake on impact of service on attendance rates, on LAS activity and on emergency admissions. Development plan for 2017/18 agreed with partners and CCG Page 102 of 235

103 Quadrants gateways Led by Jennifer Walker Gateway 1 - End October 2016 Project plan to establish core team for each quadrant Outline model ready for engagement with public (via devoppi event) on quadrant working Page 103 of 235

104 Quadrants gateways Gateway 2 - Mid December 2016 Defined offer to primary care including programme of input to MDTs so full team can agree at risk patients, sharing case loads and patient info across practitioners (to tie in with contract to support transfer of care plans to Cmc) Agreed model for Community Matron and District Nursing membership of teams, underpinned by delivery model Agreed model for the City Governance model defined including IG model Team leader role defined and plan in place to establish Proposals to CCG on any changes needed to Duty doctor and/or FHV contract specifications for 17/18 to support delivery of model Proposal to CCG on any other changes needed to service specifications for 17/18 to support delivery model - including practice based community matron services and CHS Agreed model for GP leadership and care of elderly consultant input to teams Immediate plans to support improvement in discharge following the discharge workshop Page 104 of 235

105 Quadrants gateways Gateway 3 - End January 2017 Offer to Homerton to ensure care plan communicated on admission and input to discharge planning Model agreed for how quadrant teams with link with IIT/Paradoc/SPC and ensure streamlined processes Delivery model for integration with VCS via HCVS post Model for link with ACRT ensuring one common assessment process Page 105 of 235

106 Quadrants gateways Gateway 4 - End February 2017 OD plan to support team working finalised Offer in relation to patients with dementia to tie in with wider dementia services Proposal to CEPN for exploration of new roles Proposal for IT to support delivery model Proposed KPIs and "service failures which need audit/case review defined Page 106 of 235

107 Quadrants gateways Gateway 5 end March 2017 Plan to collapse One Hackney learning/posts and delivery model into quadrant model and one Hackney exit strategy agreed Protocol for further integration with mental health services More formal offer to Homerton and practices in relation to discharge in light of outcome of workshop Agreed model for how the quadrant teams work with other services Test of model with PPI Gateway 6 end June 2017 Project plan to offer integrated service for people with LTC/next level of pyramid Page 107 of 235

108 Page 108 of 235 PLANNING GUIDANCE

109 PLANNING GUIDANCE Issued end of September 2 year contracts to be signed with providers by Christmas need to demonstrate how contracts will deliver STP ambitions If not signed provider and CCG fines -> intervention Individual financial control totals for each organisation plus a combined STP total expected to deliver Moving money across an STP footprint needs approval of the CCGs as statutory bodies Monthly central monitoring of activity and money against plan New NHS money going straight to acute providers again in 17/18 and 18/19 to address deficits Page 109 of 235

110 MUST DOS 1. Deliver STP trajectories for Deliver finance Right care; back office savings; pathology; agency staff 3. Improve GP access An additional 1.5hours of prebookable appts per day plus weekends 4. Achieve A&E targets, make progress on 7 day services, implement integrated 111/OOH by Reduce A&E transportation from 999 calls 6. Deliver RTT (waiting times) 7. Implement national cancer strategy 62 day waits, one year survival, stratified opd followup and improved after care 8. Increase psychological therapies, improve CAMHS, reduce waits, improve crisis care 9. Improve services for people with LD 10. Achieve metrics -> CCG assessment framework Page 110 of 235

111 BUSINESS RULES CCGs must spend 3 per patient on supporting primary care improvements 1% of CCG budget to remain uncommitted CQUIN will continue at 2.5% 1.5% of the 2.5% will be linked to nationally mandated areas staff health and wellbeing; discharge, reducing ambulance conveyance, reduce infections, improve wound care, improve A&E response for those with MH problems; transition in MH services 0.5% released to providers if delivers its control total but cant be spent Other 0.5% is linked to provider engagement in STP Page 111 of 235

112 CCG QUALITY PREMIUM Cancer diagnosis staging Patient experience of GP access Bloodstream infections Right Care Continuing Health care Mental health - TBC Page 112 of 235

113 COMMISSIONING LANDSCAPE As new care models (ACO) evolve, need to consider CCG role Whilst still must be a commissioner, some functions could transfer into ACO and other functions done at an STP footprint supported to merge leadership and governance Page 113 of 235

114 DEVELOPMENT OF INTEGRATED COMMISSIONING MODEL UPDATE ON PROGRESS FOR INFORMATION OCTOBER 2016 Page 114 of 235

115 CONTEXT Further to the paper to the GB on devolution next steps and integrated commissioning the following provides an update The devolution business case outlining the asks will be submitted to the London Devolution Board in early November a copy will be shared with GB members With LBH and the COL on integrated commissioning we have agreed To sign a Memorandum of Understanding draft attached to confirm our commitment to exploring this To work within the attached principles and to the gateways/timetable outlined these are still in draft but I wanted the GB to have sight of this Page 115 of 235 2

116 PROPOSED PRINCIPLES Approach with a can do/resolve problems attitude Have gateways which allow us to keep up momentum but also take stock see these as stop/go points Agree what s mission critical for 1 April and have a post April to do list Mission critical is:- ICB, Transformation Board, financial framework, scheme of delegation, signed s75s assured by Audit Committees Use crisis care and some potential issues and scenarios to test governance and approach Recognise we may not get it right on 1/4/17 so we will need to build in flexibility to change things Recognise that sometimes 80% detail/completion of something may good enough to proceed as long as we are clear about any risks in doing so Limit changes to existing governance and current officer responsibilities within the schemes of delegation No change for staff on 1 April Aspiration to have joint commissioning team(s) revisit in April Have one lead across organisation for workstream initiatives Take stock in January what are the opportunities for new joint initiatives and agree a plan to take these forward expect these to feed into changes by April 2018 Discuss with HWBBs our big ticket improvements in new year to take forward the JHWBSs Believe change in s75 legislation only when it happens! Don t undermine existing organisational medium term financial strategies Recognise the City as a separate entity consider opportunities where it makes sense to do things together Ensure the plans fit with our devolution aspirations and will both support and not exclude exploration of different provider delivery arrangements and different approaches to contracts Page 116 of 235 3

117 PROPOSED GATEWAYS 1 st week in November Sign an MOU Agree vision and rationale for doing integrated commissioning use for all communications 2 nd Steering Group meeting date in early November TBA Use some scenarios to test out the proposed governance and scheme of delegation Confirm legal position of proposed ICB and members Agree communications plan and messages End November First draft of risk register Mid December Have draft of proposed governance, financial framework and scheme of delegation in light of scenario work Agree further stress tests for governance and financial framework Ensure Crisis care group has handle on 16/17 money, issues and risk management and we use this to inform our learning and model End December Discussions with all 3 external auditors about emerging proposition Take stock of emerging CCG financial position post contractual agreements and future NHS financial policy framework Agree the main components of the pooled budgets and aligned budgets, split with City Mid January Take stock on crisis care and implications for future operational model - all End January Final drafts of governance and Financial framework First draft s75 agreements TB agrees areas for deep joint work in 17/18 TB agrees big ticket improvement plans to take forward JHWBSs for HWBBs debate Page 117 of 235 4

118 THIS MEMORANDUM OF UNDERSTANDING is dated 2016 BETWEEN: (1) NHS CITY AND HACKNEY CLINICAL COMMISSIONING GROUP of 3 rd Floor, A Block, St Leonards, Nuttall Street, London N1 5LZ ("CCG"); (2) LONDON BOROUGH OF HACKNEY of 1 Hillman Street London E8 1DY ("LBH"); and (3) CITY OF LONDON CORPORATION of City of London Guildhall, PO Box 270, London EC2P 2EJ ("CLC"). The CCG, LBH and CLC are together referred to in this Memorandum of Understanding as the "Partners". 1. BACKGROUND 1.1. The Partners have agreed to work together to explore the introducintroduction ofe fully integrated commissioning across health, public health and social care between the CCG, LBH and CLC, as the next step in the Partners' integration journey towards a fully accountable place based health and care system by 1 April 2017 (the "Project") The Partners intend that their integrated commissioning model will not only improve outcomes for local people but will also provide a more aligned and integrated delivery vehicle for our local ambitions and for the nel the Sustainability & Transformation Plan ("STP"), ensuring the Partners can easily articulate and demonstrate their local system's contribution to the STP priorities and workstreams The Partners envisage that the model will provide learning to the other delivery systems in the STP on integration plans, as well as taking learning into City & Hackney from the rest of North East London. The Partners envisage that the model will give both confidence and coherence to the local delivery arrangements for the STP and help to ensure one system voice, response and delivery mechanism The Partners are committed to an overall project plan which maintains pace to achieve the 1 April 2017 deadline but with a series of milestones/gateways where there will be a formal stock take of progress and agreement to move to the next step.(we could spell out the gateways?) 1.5. The Partners wish to record the basis on which they will collaborate with each other on the Project. In particular, this Memorandum of Understanding ("MoU") sets out: the key objectives of the Project and the opportunities it presents; the principles of collaboration, including the governance structures the Partners will put in place to implement the Project This MoU is not intended to be legally binding, and no legal obligations or legal rights shall arise between the Partners from this MoU. The Partners enter into the MoU intending to honour all their obligations. 2. KEY OBJECTIVES AND OPPORTUNITIES 2.1. The Partners shall undertake the Project to achieve the following key objectives: to drive improvement in outcomes and ensure the Partners' providers work together to take collective responsibility for achieving such improvements; to bring together patient, clinical and practitioner views alongside best practice and benchmarked information to define the Partners' plans; and Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 1 of 6 Page 118 of 235

119 to support the Partners' providers to move to an accountable care system and the exploration of more integrated delivery arrangements, where the needs of the Partners' patients overrides the organisational arrangements the Partners' have in place The Partners consider that the Project offers a number of exciting opportunities linked to the Partners' wider devolution programme and existing locality plans, if the Partners start to look outside the traditional box of health and social care, including the following: working across LBH, CLC and the CCG to commission not just health and wellbeing but wider community [needs a better word for leisure and other LA things] [NOTE: Partners to confirm] services and initiatives from a combined estates portfolio; taking the Partners' quadrant model beyond health and social care to wrap services around residents at a local level and expand the offer on self help and on social prescribing (which the Partners have had in place for 2 years); a more integrated digital offer of advice and access to local people; and a fully integrated primary and secondary prevention strategy. 3. PRINCIPLES OF COLLABORATION 3.1. The Partners agree to put in place and commit to a steering group to explore adoptbest model of integrated commissioning for hackney and for the city by April The principles underpinning this exploratory stage are xxx (lift from the document) The direction of travel is to explore the following governance arrangements when carrying out the Project: the CCG will enter into section 75 agreements with each of LBH and CLC, to take effect from 1 April 2017; each such section 75 agreement will cover the pooling of budgets and, where agreed, the exercise of each other's functions when commissioning services; the section 75 agreements will set out the governance arrangements to be implemented by the Partners and will establish joint committees of the CCG with each of LBH and CLC; the joint committees will bind the CCG, LBH and CLC, including committing the pooled funds, and their membership will be set appropriately to the committees' remits and within schemes of delegation agreed by the statutory bodies; the joint committees will be established through the section 75 agreements but must be recognised in the CCG's constitution (with separate terms of reference) and so require the approval of member practices and NHS England; NHS England may ask the CCG to take delegated authority for commissioning primary care to ensure full integration of commissioning The Partners' current transformation board, which is made up of the local system leaders, will take full collective ownership and responsibility for developing and delivering the Partners' improvement plans and making recommendations to the joint committees The Partners have agreed to shadow the model during the autumn and winter of 2016, in order to stress test the model and help the Partners learn together how they will need Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 2 of 6 Page 119 of 235

120 to work together in a different way when the model 'goes live'. The Partners will begin the shadow arrangements with crisis care and look at how the Partners align clinical behaviours and service delivery across organisational boundaries within a ring fenced budget The Partners will start this model using current contractual arrangements, for example, 'block' and full 'payment by results'. This will however help the Partners to understand the levers and risk/gain share the Partners will need to have in place to maintain financial balance within the ring fence, as the Partners explore moving to a more outcome based capitation arrangement The Partners wouldill enter into section 75 agreements as discussed above but, in line with current legislation, certain functions will be excluded from those agreements. The Partners will treat these functions as 'aligned services', where the transformation board and joint committees will decide on the strategy but the formal decision will not be delegated to the joint committees and instead will be retained by the CCG's Governing Board and the Local Authorities The Partners welcome the national plans to amend legislation which will allow full pooling between the CCG, LBH and CLC and will therefore streamline this decision making and governance. Depending on the timescale for such amendments, the Partners will aim to amend the governance structure to capitalise on the new flexibilities within 6 to 12 months of these flexibilities becoming available. 4. FINANCIAL FRAMEWORK The final governance arrangement will need to be agreed by the 3 statutory organisations after taking appropriate legal and audit advice on the recommendation of the steering group Each section 75 agreement between the Partners would ill be supplemented by a financial framework. The financial framework will be incorporated into the relevant section 75 agreement and will set out the financial matters, while allowing the Partners some flexibility to work through and agree the detail of such matters. It is expected that the framework will be developed in the light of the pilot phase and will be subject to agreement by the 3 statutory organisations on the recommendation of the steering group 5. MILESTONES 5.1. The Partners will, as soon as reasonably practicable following the date of this MoU, seek to agree a set of 'stop/go' milestones/gateways, which maintains pace to achieve the Partners' 1 April 2017 deadline for entry into force of the section 75 agreements Such milestones/gateways shall include the following: [NOTE: Partners to consider key steps and realistic timescales for each.] 6. PROGRAMME DIRECTOR 6.1. The Partners will appoint a Programme Director by agreement, to fulfil the role outline set out in Annex A to this MoU [NOTE: We assume that one Partner will employ or engage the Programme Director? Will costs (e.g. wages and other benefits) and liabilities (e.g. negligence and employment-related liabilities) connected with such staff be apportioned between the Partners?] The ccg will meet the costs of the programme director who will support the exploration and implementation of these arrangements and other costs associated with the programme and agreed by the steering group, pmo support to the group will be via the already funded devolution pmo Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 3 of 6 Page 120 of 235

121 team 7. ESCALATION If a Partner has any issues or concerns about the Project, or any matter addressed in this MoU, that Partner shall notify the other Partners and the Partners shall then seek to resolve the matter by a process of consultation. If the issue cannot be resolved within a reasonable period of time, the matter shall be escalated to the [current transformation board] [NOTE: Partners to confirm], which shall decide on the appropriate course of action to take. If the matter cannot be resolved by the [current transformation board] [NOTE: Partners to confirm] within [NUMBER] days, the matter may be escalated to the Partners' respective [INSERT] [NOTE: Partners to confirm] for resolution. 8. VARIATION 9. COSTS This MoU, including the Annex, may only be varied by written agreement of the Partners. Except as otherwise agreed in writing, the Partners shall each bear their own costs and expenses incurred in complying with their obligations under this MoU. 10. NO PARTNERSHIP Nothing in this MoU is intended to, or shall be deemed to, establish any partnership or joint venture between the Partners, constitute any Partner as the agent of any other Partner, nor authorise any of the Partners to make or enter into any commitments for or on behalf of any other Partner. Signed for and on behalf of NHS CITY AND HACKNEY CLINICAL COMMISSIONING GROUP Signature:... Name:... Position:... Date:... Signed for and on behalf of LONDON BOROUGH OF HACKNEY Signature:... Name:... Position:... Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 4 of 6 Page 121 of 235

122 Date:... Signed for and on behalf of CITY OF LONDON CORPORATION Signature:... Name:... Position:... Date:... Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 5 of 6 Page 122 of 235

123 ANNEX A [NOTE: Insert Role Outline for Programme Director once agreed by Partners] Agenda Item 5c DRAFT Devo Hackney MoU _1 Page 6 of 6 Page 123 of 235

124 From: nel.stppmo Date: 27 October 2016 at 13:05:03 BST Subject: Message from Jane Milligan on the north east London STP MESSAGE SENT ON BEHALF OF JANE MILLIGAN Dear All, First, thank you all for your contributions to the next iteration of the STP, which was submitted to NHS England on Friday 21 October. The publication of STPs continue to be a focus, so I felt it would be helpful to set out how we are managing this in north east London. As previously advised, NHS England has asked for a pause before publishing STPs so they can reflect on the drafts we submitted last week. We expect this pause to last around two weeks. We intend to give you the following documents for discussion at the public section of your boards, governing bodies and HWBBs by the end of next week: Revised STP summary as per the June submission The STP narrative An explanatory slide pack We also intend to publish these on our website as soon as we are able to. Please let the team (nel.stppmo@towerhamletsccg.nhs.uk) if you want to take more detailed plans to your meetings and we can discuss how we can support you with this. In the meantime our line to take remains: The latest draft NEL STP was submitted to NHS England for assurance on 21 October. Once the plan has been assured, we intend to publish it, for discussion with local people. Thank you for your cooperation. I am well aware this pause is not ideal, and am keen that we share the STP widely as soon as we are able. Kind regards Joy Ogbonna on behalf of Jane Milligan Programme Support Officer NEL Sustainability and Transformation Plan (STP) NHS Tower Hamlets Clinical Commissioning Group 2nd Floor Alderney Building Mile End Hospital Bancroft Road London E1 4DG Page 124 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

125 MEETING PAPER COVER SHEET Meeting Title City and Hackney CCG Governing Body Meeting Date 28 th October 2016 Paper Title CHUHSE Action Plan Update Paper Number Paper Author Lead Director FOI status Paper Summary (Provide relevant background to the paper) Purpose (tick one only) Leah Herridge (Urgent Care Programme Manager) Mark Scott (Director of Integrated and Urgent Care) Available under FOI On the 29th April 2016 CCG Governing Body CHUHSE presented an action plan in response to the Verita Report on the CHUHSE Out of Hours Service. The Governing Body tasked the Quality and Performance Review Group to track progress made against delivery of the plan and report back to the Governing Body in October The paper provides an update against each of the actions. 1. For Approval 2. To receive item 3. For Other Decision Recommendation (state what you are asking the committee/governing body to do; i.e. support a proposal, provide feedback, note the paper, etc. List all that's applicable) The Governing Body is hereby asked to: To note the progress CHUHSE has made against the action plan in response to the Verita Report Support the Quality and Performance Review Group recommendation that all actions points have been completed. Where was this paper previously discussed? What was the outcome? CHUHSE presented an update against the action plan at Quality and Performance Review 23 rd June The Group has concluded that all actions set out have been achieved and recommend that the actions are now closed. Page 125 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

126 Page 126 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

127 CHUHSE Action Plan Update Background On the 29 th April 2016 CHUHSE presented an action plan in response to the Verita Report at the CCG Governing Body. The Quality and Performance Review Group was tasked with tracking progress made against delivery of the action plan. The Group has concluded that all actions set out have been achieved and recommend that the actions are now closed. The Quality and Performance Review Group has also tracked progress against taking forward recommendations in the RSM Internal Audit Report and the Primary Care Foundation Report. All actions/recommendations have now been closed, apart from a PCF recommendation that there are real opportunities for CHUHSE to lead with changes in arrangements with NHS 111 and 7 day working as well as opportunities to work more closely with PUCC and through One Hackney. The Quality and Performance review group agreed that this action should remain open while development of the single point of coordination takes place. Progress against Action Plan Summary of Issues identified in Verita Report CHUHSE Summary of actions/progress Comments/Recommendations from the Quality and Performance Review Group Performance: The report makes reference to local GP support as a source of strength CHUHSE retain the confidence of local GPs, however in keeping with other providers it is now regularly struggling to fill certain shifts. CHUHSE has with effect from 1 st June 2016 raised their night shift rates of pay. They have said that this will present a budgetary challenge which will need careful management. CHUHSE have met with GP Confed to look at innovative use of CPEN funds to create a new urgent care workforce. A Person Specification and Job Description was created for four salaried GP posts offering a portfolio of work which also had a requirement to work 2 weekdays out of hours shift a month. There were no candidates for these roles and feedback suggested that the out of hours stipulation The group were satisfied with progress made by CHUHSE, recognizing that recruitment of GPs to OOH is a national issue that may not be resolved by any individual organization, or health system. Ongoing difficulties in recruiting staff within OOH, A&E and Primary Care is included within the Urgent Care Programme Board risk register. CHUHSE have said that medical workforce issues remain a critical area of concern. They have said that this is reinforced by the fact that there is a fixed income with potentially uncapped expenditure in terms of having to pay enhanced rates to keep up with local market rates. Page 127 of 235

128 Governance: Previous chair should apologise on behalf of the organisation to the non-executive directors for the way they were treated. Governance: CHUHSE should appoint an additional non-executive director Governance: Board transparency was seen as a barrier to recruitment. The posts were re-advertised without this requirement. There is ongoing dialogue with the GP Confederation regarding encouraging members to work for CHUHSE. This is ongoing and in the past months CHUHSE has taken on two more Doctors but have lost one and look likely to lose another shortly. The previous chair has now left the organisation and CHUHSE has no leverage over this individual. The group agreed with CHUHSE s position on this and recommended that this action is closed. CHUHSE have now appointed a non-executive director A CCG member supported CHUHSE in the recruitment by providing independence to the selection process. The group recommends that this action is closed. Part 1. Board minutes are now shared with the CCG Quality and Performance Review Group At the Quality and Performance Review meeting the group discussed that CHUHSE are working to improve their website to allow for Board papers to be uploaded. In the meantime it was agreed that CHUHSE will ask Healthwatch to share the Board papers via their website on CHUHSE s behalf. The group were satisfied with the actions taken and recommended that this action is closed. CHUHSE also confirmed that board meetings take place in public. Page 128 of 235

129 Finance: The report makes reference to the Primary Care Foundations comment that the contract with the CCG and its small size mean that it faces challenges to remain viable Finance: Board monitoring of finances Contracting: CCG should have a clear process for determining what level of oversight is appropriate to monitoring its providers Consistent monitoring of Quality Premium and activity A major piece of work was undertaken with the CCG to rebase core contract to ensure that activity is accurately reflected and paid for at the correct tariff. A case was made for project management to support the development of an options appraisal for CHUHSE and GP Confederation as independent providers of primary care to City and Hackney CCG. CCG approved the funding for a PM to explore collaboration up to and including a full merger of the two organisations. PM identified and he will be working with CHUHSE later this month. Detailed finance reports now received at each Part 1 Board meeting. Independent finance consultancy retained by the Board to assist with scrutiny and assurance. Audit Committee established (3 meetings per year) Cycle of internal and external audit established (annual cycle) Quality and contractual performance for both CHUHSE OOH and ParaDoc now come under the bi-monthly Quality and Performance Review meeting. The group were confident that the recommendations made by the primary care foundation have been taken forward by both the CCG and CHUHSE in order for this action to be closed. CHUHSE did set out that there remains a challenge as a single CCG provider. The challenge of size is still an issue in terms of turnover, cash and management headroom. There were discussions in terms of how CHUHSE can be involved in future developments around creating a single point of co-ordination and the opportunities for working in new models of care. Such developments may address issues around the size and scale of CHUHSE as an independent organization. The group were satisfied with progress against this action and recommended that this action is closed. The group are confident that the Quality and Performance Review meeting is an appropriate level of oversight to monitor CHUHSE services. In addition, CHUHSE KPIs (including National Quality Requirement) and performance is discussed at the Urgent Care Programme Board and Contracts Committee. The group recommended that this action should be closed. Page 129 of 235

130 FINANCE & ACTIVITY REPORT Month /17 NHS CITY & HACKNEY CCG 28 October 2016 Page NHS 130 City of & 235 Hackney CCG

131 Contents Executive summary Finance and activity dashboard & trend Key risks narrative Running costs performance Financial Statements Page NHS 131 City of & 235 Hackney CCG

132 Executive Summary A review of month 6 financial position and month 5 activity was undertaken to compile the month 6 position. At month 6, City & Hackney CCG declared a 545k actual surplus with an in-month 26k favourable movement. Cost pressures were contained within the acute portfolio by utilising the Acute Reserve. The non-acute portfolio saw further increased Continuing Health Care cost pressure following the trend of previous months. Underspends were recognised in Reserves and Running costs totalling 1,923k, although these may reduce given pressures to fund the STP, devolution (in the absence of drawdown) and pressure in the wider NHS and social care system. The 30.19m surplus forecast outturn was risk assessed and delivery expected to be on-target. The surplus is net of the cumulative brought forward surplus of 38.19m and 8.0m planned drawdown agreed by NHSE and formalised in the 2016/17 Plan. The non-recurrent programme for 2016/17 is a key deliverable and most all investments on an individual basis continue to be reviewed and monitored. Within the STP footprint, the CCG continues to closely monitor the emerging Bart s risk around delivery of its operating plan and BHR CCGs corporate recovery plan. NHS England is pushing for a local NE London (NEL) resolution. The only mitigation available is the CCG 1% Strategic Reserve, currently ringfenced by NHSE, which can be issued via the 'WELC' risk share. Indications are the risk of these funds being lost will most likely materialise in quarter 4. The CCG may be required to report an increase in surplus to reluctantly underwrite the situation. Also, without having access to drawdown, the CCG is now funding the Hackney Devolution project and associated transformation work streams for which the scope of future costs are being finalized; this will be an additional cost pressure for the CCG to manage and contain. Previously reported disputes from prior year and accruals are expected to be concluded in 2016/17. This may result in a small net in-year benefit to be reviewed on a case by case basis. The Dashboard (page 4) highlights a GREEN RAG rating against the CCG Income & Expenditure position. QIPP for month 6 delivered a GREEN RAG rating with a 2.50m actual recognised with on-plan expectation for the full year. Page NHS 132 City of 235 & Hackney CCG

133 Page 133 of 235 NHS City & Hackney CCG

134 Key Risks - Finance Key risks are quantified on Page 7 and are based on the main drivers behind the performance shown in the dashboard on Page 4. The Finance & Performance Committee will review the month 6 financial position on 26 October and any further issues will be reported to the Governing Body at the October meeting. The year-to-date acute position declared across the portfolio was breakeven; albeit cost pressures with north central London providers were recognised. Approximately 43% of the Acute Reserve was utilised in delivering a break-even portfolio with the year-to-go position being very closely monitored. Homerton contract shows the year to date position as being on plan at 58.8m and on forecast. Bart s Health year to date position reported was 14.5m and 0.3m overspent with a full year adverse position of 0.5m. Whilst the adverse position is not the largest in the acute portfolio, it has the greatest risk on a year to go basis and is being reviewed and monitored very closely. As previously reported, the contract is materially higher in value than 2015/16 due to a combination of exceptional corrections relating to legacy tariff reinstatement and unwinding of the 2015/16 year end settlement. There was also increased activity growth and net activity transfers in from UCLH. Furthermore, Specialist misattributions/budget issues may still exist and will require close working with the lead commissioner and other CCGs to ensure the risk is managed. During 2015/16 the Finance and Performance Committee undertook monthly deep dives in rotation of Programme Boards and will continue to do so in 2016/17. Actions: Pursue the claims challenges across the acute portfolio. Work with NEL CSU to conclude contract agreements Review, monitor and manage the impact of Specialist misattributions. Non-Acute expenditure on Continuing Health Care (CHC) and Funded Nursing Care (FNC) on a year to date basis reported an increased overspend totalling 1,057k and a forecast overspend of 2,122k. The portfolio recognised an increased cost pressure for Mental Health and Physical Disabilities totalling 923k, pressures recognised for Funded Nursing Care (FNC) relating to new tariff rates belatedly agreed by DH and applied retrospectively to 1 st April 2016 of 134k and Programme costs of 347k. Underspends were recognised in Reserves and Running costs totalling 1,923k, although these may reduce given pressures to fund the STP, devolution (in the absence of drawdown) and pressure in the wider NHS and social care system. Prescribing expenditure on a year to date and full year basis was reported on plan. The budget set is net of QIPP with full year delivery expectation. QIPP delivery was on plan both on a year to date and full year basis. The non-recurrent (NR) investment programme in 2016/17 was risk assessed and considered to be on plan. The risk around non-delivery and slippage will be managed accordingly. All investments will be committed in contracts or contract variations. Work continues in resolving other long standing disputes from previous years. It is anticipated that these disputes will be concluded in 2016/17. The CCG had assessed the risks in making year end provision to cover these known risks. Action: Conclude negotiations on property charges and other long standing issues Page NHS 134 City of & 235 Hackney CCG

135 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 2016/17 Running Costs allocation is 6,176k. The month 6 position was a year to date underspend of 106k and a full-year forecast underspend of 1,537k. The steep rises in the planned spend graph lines demonstrate the 1,975k headroom in month 12. It is anticipated this will be transferred to be used to fund the devolution project Monthly Running Costs vs. Plan Total Planned Spend CCG Planned Spend CSU Planned Spend Page NHS 135 City of & 235 Hackney CCG

136 Summary and Progress Report on Financial Risks to 30 September 2016 Ref: Description RiskOpp '0 00 Prob.% Adj. risk/opp Recurring '000 Adj. risk/opp Non Recurring '000 Narrative 1 Risk HUH Acute contract 2,000 34% Risk Bart's contract performance 3,500 28% Risk Outer sector - Acute contracts including London Ambulance Service (LAS) 5,000 45% 2, Opp Claims and Challenges Acute contracts (2,000) 56% (1,120) 5 Opp Acute Reserve (3,227) 85% (2,754) 0 6 Risk NCA 500 0% Opp Contingency (4,140) 28% (1,164) 0 8 Risk Continuing Healthcare, LD & EOL 4,000 53% 2,122 9 Opp Prescribing (1,000) 0% Opp Running Costs (2,000) 77% (1,537) 0 11 Risk Programme Costs 1,000 0% Opp Non Acute 1,000 34% Risk Specialist Commissioning 200 0% Risk Risk share % Risk QIPP Under Delivery 750 0% Opp QIPP Over Delivery (750) 0% 0 17 Risk Property Costs 700 0% Opp Prior year Items (8,005) 31% 0 (2,500) 19 Risk Non Recurrent Investment Cost Pressure 3,500 57% 0 20 Opp Non Recurrent Investment slippage (2,000) 0% ,000 Gross position based on historic trend. Net risk based on the trend relating to claims and challenges. Gross position reflects over-performance risk and possible NHSE disputed misattribution.net risk based on month 6 recognised position the trend relating to claims and challenges. Gross risk includes 500k for emerging LAS over-performance contribution. Net risk reflects increased NCL provider over-performance contained by Acute Reserve. Based on historic trend. Release of reserve to offset activity pressure. Ca. 14% balance of reserve remains as mitigation on a year to go basis. Gross position reflects uncertainty of costs, including mental health choice, resulting in a recognised cost pressure. Release of contingency. Risk relating to activity increase above forecast, high cost patients packages and service provision. Gross risk high given worsening 2016/17 trends and increased FNC tariff pressure. Trend indicating possible underspend on a year-to-go basis. Additional headroom declared to contain CHC & FNC pressures. In-year non-recurrent costs in support of non-recurrent investment schemes, new programmes of work and Devoution. Non acute cost pressure across the portfolio including 111 Potential estimate of funding for Obesity activity transfer. Continuing Healthcare National Risk share contribution crystalised. Potential under-delivery for schemes phased on a year to go basis. Expectation is minimum on-plan delivery. Property services potential cost pressure. Opportunities arising from settlement of disputed items, accruals etc. invoices provided for in prior year resulting in an upside available 2016/17 Additional cost of non-recurrent schemes including devolution project. Reviewed and risk assessed with position contained. (240) 240 Underlying Forecast Outturn 0 Risk Drawdown of Surplus for Non Recurrent Investment 8, % 0 8,000 Opp Strategic Reserve (3,696) 0% 0 0 Risk Strategic Reserve 3,696 0% 0 0 Agreed Drawdown of previous years surplus. Ringfenced pending advice and direction from NHSE. Ringfenced pending advice and direction from NHSE. Opp Carry Forward cumulative surplus from prior years (38,189) 100% 0 (38,189) Surplus carried forward from previous years Net Cumulative Brought Forward surplus Headline Forecast Outturn Cumulative (30,189) 100% 0 (30,189) 0 (30,189) (30,189) Net cumulative surplus MEMO Risk/Opp '000 Opp 2015/16 0 Risk 2015/16 0 Page NHS 136 City of & 235 Hackney CCG

137 NHS City & Hackney CCG Page 137 of 235

138 Financial Statements - 1 INCOME & EXPENDITURE ACCOUNT Page NHS 138 City of & 235 Hackney CCG

139 Financial Statements - 2 KEY BALANCE SHEET INDICATORS Compliance with Public Sector Payment Performance Target 98.1% The cash balance as at end of September was not within the national target of 1.25% of September drawdown. Provider payments relating to 2015/16 were lower than expected and payments made on the last working day of September were recognised in October. The underlying cash balance was there 1.0m. Page NHS 139 City of & 235 Hackney CCG

140 MEETING PAPER COVER SHEET Meeting Title Governing Body Meeting Date 28 th October 2016 Paper Title CMC Data Overview Update Paper Number Paper Author Leah Herridge (Urgent Care Programme Manager) Lead Director Mark Scott (Director of Integrated and Urgent Care) FOI status Available under FOI Paper Summary (Provide relevant background to the paper) Purpose (tick one only) Recommendation (state what you are asking the committee/governing body to do; i.e. support a proposal, provide feedback, note the paper, etc. List all that's applicable) Where was this paper previously discussed? What was the outcome? The Integrated Care Programme Board agreed that Coordinate My Care (CMC) will be used for care planning across as many care settings as possible to improve patient care. The CCG set up a Care Planning Group, chaired by Dr Nikhil Katiyar (CCG Care Planning Clinical Lead), to develop care plan solutions for the most frail and vulnerable patients. This presentation provides an update to the Governing Body on the implementation of CMC in City and Hackney for the frail elderly and end of life patients. 1. For Approval 2. To receive item 3. For Other Decision The Governing Body is hereby asked to: Note the uptake of CMC across City and Hackney Data on the update of CMC is reviewed at each Care Planning Group n/a Page 140 of 235

141 Governing Body 28 th October 2016 Coordinate My Care (CMC) Data Overview UPDATE Page 141 of 235

142 What is Co-ordinate my Care (CMC) CMC allows patients to work with their clinicians to record their preferences and wishes within an electronic personalised urgent care plan. This care plan can be viewed by all the healthcare professional teams involved in the patient s care, including general practice, adult community nursing, St Joseph s Hospice and Homerton Hospital Elderly Care Unit, and can be updated when clinically appropriate. Urgent and emergency services including the ambulance service, NHS 111, the out of hours GP service and Paradoc will be more informed about the patient they are attending to and better enabled to provide continuity of care in accordance with the patient s healthcare plan and wishes. Page 142 of 235

143 Introduction Embedding multi-disciplinary care planning across the local health and social care economy is a long-term objective, which will take time to realise. City and Hackney CCG agreed that Coordinate My Care (CMC) will be used as the shared urgent care plan across as many care settings as possible to improve patient care. Initial focus has been on implementation of CMC as the shared urgent care plan for the frail elderly and those patients at the end of life in primary (including OOH), secondary and community care, focusing on the most vulnerable patients at risk of admission. Proposed that the next focus of implementation of CMC Care Planning across City and Hackney will be on the top 2% of patients at risk of admission (AUA DES register). A GP-led care planning group is in operation with buy in from all local providers and patient representation to drive implementation Page 143 of 235

144 Current CMC Implementation across City and Hackney Homerton Elderly Care Unit (concrete plans via CQUIN) One Hackney (pilot use of CMC in North West Quadrant) Paradoc (review and update of CMC included within contract) Page 144 of 235 CHUHSE Out of Hours (review and update of CMC included within contract) Primary Care (Frail home visiting and End of Life Care contracts) Adult Community Nursing (working in collaboration with GPs) St Joseph's Hospice LAS and 111 (London wider initiative to ensure uptake) Mary Seacole Nursing Home (work to be done to embed within other nursing homes in C&H) Initial focus is getting CMC embedded in primary, secondary and community care. In the future we will be looking at how social care professionals can view and input into CMC care plans. Discussions taking place looking at how mental health professionals can view and input into CMC care plans for frail elderly patients.

145 Improved Uptake of CMC 950 patients in City and Hackney have had CMC records created. City and Hackney CCG previously had a low uptake of CMC and now has the highest number of patients added to CMC in the last 12 months across London (737). Over the last 4 months since the project mobilised 606 urgent care plans have been added to CMC. Page 145 of 235 Aim is that by the end of March 2017, all patients on the end of life care register and frail home visiting register will have a CMC care plan in place, allowing health professionals the ability to have input into virtual multidisciplinary care planning across primary, secondary and community care.

146 Additions to CMC in City and Hackney Page 146 of 235

147 Making a Difference via Shared Care Plans/CMC Activity and Finance CMC patients make less use of hospital, emergency and unplanned care. For example, The average number of hospital inpatient attendances is 1.7 for CMC patients and for non- CMC patients. CMC patients also make greater use of community services. For example, CMC patients have approximately 15.5 GP surgery encounters compared with for non-cmc patients. Average cost of treating CMC patients is 2,102 lower than non-cmc patients. Source: CMC Frontier Economics, CMC Pilot cost analysis Patients Achieving Preferred Place of Death Overall 74% of City and Hackney CCG CMC patients have died in their preferred place. Where City and Hackney patients have a CMC record, 13% die in hospital. However, nationally, 47% die in hospital. Page 147 of 235

148 Coordinate My Care SEPTEMBER 2016 Welcome Welcome to the first Coordinate My Care (CMC) project update for health and social care professionals working in City and Hackney. CMC forms part of our ongoing focus of increasing integration and working more closely together to deliver better care for our patients and service users. It will enable the frailest and most vulnerable patients to plan their care in collaboration with their GP and a multi-disciplinary team of health and social care professionals. Many of you will be new to CMC, so this update gives an overview of the project, its aims and ambitions, where we are now, and what we want to achieve in the future. We ll make sure you re kept up to date as the project develops. What is Coordinate My Care? CMC is an NHS Clinical Service, commissioned by the London Office of CCGs, which allows clinicians to record their patient s preferences within an electronic care plan. It contains information about the patient s diagnosis, allergies, medications and resuscitation status as well as their wishes where they would prefer to be cared for and, if appropriate, where they would wish to die. Key contacts, both clinical and family and friends, the patient s social situation and cultural and religious beliefs can all be included. CMC can allow different health and social care professionals involved in the patient s care to view and input into the plan. The Integrated Care Programme Board has agreed that CMC will be used as the shared urgent care plan for end of life care patients and frail elderly patients across as many care settings as possible. During 2016/17 the implementation will be staggered to make sure it s embedded properly, that staff are fully trained, and that it integrates with our existing systems. The approach has been agreed and endorsed by the Integrated Care Programme Board which comprises City and Hackney CCG, Hackney Council, The City of London Corporation, East London NHS Foundation Trust (ELFT), Homerton University Hospital, One Hackney and the City, and the City and Hackney GP Confederation. If you have questions about the project, please contact leahherridge@nhs.net Dr Nikhil Katiyar, Care Planning GP Clinical Lead, City and Hackney CCG Page 148 of 235

149 How will our patients and service users benefit? A CMC care plan supports a patient if they have an urgent care need. Health care professionals will be more informed about the patient they are attending to and better able to provide care in accordance with the patient s needs and wishes. We hope it will also help to ease the pressure on patients and their carers at a time of crisis. CMC should also help to avoid unnecessary hospital admissions by giving professionals the information they need at the first point of contact with a patient in an urgent care situation. Homerton Secondary Care: CMC will be used by clinicians in the Elderly Care Unit at Homerton University Hospital. Clinicians will be able to create, view and edit care plans. Others: The wider urgent care system, including 111, London Ambulance Service, and our out of hours GP service (CHUHSE) have permission to view the plan and provide updates. Each of these organisations has a flag in its host system to indicate whether there is a CMC care plan in place. What happens next? While the initial focus is getting CMC embedded in primary, secondary and community care, in the future we will be looking at how social care professionals can view and input into care plans for frail elderly and end of life patients. There are also discussions taking place looking at how mental health professionals can view and input into CMC care plans for frail elderly patients. In the future we would also like to work with our nursing homes and Hospice to explore how these organisations can be included. Our Patient User Experience Group (above) has said CMC will provide the joined up care I ve always wanted and never thought I d get. Nula, an experienced Nurse at St Anne s Nursing Home (below) said: It would be really useful to have access to CMC so that we can deal with situations on evenings and weekends better when we might call the out of hours GP. Where are we now? There are currently around 728 patients in City and Hackney with a CMC care plan and the aim is that by the end of March 2017, all patients who consent who are on the end of life care register and frail home visiting register (around 1,750) will have a plan in place. Specific plans on how to embed CMC have been agreed for some key providers. Primary Care: GPs have a flag in EMIS to tell them if a patient has a CMC care plan in place. Over the next year, all care plans created under the end of life care contract and frail home visiting contract should be on CMC. Homerton Adult Community Nursing: When a CMC care plan is created for a patient under the frail home visiting contract, it should be a shared plan between the patient s GP and the Adult Community Nursing Team. For frail elderly patients where the team have significant involvement, the nursing team will take a key lead in the creation of the plan. Homerton Hospital is in the process of developing a flag in its IT system, which will enable clinicians across the hospital to be able to quickly identify whether a CMC care plan is in place. Once this has been established, Homerton will consider expanding roll out of CMC to other areas of the Hospital, including A&E. Page 149 of 235 Produced & Designed by Communications Hackney Council September HDS428

150 October 2016 update of the CCG Constitution Presentation to the October 2016 Governing Body FOR DECISION Page 150 of 235

151 Decisions agreed by the Thursday 6 October 2016 Members Forum 1. The Members Forum agreed the new clauses in the Constitution to allow one year extensions to Governing Body (GB) terms of office; 2. The Members Forum agreed to extend the GB Consultant s contract (Christine Blanshard) for one year, now due to end 31/03/2017; 3. The Members Forum agreed to extend the GB Nurse s contract (Siobhan Clarke) for one year, now due to end 31/03/2017; 4. The Members Forum agreed the appointment of a new third Lay Member (Honor Rhodes) to the GB; 5. The Members Forum agreed the appointment of a new Associate Lay Member (Nina Hingorani-Crain) to the GB; 6. The Members Forum agreed the new clauses in the Constitution regarding the reconstitution of the Governing Body; 7. The Members Forum agreed a variety of other changes to the Constitution, comprising edits to internal references and making sure that the language used is consistent through the document. Page 151 of 235

152 Governing Body decisions sought 1. Each of these seven decisions needs to be agreed to by both the Members Forum and Governing Body. Please consider each of the Members Forum decisions on the previous slide and the background information available in this paper. 2. In line with the new clauses in the Constitution allowing one year extensions to Governing Members terms of service, we are now proposing to extend Dr Gary Marlowe for one additional year, so that his contract for service ends on 31 March This is in line with clause If the Governing Body agrees to this proposal, we will take it to the Thursday 3 November 2016 Members Forum for their agreement. 3. If the Governing Body agrees to the changes to the Constitution covered in this paper, the document will be submitted to NHS England for approval. Page 152 of 235

153 ABILITY TO EXTEND GB ROLES BY ONE YEAR We requested Members Forum approval to one year extensions to Governing Body terms of office: 1. We ve added the ability to extend Governing Body members contracts for one year beyond the normal two terms of two years each. This enables us to handle any issues in recruitment and adds some flexibility to deal with changes in the CCGs future and ensures that succession planning can be delivered consistently. 2. Sections of the Constitution and the relevant following sections for each GB role outline how these extensions function. Page 153 of 235

154 EXTENSIONS TO TERMS OF OFFICE We requested Members Forum approval to extend two GB roles for an additional year each: 1. Christine Blanshard has occupied the GB Consultant role since 01/04/2013. She took up a second two year term on 01/04/2015 and her final term is due to end on 31/03/2017. We are seeking to extend this by one year to 31/03/2018 in order to ensure that the GB remains quorate and consistent at this time; 2. Siobhan Clarke has occupied the GB Nurse role since 01/04/2013. She took up a second two year term on 01/04/2015 and her final term is due to end on 31/03/2017. We advertised for a replacement Nurse through NHS Jobs in July to August 2016 and interviewed one candidate in mid August The candidate was not successful and we are now seeking Members Forum approval to extend the existing contract for one year to 31/03/2018 to ensure that the GB remains quorate and consistent while we continue the search. Page 154 of 235

155 APPOINTMENT OF LAY MEMBER We requested Members Forum approval to confirm Honor Rhodes to the new Lay Member position on the GB: 1. The Members Forum agreed the creation of a new third Lay Member in June 2016, following guidance from NHS England (NHSE) that this role should be created; 2. Honor will provide support to the GB on commissioned services and sit on the GB, Audit Committee, Prioritisation and Investment Committee, Local GP Provider Contracts Committee and Remuneration Committee. Should the CCG create a Primary Care Commissioning Committee in the future, Honor will chair this Committee; 3. Recruitment ran through NHS Jobs in July 2016 and the CCG interviewed shortlisted candidates in September Honor has been Associate Lay Member since April Page 155 of 235

156 APPOINTMENT OF ASSOCIATE LAY MEMBER We requested Members Forum approval to appoint Nina Hingorani- Crain as a new Associate Lay Member with finance skills to join the Audit Committee (AC) to replace Catherine McAdam, who is stepping down from the AC: 1. The post was advertised through a variety of sources across Hackney and the City in May 2016, and the CCG interviewed shortlisted candidates in June/July Page 156 of 235

157 RECONSTITUTING THE GOVERNING BODY The process of reconstituting and reforming the GB remains the same as previously discussed with the LMC, Members Forum and consistent with the legal advice we have received; Any reconstitution of the GB would need to take a phased approach to ensure that it stays quorate at all times: A quorum of the GB consists of two GPs, one Lay Member and one Officer (Chief Officer or Chief Financial Officer). A quorum for reaching decisions in matters of conflicts of interest consists of one Lay Member, one Clinician (Consultant or Nurse) and one Officer. See section 3.7 of the Standing Orders. The Constitution and Standing Orders contains measures for the Members Forum to take a vote of no confidence in the GB, or individual members of the GB. See sections 7.6, 7.7.6, in the Constitution; Decisions from the Members Forum are binding on the GB, except in matters where they would represent a conflict of interest. See section 7.6. Page 157 of 235

158 RECONSTITUTING THE GOVERNING BODY In the case of GPs leaving or being removed from the GB, GPs appointed to the CEC would move up to take up those roles. See section of the Standing Orders: This does mean that two votes of no confidence would be required to remove all GPs involved in the governance structure of the CCG once to remove the first 3 GPs on the GB, then again to remove those having moved up from the CEC. Lay Members can be removed under a vote of no confidence and an Associate Lay Member will take on their responsibilities while recruitment is undertaken. Section of the Standing Orders outlines this process. Clinicians can be removed under a vote of no confidence. Since a Clinician is not required for a decision of the GB under it s normal quorum and that the CCG has one Consultant and one Nurse, there are not appropriate measures available to take to ensure consistent succession. Do note that this may mean that if the GB needs to take a decision on a matter of conflicted interests, it will be unable to do so with both Clinician roles unfilled; Officers of the CCG are employed by the CCG and while a vote of no confidence can be undertaken, this will not remove them from the GB automatically. Their contracts of employment take precedence in this case and this is covered in section of the Constitution. The CCGs disciplinary procedure would need to be followed and there is provision made in the Constitution for interim Officers to be appointed in sections and of the Standing Orders. All GB positions are subject to a three month notice period as outlined in the Constitution, Standing Orders and each individuals contracts for service. This period of time can be used for any recruitment needed. Page 158 of 235

159 RECONSTITUTION OF GB For CCG to function, a Governing Body needs at least two GPs, one lay member and one officer If all GPs have resigned from the Governing Body, the remaining GPs from the Clinical Executive Committee become two Governing Body members and agree interim CCG Chair pending a new election process CCG Chief Officer / Chief Financial Officer can transfer responsibility to a CCG member of staff pending formal reappointment to role Lay Member can come from Governing Body Associate Lay Members pending new appointment Page 159 of 235

160 DISPUTES RESOLUTION AND RECONSTITUTION We have clarified the routes and processes available to local GPs and Member Practices to raise concerns regarding CCG Governing Body decisions or actions and documented the process for local GPs and Member Practices to raise a motion of no confidence in a CCG Governing Body Member or the Body as a whole, resulting in its dissolution and reconstitution. 1. Section of the Constitution sets out the dispute resolution process and the powers of CCG members to bring a challenge to the Members Forum. Section 6.5 sets out the role of the Members Forum and section 7.6 states that resolutions of the Members Forum are binding upon the GB. 2. We have discussed these processes with the Local Medical Committee, who are in support; 3. Should any dispute or challenge result in a vote of no confidence in the GB that impacts on the quorum of the body, the key will be speed particularly around new elections and recruitment processes which would be done in conjunction with the Members Forum. Page 160 of 235

161 DISPUTES Discussion of issue with Consortia meeting / representative or other appropriate individual / CCG body, consider question at CCG Governing Body If concerns not resolved, Consortia Representative to call Members Forum for escalation to informal Stage 1 discussion Members Forum invites Governing Body representatives to attend If unresolved after further discussion, formal Stage 2 Disputes Resolution panel with Local Medical Committee and HWB representatives. Appeal to NHSE available at Stage 3 Page 161 of 235

162 OTHER CHANGES Minor tweaks have been made to the Constitution to bring it up to date with regards to the new measures in Conflicts of Interest and to make the document more consistent; A final version of the Constitution for Members Forum approval is available at A version of the Constitution with all track changes and comments marked up is available at With the Members Forum agreement to these seven changes, the Constitution will proceed to NHSE for final approval. Page 162 of 235

163 OTHER CHANGES Minor tweaks have been made to the Constitution to bring it up to date with regards to the new measures in Conflicts of Interest and to make the document more consistent; A final version of the Constitution for Members Forum approval is available at A version of the Constitution with all track changes and comments marked up is available at With the Members Forum agreement to these seven changes, the Constitution will proceed to NHSE for final approval. Page 163 of 235

164 City and Hackney CCG Governing Body Recommendation that the Local GP Provider Contracts Committee is given responsibility for deciding the 2017/19 contractual arrangements for the Homerton NHS Foundation Trust Page 164 of 235

165 Background In previous contracting rounds the CCG has needed to comply with The NHS Procurement, Patient Choice and Competition Regulations 2013 implementing Section 75 of the Health and Social Care Act These regulations: Prohibited the CCG from engaging in anti-competitive behaviour (i.e. awarding contracts without competitive tendering) unless tendering would not be in the interests of patients; Allow commissioners to decide which service to procure and how best to secure the interest of patients on a case by case basis; Allow the CCG to manage potential conflicts of interest using appropriate safeguards; Were enforced by Monitor (now NHSI) so the likelihood of a contract decision being investigated was very low. Under these regulations the CCG Governing Body could make decisions about whether to award contracts to NHS Trusts and, because of potential conflicts of interest, the Local GP Provider Contracts Committee could make decisions about awarding contracts to GP Provider organisations. Page 165 of 235

166 Additional Regulations For this years contracting round the CCG must also comply with the Public Contracts Regulations These additional new regulations: Have removed the Part B tendering exemption for Health Services; Set a minimum threshold of 750,000 for advertising contracts at an EU level; Do not recognise when not tendering a service may be in the best interests of patients; Require commissioners to ensure all contract awards are transparent and that all potential provider have equal treatment; Require commissioners to ensure all contract award decisions have no potential conflicts of interest managing or declaring possible interests is not satisfactory; All potential providers to challenge CCG procurement decisions through the High Court. Potential providers will be able to challenge CCG contract award decisions using both the new and old regulations in this contracting round. Page 166 of 235

167 Key Risks In accordance with NHS England guidance, The CCG must award Community and Acute Contracts for at least 2 years, April 2017 to March 2019 Tower Hamlets, Newham and Waltham Forest CCGs either planning to tender or have retendered CHS contracts The new regulations were only effective from 18 th April 2016 In 2017 to 2019 the CCG would like to progress the Devolution and Crisis Care Services The greater the contract value and duration the more likely it is that the CCG will be challenged by an external provider. The cost of a legal challenge is justified by the prospect of winning a large contract. There are more providers in the market who are capable of providing CHS service than Acute services AND they may be expecting City and Hackney to follow suit. This is the first year that the new regulations apply and there is a lack of case law to know how the CCG can definitely avoid a legal challenge. A legal challenge would be very expensive and embarrassing for the CCG. The CCG needs to work with Providers who understand and have experience of local healthcare services, future services should be more integrated. Removing the Homerton as the CHS or Acute provider will fragment services and could destabilise the provider. Page 167 of 235

168 What the implications of the new Regulations? Under the new regulations the default position is that the CCG should retender Community and Acute Contracts before they can be awarded because they are above the financial threshold; If the CCG wants to award these Contracts without tendering it must go through a process which: Is TRANSPARENT The decision is made in the pubic domain, it is documented and considers all of the important requirements of both sets of regulations. The main function of the LGPPCC is to consider multiple factors and make decisions about the appropriateness of awarding contracts to GP providers without tendering this process can be adapted to consider the award of contracts to the Homerton in The LGPPCC meets in public and its members have no declared conflicts of interest in City or Hackney health services. Ensures EQUAL TREATMENT of all potential providers The CCG can publish a Prior Information Notice* at an EU level before contract award. Expressions of interested can be considered by the Contracts Committee. Page 168 of 235 * A Prior Information Notice is a procurement device recognised by the Public Contracts Regulations

169 The Recommendation The CCG governing body is asked to endorse a recommendation that the Local GP Provider Contracts Committee is given responsibility for deciding the 2017/19 contractual arrangements for the Homerton NHS Foundation Trust. The new regulations present a new set of challenges for the CCG which, because of the compressed timescales of the contracting round, need to be dealt with promptly; Although the CCG GB has previously held responsibility for approving the award of Contracts to the local Provider the LGPPCC has been set up as a CCG committee that does not have conflicts of interest and is therefore better prepared to consider a complex procurement decision and document the reasons for that decision in a way that can be used to defend the CCG when the decision is challenged; All decisions will be reported back at the CCG GB to provide full transparency; The CCGs procurement strategy will need to be revised to address issues raised by the new regulations Beachcrofts are providing legal advice on this matter. Page 169 of 235

170 MEETING PAPER COVER SHEET Meeting Title City and Hackney CCG Governing Body Meeting Meeting Date Friday 28 October 2016 Paper Title Annual PPI report Paper Number Paper Author PPI Team / Eeva Huoviala Lead Director Siobhan Harper FOI status Available under FOI Paper Summary (Provide relevant background to the paper) Purpose (tick one only) Annual PPI report which details how the CCG is meeting its legislative duties around patient and public involvement. For information ahead of submission to NHS England Recommendation (state what you are asking the committee/governing body to do; i.e. support a proposal, provide feedback, note the paper, etc. List all that's applicable) Where was this paper previously discussed? What was the outcome? The Committee/Governing Body is hereby asked to: Support the attached report PPI Team PPI Committee (Healthwatch Hackney and Healthwatch City of London to provide statements which will be added and included w/c 31 Oct) Content submitted by PPI representatives Content agreed with PPI team Page 170 of 235 Chair: Dr Clare Highton Chief Officer: Paul Haigh

171 NHS City and Hackney Clinical Commissioning Group Patient and Public Involvement Annual Report 2015/16 Name CCG: NHS City and Hackney CCG Name person completed this report: Eeva Huoviala Internal sign off obtained from: City and Hackney CCG Governing Board Healthwatch statement completed by: Healthwatch Hackney and Healthwatch City of London Date submitted to NHS England: 04/11/ Setting the context The population of City and Hackney Demographic data shows that the population of City and Hackney continues to grow. This is particularly the case for the working age population and the over 65 s, a group expected to grow fastest in the next 25 years. Fertility rates continue to decline, while life expectancy continues to rise. According to 2012 Census, the population of Hackney is 252,119 whilst the neighbouring City of London Corporation has 7,604 full time residents, although hundreds of thousands commute to and from the area daily (City and Hackney JSNA, 2014 update). The population in City and Hackney continues to grow and both international and UK migration are up. The population of Hackney is characterised by a diverse mix of ethnicities and cultures as well as over 100 spoken languages. 39% of the people in Hackney are born outside UK and two thirds of the population come from non-white ethnic backgrounds. Hackney also has the largest Charedi Orthodox-Jewish community outside New York and Israel, significant Turkish and Kurdish speaking communities, as well as Caribbean, Vietnamese, Chinese, African and Eastern European populations. City of London Corporation attracts people from outside the UK with US, Australian and Western European residents well represented in the area. In terms of ethnicity, City population is largely white (78.6 %) with Asian population representing 12.7% (City and Hackney JSNA, 2014 update). The health and wellbeing of the population in City and Hackney, as well as the common health issues and risk factors in the area reflect the diverse population as well as socioeconomic factors, including deprivation, age, gender and ethnicity. The 2010 Index for Page 171 of 235

172 Multiple Deprivation placed Hackney as the second most deprived borough in the country after Liverpool (City and Hackney JSNA 2012, updated in 2014). It is worth noting though, that significant differences exist between different areas within Hackney and prosperity and deprivation live closely together and impact of gentrification in Hackney is clearly visible in parts of the borough. Full City and Hackney Health and Wellbeing Profile which is now updated on rolling basis, is available here. Our vision for engagement We are responsible for making arrangements to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements. We do this by involving local patients and members of public in our decision making processes from planning and procurement through to evaluating the effectiveness of services and by ensuring that the providers we work with also measure and act on patient feedback. The two-fold PPI duty states, that as well as ensuring collective involvement throughout the commissioning cycle, all CCGs must take steps to ensure that the services they commission enable patients to look after themselves, make choices about the care and treatment they receive, self-manage their conditions and take personal responsibility for their health and wellbeing where possible. During 2015/16 work has been taking place to ensure that patient information is accessible and easy to understand, that information and support around Personal Health Budgets is available to those who are eligible for them and that selfmanagement and patient activation feature across all our Programme Boards. It is our aim to reflect the diverse populations and their needs in the way that services are commissioned. Over the recent years we have focused on ensuring that the appropriate involvement structures are in place, enabling us to inform, involve and consult with people. We are committed to working for, and with, the local public and patients, and are proud of the relationships and trust we have built in the community. We believe that working in partnership with members of public as well as the local government, voluntary organisations and the wider community is the way to achieve best outcomes for residents. Both City and Hackney have vibrant community and voluntary sectors and their role in our involvement structures cannot be emphasised enough. We recognise that having involvement structures in place alone is not enough. We want to make involvement opportunities relevant, meaningful and accessible. In particular, we want to continue to make sure that the voices of vulnerable and hard to reach and seldom heard groups are represented, noted and responded to. Our Engagement Strategy will be reviewed and updated during autumn 2016 to ensure that it reflects the above. Page 172 of 235

173 Patient and Public Involvement Structures and Resources Patient and Public Involvement Team The Patient and Public Involvement (PPI) team consists of a Lay PPI Chair, 2x PPI Clinical Leads, PPI Programme Board Director and Engagement Manager. The team works closely with internal and external communications departments as well as the CCG s membership engagement colleagues. The PPI Lay Chair tenure is for two years at a time and the sessional commitment for the role is five meetings per month, representing one for the CCG Governing Body and one for the Clinical Executive, as well as the Prioritisation and Investment Committee, Audit Committee and PPI Committee. In addition to the non-pay budget allocated for PPI, we also have a contract with London Borough of Hackney for PPI related communications. PPI Team works across all nine CCG Programme Boards, each responsible for commissioning for specific service area. This includes providing strategic and clinical input, ensuring that involvement is embedded in all CCG processes and that CCG s involvement structures have regular input into decision making. Our remit also covers supporting patient and service user representatives and overseeing a number of targeted involvement projects. In 2016/17 one the areas we will be focussing on is making patient information accessible and available at relevant throughout patient pathways. Recruitment is on-going for a Clinical Pathway Co-ordinator and Patient Information Co-ordinator, who will work closely with the PPI team in making sure that information about and within patient pathways is easy to understand and has links to local support services. The non-pay budget allocated for PPI in 2015/16 is 181,000. Programme Board Representatives NHS City and Hackney CCG consists of nine Programme Boards, each responsible for commissioning a specific service area Long Term Conditions Primary Care Quality Planned Care Maternity Children Mental Health Medicines Management and Prescribing Urgent Care Integrated Care Page 173 of 235

174 Each Programme Board works with patients and service user representatives who are recruited from the local communities and who play an important role in helping to ensure that services are Communicating with patients in an accessible and effective way Involving service users in service delivery and decision making Providing sufficient information to allow informed decision making at all times, Providing good quality care Patient and service user representatives attend Programme Board meetings, raise issues important to local residents about healthcare services and maintain links with other user groups, current and recent users to ensure their views are heard on the Programme Board. It is their role to comment on issues from a broader user perspective providing an impartial and independent view and engage with wider CCG activities such as events and public meetings to capture issues relevant to and affecting the Programme Board. Patient and Public Involvement Committee All Programme Board representatives come together as the CCG s PPI Committee which has a Lay Chair and representation also from GP practice based patient participation groups, community and voluntary sector groups, local Healthwatch branches and statutory partners. PPI Committee is a formal sub-committee of the CCG s Governing Body and it plays an important role in ensuring that all CCG decisions are informed by patient voice. NHS Community Voice NHS Community Voice is a patient led involvement forum, funded by the CCG and facilitated and co-ordinated by Healthwatch Hackney. The service delivers monthly open meetings on a number of health issues identified by local patients and residents and the feedback from these meetings is shared with relevant bodies who are asked to respond accordingly. NHS Community Voice also acts as a link between the CCG and the GP practice based patient participation groups, gathering feedback, passing on information and signposting people to them. Patient and Public Involvement into Hackney Devolution Pilot PPI groups are kept involved in and informed about the progress of the Hackney Devolution Pilot. There is a commitment to ensure that alongside our clinicians and practitioners, our citizens are at the centre of service redesign and decision making. A Devolution Engagement and Communications work stream has been set up to take forward this work and each of the devolution workstreams now have a patient/service user representative within them. Useful links: Information about NHS Community Voice and the NHS Community Voice 2015 Report can be viewed here. Information about Patient and Public Involvement at City and Hackney CCG is available here. Page 174 of 235

175 City and Hackney CCG Patient and Public Involvement Structures Events, Consultations, Community and Voluntary Sector Groups, GP Practice based Patient Participation Groups NHS Community Voice, Older People's Reference Group, Health and Social Care Forum, Hackney Refugee Forum, Healthwatch Programme Board Representatives PPI Committee Page 175 of 235

176 2. Developing the Infrastructure for Engagement and Participation Six principles for involvement Delivering the Forward View: NHS planning guidance 2016/ /21 identifies prevention, patient activation, choice, control and community engagement as key enablers for addressing the national challenges around 1) closing the health and wellbeing gap, 2)closing the quality gap and 3) achieving financial balance. Achieving these aims requires working in partnership with patients and the wider community in a range of different ways which are reflected in The six principles of engagement and involvement designed to support CCGs with their plans for the next five years. Our PPI activities are aligned to these principles and the examples included in this report reflect how these principles have been embedded in our work. Care and support is person centred: personalised and empowering Services which are created in partnership with citizens and communities Focus is on equality and narrowing health inequalities Carers are identified, supported and involved Voluntary, community, social enterprise and housing sectors as key partne and enablers Volunteering and social action are recognised as key enablers. Processes for involvement We want people to feel that they are being listened to, and that their views are making a valuable contribution in setting health priorities for City and Hackney. To achieve this we have tried to make a wide range of options available for people who would like to have their say and help shape local health services. People can Take part in local and national consultations We ensure that information of all local and national consultations is circulated to our PPI representatives and where relevant to the CCG, discussed at the PPI Committee. Become Programme Board Representatives Local patients and residents with an interest in particular services or with lived in experience of specific conditions can apply to become PPI representatives for one of our nine Programme Boards. Page 176 of 235

177 Attend meetings such as those organised by their GP practice patient participation group, NHS Community Voice and the CCG s PPI Committee We facilitate a number of regular meetings, through which people can have their say on NHS services. Attend events We host regular public events aimed at discussing local services, commissioning intentions, future plans, service changes and more. In 2015/16 these included monthly patient led NHS Community Voice events to discuss health, wellbeing and health services, City and Hackney CCG Annual General Meeting (July 2015), Self-Care event (November 2015) and our Commissioning Intentions Events which were delivered in partnership with London Borough of Hackney (January 2015) and City of London Corporation (February 2016). Provide feedback about services and where applicable make a complaint We recognise that making a complaint is one way that helps organisations to learn lessons from their mistakes and prevent them from happening to anyone else. We welcome all feedback and can signpost and provide guidance to people wishing to make a complaint. Apply for grant funding City and Hackney CCG Innovation Fund has been running since 2014, providing an opportunity for local grassroots groups and organisations as well as individuals able to demonstrate sufficient skills and knowledge, with an opportunity to access grant funding to deliver and test out new and different ways of meeting local health needs. Visit our website and subscribe to the PPI newsletter To keep up to date with involvement opportunities and access information and useful resources, we encourage people to visit the Get Involved section of the CCG s website and subscribe to Checking the Pulse a quarterly PPI Newsletter which goes out to all local GP practices and our involvement networks. Views of patients and public are also represented by o Lay PPI Chair who represents the patient voice at the CCG Governing Body, Clinical Executive Committee and Scrutiny Committee, as well as the Investment and Prioritisation Committee. o GP clinical leads who provide clinical overview and represent the patient voice at the Clinical Executive Committee. o Healthwatch Hackney and Healthwatch City of London who are in attendance at the Governing Body s meetings, Contracts Committee meetings and Prioritisation and Investment Committee. Page 177 of 235

178 Partnership working Providers and statutory partners We work in partnership with our providers, including Homerton University Hospital, Bart s Health NHS Trust, East London Foundation Trust, GP Confederation, multidisciplinary teams and others. We regularly invite the patient experience teams from these providers to attend PPI meetings and to provide updates on their work. 2015/16 and the increasing focus on integrated services and the new Hackney Devolution Pilot means that we have continued to work closely and in partnership with local statutory bodies including London Borough of Hackney and City of London Corporation and their Public Health teams, as well as with Healthwatch Hackney and Healthwatch City of London. Through the North East London wide Sustainable Transformation Plan we are now also collaborate with the surrounding CCGs in Tower Hamlets, Waltham Forest, Newham, Redbridge, Havering and Barking. Community and Voluntary Sector Groups The various community and voluntary sector organisations in City and Hackney are important partners to us. Working together with a number of local grass roots groups enables us to reach out and engage with groups considered vulnerable and hard to reach, including BAMER groups, those with long term conditions or mental health problems and older people, as well as children and young people, people with disabilities, those caring for others and many more. Community and voluntary sector are also key partners in various CCG work streams and alliance service models, including work around Patient and Public Involvement, Early Years Strategy, Mental Health Alliance, Better Care Fund/Integrated Care and Hackney Devolution Pilot. Our Maternity Programme Board are looking into the possibility of Maternity Alliance or similar, that would bring together community and voluntary sector services working with mothers and Prescribing and Medicines Management Programme Board are working closely with the community and voluntary sector to ensure that community pharmacists have information and can signpost to local services. We have facilitated funding opportunities such as the City and Hackney Innovation Fund through which a number of grant agreements have been established with local community and voluntary sector groups. These funds have also acted as an opportunity for developing the market and making funding opportunities more equal for community and voluntary sector. You can read more about the latest round of the fund under section 4. In 2015/16 the PPI Team has worked together with the following community and voluntary sector groups: City and Hackney Older People s Reference Group, Hackney Refugee Forum, Page 178 of 235

179 Health and Social Care Forum, Hackney Carers, POhWER (advocacy service for people with learning disabilities), Hackney Community Empowerment Networks and more. Page 179 of 235

180 Programme Board Representatives "We represent patient voice" - Maternity Services Liaison Committe - Children's Disability Forum - Integrated Care Patient aand Service User Group - Long Term Conditions representatives - Urgent Care representatives - Ad hoc involvement into Planned Care, Mental Health, Prescribing and Primary Care Quality PPI Committee "This is where debates happen" Supported by the PPI Team, the Committee meets once a month todiscuss topics relevant to the CCG and the services it commissions, as well as local and wider NHS issues, consultations and other engagement. Involved throughout the commissioning cycle including evaluation, service design /re-design, consultations, commissioning plans and procurement. NHS Community Voice "Meetings on issues that matter to you" NHS Community Voice is a patient led project. Open monthly meetings take place at venues across City and Hackney and bring together patients from all GP practices in City and Hackney to discuss the things that matter to them about health. Each meeting is focused on a topic chosen by patients, and the feedback from discussions will help improve local health services. Older People's Reference Group "Collective Voice for Older People" The City & Hackney Older People s Reference Group (OPRG) has for 16 years been giving older people the chance to speak up for themselves on issues that affect them and on the design and delivery of services. Hosted by Age UK East London, the Group holds regular big open meetings on services for older people present and future, a high profile annual event, periodic focus groups on particular areas of concern and is represented on numerous external bodies. Health and Social Care Forum &Hackney Refugee Forum "We represent the health community and voluntary sector health and care providers" "We bring together the voice of local refugee and migrant groups." Hackney Refugee Forum is an umbrella organization that brings refugee and migrant s organisations (RMO) together to work,campaign and raise awareness about health, social care, and employment, education and welfare issues. Page 180 of 235

181 3. Involving local communities in commissioning: meeting the collective duty Since April 2012, we have worked on embedding patient and public involvement into our commissioning processes. This happens through one or more of the CCG s Patient and Public Involvement structures, including PPI Committee, Programme Board Representatives and NHS Community Voice. Included below are a number of examples demonstrating how we ve worked with patients, service users and the wider community during April March Targeted Community Involvement Projects Targeted community involvement projects are an important part of our engagement strategy. We place great value on working closely with community and voluntary sector groups, thus building on existing assets, knowledge and relationships. This enables us to hear from a wider range of people, including those often considered heard to reach, and ensure that their voice informs our decisions. We are pleased to be funding the following projects and have asked them to describe in their own words, the work they do and their thoughts on how it supports a stronger, collective involvement. NHS Community Voice (January 2015 on-going) Objective To make involvement opportunities available to everyone in the community with particular focus on vulnerable and seldom heard communities. To deliver a patient led involvement forum. To raise awareness of and signpost people to GP practice based participation groups. Activity Who was involved How were participants recruited and what were their roles and responsibilities Monthly forum meetings take place across City and Hackney on topics identified by patients. Meetings are open to everyone and no booking is required. This services is funded by City and Hackney CCG and delivered by Healthwatch Hackney in partnership with Age UK East London. Patient led steering group supports meeting planning. Healthwatch Hackney and Age UK East London were given a grant agreement following a procurement process in Patient representatives took part in reviewing and scoring applications. NHS Community Voice patient led steering group representatives come from the six consortia that City and Hackney are divided to. Page 181 of 235

182 They are members of their local patient participation groups. Outputs, Impact &Outcome Monthly meetings where issues important to patients and members of public take place across City and Hackney. Health professionals, speakers from provider organisations and commissioning bodies are invited to attend. Recommendations from meetings are noted and shared with relevant organisations who are asked to respond accordingly. In 2015/16 11 meetings were delivered on 11 different topics 410 people attended 54% of attendees were from BME groups 27% have English as a second language 37% reported having a disability 82% of people who attended reported feeling better informed about health services and how to influence them 82% felt better informed about patient and public involvement 62% said they felt better informed about self-management. Co-ordinating a community based involvement forum (by Sulekha Hassan, Co-ordinator for NHS Community Voice, Hackney Healthwatch) NHS Community Voice is a patient led forum commissioned by City and Hackney Clinical Commissioning Group (CCG). Healthwatch Hackney delivers the project in partnership with Age UK East London. The forum aims to help the CCG engage more widely with the diverse communities in City and Hackney to help inform the planning and commissioning of health services in line with identified health priorities. The first step two years ago was to establish a steering group of local patient representatives drawn from local Patient Participation Groups across City and Hackney. Our patient representatives volunteer their time, knowledge and skills, to ensure NHS Community Voice gives local people a real opportunity to influence local health services. Steering group member Shirley Murgraff told us: Page 182 of 235

183 Since even before Community Health Council days (the 1970s) I ve been convinced of the importance of the voice of patients and public being not only heard on the provision and quality of health and social services, but also involved in decision-making about them. I thought NHS Community Voice was a great idea, and Healthwatch Hackney has implemented it splendidly to increase significantly those possibilities: they have increased both public awareness of the issues and the number of people willing and able to express their views on them. In we delivered 11 NHS Community voice meetings on a range of health issues including the menopause, sickle cell and thalassemia, end of life care and Education, Health and Care plans for disabled children. Our meetings attracted a total of 410 people across City and Hackney. o 82% of people who attended reported feeling better informed about health services and how to influence them o 82% felt better informed about patient and public involvement o 62% said they felt better informed about self-management. Each meeting generates feedback including recommendations from patients and service users. We send the feedback to the relevant CCG programme boards, service providers and other partner agencies for a response. Feedback from attendees tells us that patient engagement and involvement in City and Hackney is important and valued, as one resident told us at an extremely well attended NHS Community Voice meeting on the menopause: It was really helpful to hear the menopause being considered seriously and the number of people attending showed the huge interest in improving services within the area. We are very grateful to local commissioners and service providers who have actively engaged in our public meetings and events, providing speakers and listening to patients voices. Patients and service users greatly appreciate this involvement. NHS Community Voice is also committed to ensuring City and Hackney residents unlikely to attend monthly forum meetings can also have a voice. With this in mind our future meetings include targeted sessions with homeless people, refugee and migrant communities and disabled people in the borough. Page 183 of 235

184 Health and Social Care Forum and Hackney Refugee Forum (April 2015 on-going) Objective To act as an involvement link between the CCG and the community and voluntary sector groups delivering health and wellbeing services. To bring together refugee and migrant s organisations to work and campaign and raise awareness about health, social care, employment, education and welfare issues. Activity Health and Social Care Forum and Hackney Refugee Forum representation at the monthly PPI committee meetings and ongoing input into involvement work. Attending CCG events such as the annual Commissioning Intentions Event, Annual General Meeting and other such meetings, and encouraging participation from own networks. Organising and facilitating x4 focus groups annually to engage with and seek the views of the migrant and refugee communities in City and Hackney and share feedback and comments with the CCG. Raising awareness of NHS Community Voice and encouraging participation in the NHS Community Voice meetings across migrant and refugee communities in City and Hackney. Raising awareness of the practice based Patient Participation Groups and building links between them and the community and voluntary sector health and social care providers. Promoting and encouraging partnership working between the CCG and community & voluntary sector organisations. Who was involved Health and Social Care Forum Hackney Refugee Forum CCG s Patient and Public Involvement team CCG s Planned Care Programme Board CCG s Mental Health Programme Board Community and Voluntary sector organisations working with migrant and refugee communities and delivering health and care Page 184 of 235

185 services. How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Health and Social Care Forum and Hackney Refugee Forum work with a number of local grass roots organisations. Representation at monthly PPI meetings, feeding back to members and contributing to discussions to ensure the needs of VCS and Refugees and Migrants are taken account. Attending and actively promoting CCG events and NHS Community Voices Events through our weekly e newsletter that goes to 450 individuals (the majority of whom who work with local Voluntary & Community Sector organisations) and contains local events, policy, funding and jobs. Input into the Devolution Pilot planning Input into the Bi-lingual advocacy service review Representing the refugee and migrant population in Hackney (by Ali Aksoy, Director of Hackney Refugee Forum) I am the director of Hackney Refugee Forum (HRF), which is an umbrella organization that brings refugee and migrant s organisations (RMO) together to work and campaign, raising awareness about our health, social care, and employment, education and welfare issues. We also work together with the local council and other service providers by organizing steering groups according to topics and activities. I also work for Healthwatch Hackney as their Volunteers, Outreach and Signposting Manager. My tasks include organising sessions to collect comments and feedback from people, on health and social care services in Hackney. I also represent refugee and migrant organisations (42 of them from various communities) and help them access resources that enable them to better serve their disadvantaged users and members. For almost for 2 years now, we have been better involved with the CCG by attending their specific meetings, including the monthly Patient and Public Involvement Committee. This gives us an opportunity to voice our communities health and social care issues which include things like access to information and services, mental health problems, advocacy and interpreting needs. Firstly we have secured a very useful grant from CCG for six of our refugee organisations to help them signpost better, and provide basic advocacy services for their users who need to access health and social care services in Hackney. Hundreds of more people from refugee and migrant communities have been accessing the services which they weren t aware of before. We have also found opportunities to raise awareness of our communities mental health and Page 185 of 235

186 advocacy support needs, especially by regularly attending PPI meetings. We also have organized speak up meetings on mental health together with Healthwatch and refugee groups on mental health needs. Now we will come together with reps from CCG in a planning meeting to discuss on ways of research and investigate on how can we better hear those vulnerable people voices and suggestions to solve above crucial problems together. We also have received a small grant from CCG supporting HRF to better help organisations and leading individuals from RMO to improve their knowledge, capacity and skills by organizing trainings (First Aid, Volunteer Management, mental health at work etc.) and visits to certain health services (Homerton Hospital, H Recovery Service ) I am happy to say that our recent involvement and getting support from the CCG helped us to better reach and serve our refugee and migrant groups improve their knowledge and helped change their mind and encouraged them reaching health and social care services much better than before. Working with the Huddleston Centre to develop involvement mechanisms for children and young people (April 2015 on-going) We have commissioned the Huddleston Centre to facilitate engagement and consultation with both young people with disabilities, and their parents and carers. The Huddleston have been effective at establishing their parents/ carer steering group, open coffee mornings, themed condition / pathway meetings, and promoting the forum to existing community and engagement groups in Hackney and the City. The purpose of this group is to be a space where parents of newly diagnosed children can come and meet other parents (emphasis was placed upon peer support and the importance of combatting the huge isolation felt by parents immediately after diagnosis). We also wanted the group to act as an involvement forum increasing the number of children, young people and their carers who are involved in service development and delivery. Objective Give families a stronger voice in improving services Empower young people and their families in communicating with healthcare professionals. Support commissioners in developing services based on the needs of individual patients and groups of patients. Provide a qualitative perspective in the monitoring and evaluation of services. Ensure that the views of children, young people and their families in City and Hackney are placed at the heart of healthcare services and practice. Page 186 of 235

187 Support the development of a work plan that will contribute to improving service quality and increasing patient involvement. Activity Regular coffee mornings with focus on a relevant health topic are taking place monthly. Professionals attend these meetings to give advice and share expertise. The group has provided feedback on a number of issues including needs around access to information, support for families with children with ADHD, autism or epilepsy as well as support for siblings. Who was involved How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome City and Hackney CCG Children s Programme Board The Huddleston Centre Local children and young people with disabilities, their families and carers A procurement process took place to identify the service provider for the forum. Huddleston Centre is a short breaks provider for children and young people in City and Hackney and they have been able to identify participants through their existing networks and contacts. Events and meetings have been advertised online as well as via local papers. Feedback gathered from the group has resulted in Children s Programme Board seeking o o o ADHD specific information sought from the CAMHS Pharmacist at The East London Foundation Trust (ELFT) and shared with the forum members, in addition to alternative information sources The Young Person s Carer pathway and support information, developed by the GP Confederation as part of the 2015/16 Vulnerable Children s Contract has been shared with the CDF Agreeing a regular schedule of CCG updates to the forum detailing how recommendations and feedback will be addressed. Children s Programme Board will also evidence the forum s influence via: o o o The agreement of new Community Paediatrics and Hackney Ark specifications, following joint service reviews with the Homerton Formalisation and publication of clinical pathways for the Hackney and City Local Offer websites Contribution to the CAMHS Alliance 2016/17 priority work Page 187 of 235

188 streams including parenting support Additionally, we also hope to be able to reducing A&E admissions through better understanding of a condition: more understanding of how to deal with daily situations as they arise and to recognise an emergency and when it IS necessary to seek medical intervention. We hope that parents will be sharing information around safeguarding children in the public arena/mainstream schools/youth clubs. I think that every borough should have an autism GP surgery with static GPs and Nurses and an ASD dentist (Forum member) Overall I think preventative treatment is important and the key to accessing health related stuff, so education, training, ASD friendly environments. websites that ASD people can go to so they can look at where they will need to visit before they get there - so like a virtual tour, with pictures of staff, all this can help to reduce anxieties. ASD friendly video of procedures (not too graphic though like on you tube) (Forum member) Hackney Village 2016 Event (by Anjie Mailey, Coordinator, Children s Disability Forum, The Huddleston Centre) The Hackney Village project has been partly funded by City and Hackney CCG. The aim of this project is to give voice and visibility to disabled young people within City and Hackney. Allowing a safe space where young people can discuss their disability and any other health related topics they would like to talk about. Back in March 2016, I was given the contact details for staff at The Hackney Empire. Excited by this I went ahead and arranged a meeting. The possibilities in my head were endless and I knew immediately I wanted to do a BIG event for children living with disabilities in City and Hackney. Encouraged by staff at The Empire, and with the full backing of the creative staff, we set up Hackney Village 2016, a week of activities including arts and crafts, dance, music, drama, poetry and much more. Health and wellbeing were weaved into all activities. The detailed report is available here. Page 188 of 235

189 City and Hackney Older People s Reference Group (2014 on-going) Objective To promote the consultation and engagement of older people in City & Hackney in the design and delivery of services intended for them. To foster independence, health and wellbeing amongst older people. Activity o To facilitate Advisory Group meetings o Facilitate 4 open meetings for all Reference Group members o Monitor the implementation of the Dignity Code o To organise, manage and publicise the Annual Event for Older People o Administer and develop individual 'Reader Group' members and provide 'Reader Group' support to health and social care colleagues when requested o Maintain on-going database of members o o o o Develop and promote OPRG inter-active website To arrange service specific focus groups and support survey administration if requested by particular services to assist feedback from their users. To facilitate the involvement of OPRG members and other older people in the statutory partner agency tendering processes. To facilitate the involvement of OPRG members and other older people in the consultation programmes of the statutory partner agencies. Who was involved How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome City and Hackney CCG PPI Team City and Hackney Older People s Reference Group Age UK East London Residents of City and Hackney Participants were recruited through the existing membership of OPRG and Age UK East London who co-ordinate this service. Attendance at CCG PPI Committee Regular monitoring meetings where feedback and current issues are discussed. Home Sweet Home (April 2015) Questions about Dementia (July 2015) Annual OPRG event (October 2015) Five to Thrive (January 2016) Housing (March 2016) As a result of these activities, the voices of older people are now regularly represented across the CCG s involvement groups and OPRG has become a group that our Programme Boards regularly Page 189 of 235

190 speak to for advice, comments and to help them reach out to the communities. Giving older people a collective voice (by David Holland, Co-ordinator of City and Hackney Older People s Reference Group) It is not just because services are better designed if their users have a say in their design that older people need to have a collective voice. If ageist ideas and attitudes that treat older people as less than fully human are not constantly challenged, then older people s dignity and proper treatment can suffer. The City & Hackney Older People s Reference Group (OPRG) has for 16 years been giving older people the chance to speak up for themselves on issues that affect them and on the design and delivery of services. Hosted by Age UK East London, the Group holds regular big open meetings on services for older people present and future, a high profile annual event, periodic focus groups on particular areas of concern and is represented on numerous external bodies. The Group is led by an Advisory Committee made up entirely of local older people. In the year , in April we held a meeting, Home Sweet Home, on community based services, including the Chair of the local Pharmacy Committee and senior figures from community mental health services. Before the 2015 General Election we held an intergenerational meeting in which older people met a group of younger people to compare notes on their views and experiences of elections. In July we had a meeting on Questions About Dementia with representatives from the Alzheimer s Society, the Homerton Hospital and the East London Foundation Trust. Our October Annual Event was held in Clapton School for Girls and was introduced by the Chair of the Safeguarding Board and the Chair of the Clinical Commissioning Group s Patient and Public Involvement Committee, with workshops on including deaf people, convalescing at home, patient voice forums and integrated care. In January we called members together to discuss Five to Thrive, measures to improve mental health and wellbeing. In March our topic was Housing Options for Older People, introduced by the then cabinet member for housing, Cllr Philip Glanville, now Mayor of Hackney, together with other housing providers. Amongst the external bodies on which OPRG representatives serve are the Connect Hackney Steering Committee, Hackney Council s Adult Social Care Framework Group; the Safeguarding Board; the Patient & User Engagement Group for One Hackney, the Homerton Hospital Patient Engagement Group, the Integrated Independence Team Board and the National Pensioners Convention. Page 190 of 235

191 Partnership working with local community and voluntary sector groups Interlink Serving the needs of the Orthodox Jewish population in London and beyond (bv Sarah Weiss, representative of Interlink and Chair of City and Hackney CCG s Maternity Services Liaison Committee) Interlink has been around for well over 20 years serving the growing needs of the orthodox Jewish (Charedi) population in London and beyond. We have helped develop the capacity of voluntary groups, filtered and disseminated information to organisations and individuals, bridged the gap between mainstream providers and the local community through strategy groups, cultural training and other fora, as well as responding to the multiple calls for community insight, research and information both ways. Part of this work involves regular attendance at groups such as the City & Hackney Clinical Commissioning Group Patient and Public Involvement meetings. Here we share community intelligence regarding access and uptake of local health and social care services, challenges and trends with commissioners and also have opportunities for feeding into consultations and influencing commissioning intentions to make services more widely accessible. Interlink has facilitated a Maternity Services Group meeting since 2006 bringing together Charedi voluntary groups operating in Maternity, statutory commissioners and providers which has a formal reporting structure into the sector. This group meets regularly to discuss issues and trends as well as raising any concerns. Models of good practice have been shared and joint learning and solutions have been taken forward. Using this role, I became interested in the work of the Maternity Services Liaison Committee and joined the parent representatives group in the 2012 recruitment drive, subsequently becoming its joint chair. I attend the PPI meetings as the health lead for Interlink and the C&H CCG s joint lay rep for maternity and experience first-hand the genuine desire for the CCG to involve and listen to the voice of patients and the local community. They have invested resources to ensure that there is meaningful interface with individual programme boards and representatives who come from all walks of life and bring with them a wealth of experience in paid and voluntary work and patient interaction. This representation is crucial in keeping providers and commissioners in touch with local intelligence and hard to reach groups. Some of the feedback is difficult yet this has not deterred the CCG who will unpick and seek to find solutions. It can however also be difficult for communities and patient groups who identify challenges but cannot be helped because the CCG will require hard evidence. This will drive organisations and groups to formalise and collect data and do other work before they can access any level of support. I was very closely involved in a project which was funded through the Non-Recurrent Funding Programme. It was a grant awarded to Homerton University Hospital s Health Visiting team to fund Page 191 of 235

192 volunteers to engage with Charedi mothers and improve the uptake of the Healthy Child Programme, identified as having a lower uptake than in the rest of Hackney. Interlink was involved very early on, utilising community links and intelligence, to develop a delivery plan and model that would work and achieve the desired outcome. The Mothers Health Support Project was a successful partnership between eight organisations. The project was funded by the C & H CCG and also in part by Public Health (London Borough Hackney), led by Homerton University Hospital Community Services through the Health Visiting Team, supported and incubated by Interlink, coordinated by JuMP (Jewish Maternity Programme), assisted by HJMT (Hansy Josovic Maternity Trust) and Beis Brucha (Mother and Baby Home) and hosted by Tyssen Childrens Centre. Mothers health supporters were trained, went out into the community and beyond, talking to mothers at GP clinics, drop-ins in Childrens Centres, contacted them on the telephone and logged all efforts in a bid to improve the engagement and uptake of Child Developmental Health Reviews and sharing public health messages. Whilst the pilot scheme operated only from October 15 to March 16, the impact was very significant. There was a marked increase in developmental health reviews and immunisations and there were almost 1,600 contacts. The education and reach elements of the pilot went way beyond expectations and this plus an extensive list of issues and recommendations have been captured in a report which has been shared with all stakeholders and will be used to inform future provision. Due to the timing of the project, it was unable to be considered for the next round of Non-Recurrent Funding projects, which was disappointing, although there was talk of recommissioning possibly from other sources. There does sometimes seem to be a local intelligence and cultural gap on working groups considering programme directions, applications, etc.and given the time and budgetary constraints, this may not always be helpful. Maternity input has been challenging at times, but has also seen the patient voice being listened to, service adaptations made and through a series of meetings including young mothers and others; the service user s voice goes all the way up to Maternity Programme Board. It is also a place where a lot of information, audits and reports are shared and there is opportunity to share relevant information which is in the public domain for patients to be better informed and to get the true picture instead of sensationalising media items. Championing patient issues across communities and raising concerns where these are valid, leads to exploring solutions at strategic level and helps to improve the patient experience for all of City and Hackney residents. Whilst this role has its challenges, being at the heart of these discussions, there is opportunity to effect change and improve user experience and satisfaction. Skilled and confident patient representatives In order to support patient and public involvement representatives in their roles, the CCG ran a series of training and information sessions in March, April and May The topics covered in the sessions included: o Public Health in City and Hackney o What is commissioning and understanding the commissioning cycle o Introduction to City and Hackney CCG s Programme Boards o NHS Policy and Five Year Forward View Page 192 of 235

193 o Effective communication and influencing skills o Giving and receiving feedback o Patient leadership: different roles and shared decision making The training was delivered by CCG programme board directors and managers as well as external facilitators from Public Health teams and King s Fund. All the presentations and training materials are available on the CCG s website. Patient and Public Involvement in Procurement Patient and Public Involvement into Ophthalmology (Minor Eye Conditions) Procurement (November 2015 January 2016) The below sets out the detail for how patient and public involvement was ensured into the Ophthalmology (Minor Eye Conditions) procurement process, which began in the autumn of Local Healthwatch branches in Hackney and in City were asked to take the lead on running community engagement meetings and a patient representative with lived-in experience of using eye health services was involved in the procurement process throughout. Objective To conduct patient, service user and public engagement to gain feedback about current Ophthalmology services and pathways of care To gather views about the care that could be delivered in the community, rather than in a hospital setting. Focusing on location as well as the types of eye conditions. Activity Healthwatch hackney set up a small task and finish working group of key Hackney stakeholders to plan engagement with service users. This engagement included joint events with other groups, surveying users at services and general comment collecting. We will ensure that only those identified in the Briefing contribute to this feedback. Healthwatch City of London encouraged City residents and service users to attend the events organised through Healthwatch Hackney and associated groups. Questionnaires were sent to relevant individuals and telephone conversations will take place with identified service users. Who was involved Hackney Vision Group Blindaid Selected BAMER groups Page 193 of 235

194 Healthwatch City of London contacted the residents, workers, students and the homeless that are in their database and the local estates including Barbican Estate City of London Golden Lane Estate City of London North Area Middlesex Street Estate close to the Portsoken area of the City Tudor Rose Estate City of London, sheltered housing How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Participants were recruited via Healthwatch contacts and databases The report produced from the consultation activity informed the procurement process. Patient and Public Involvement in Contract and Service monitoring Patient and public involvement in contract and service monitoring takes place through: Clinical Quality Review meetings with providers as well as regular reports from providers to Programme Boards, including their patient and service user representatives. Regular updates from programme boards to PPI Committee and input from programme board representative groups such as the Children s Disability Forum, Maternity Services Liaison Group and Patient and Service User Group for Integrated Care. Walk the Patch feedback on maternity services (2015 on-going) Objective Activity Gather real time feedback from women (and partners) who have very recently had a baby at Homerton Patients and patient representatives go to Homerton hospital postnatal wards and community postnatal clinics (and other settings such as the neonatal wards and mother and baby unit) with a questionnaire to gather feedback from women on their experience of the maternity service. The results are compiled into a report and shared with the MSLC and Maternity Programme Board with actions identified to improve patient experience. Page 194 of 235

195 Who was involved How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Patients and patient reps from the MSLC and Social Action for Health ask women and partners questions. 122 parents were interviewed from January 2015 to April Interviewees put themselves forward for the role (coordinated by the MSLC and SAFH) and parents interviewed were those who were present on the postnatal ward or at clinics and were happy to be interviewed. Triage delays, long waits for admission and a space to labour consistently come up as an issue in all our patient feedback including Walk the Patch surveys. The Homerton have undertaken a quality improvement review and several audit to understand the triage and Obstetric assessment unit demand and capacity and are in the process of making changes to ensure women are assessed swiftly, see the right health professional at the right time and are quickly moved into the birth centre if booked there Patient and Public Involvement in service planning, design, re-design and de-commissioning City and Hackney Cancer Patient Experience Group (2015 on-going) Objective Activity Who was involved How were participants recruited and what were their roles and To hear from people affected by cancer and to improve cancer services in City and Hackney. To share feedback and learning with East London Cancer Board. Quarterly meetings Patient and service user representative for East London Cancer Board Input into local events Patients and members of public with lived in experience of cancer or experience of caring for someone with cancer Representatives of local community and voluntary sector groups working with those affected by cancer Transforming Cancer Services CCG s Planned Care Programme Board CCG s PPI Team London Cancer Macmillan / Bromley by Bow Centre (Social Prescribing for cancer patients) Participants were recruited through a public event to discuss cancer services in May 2015 and via community networks. Page 195 of 235

196 responsibilities Outputs, Impact &Outcome Public event in May 2015 Quarterly patient experience group meetings Input into East London Cancer Board s patient experience work stream Plans include activity to Help improve early detection of cancer so that people can get the treatment they need faster Make cancer services patient centred so that they take into consideration patients individual circumstances and needs Improve the way patients experience services from screening through to diagnosis and treatment Ensure that training and education for healthcare professionals includes patient perspective Develop on-going ways to hear from patients going through cancer treatment Let s Talk about Cancer: an event to hear from people affected by cancer (May 2015) In May 2015, City and Hackney CCG together with London Cancer hosted a community event to talk about cancer and its impact on people s lives. The event brought together local residents, patients and healthcare professionals who contributing to the discussions and shared their personal experiences. Since the event, City and Hackney CCG and London Cancer have continued to work together. The CCG is leading the patient experience work of the East London Cancer Board which has been set up to improve cancer services across City and Hackney, Tower Hamlets, Newham and Redbridge. This work is informed by the key issues raised by people at May s event. These include Living with and beyond cancer. How can we support patients to live with their condition? Holistic services. How can services ensure they meet the various needs of the patient, including physical and emotional support, information about work and financial support as well as self-care? Community perspectives. Working with community and faith leaders to reach out to local people. Full report of the event is available here. Patient and Public Involvement in setting the Commissioning Intentions City and Hackney Commissioning Intentions Events 2016/17 (January 2015 &February 2015) Page 196 of 235

197 Objective To involve local patients and residents in service planning for 2016/17 Activity Public Event(S) Who was involved NHS City and Hackney CCG London Borough of Hackney City of London Corporation PPI Committee and Programme Board Representatives Community and Voluntary Sector Groups Representatives from local providers Local patients and members of public How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Local patients, members of public and representatives of community &voluntary and advocacy groups were invited to attend. Event was promoted online as well as using local media and community networks. Two events, one for Hackney (Jan 2016) and one for City (Feb 2016) took were jointly organised and co-ordinated by the CCG and local authority representatives. Presentations highlighting key priorities for 2016/17 took place and set the scene for service based group discussions. These were focused around took place around CCG s Programme Board priorities as well as around Public Health and Social Care. Feedback from these events informed plans for 2016/17. Patient and Public Involvement in Strategy Development Involving patients and members of the public in the strategy development takes place through the CCG s structures including the Patient and Public Involvement Committee, Programme Board Representatives, NHS Community Voice, Older People s Reference Group and other community and voluntary sector partners. In 2015/16 involvement into our strategy development has been driven by two major plans taking shape in Hackney and North East London more widely; the North East London Sustainable Transformation Plan and the Hackney Devolution Pilot. Our commissioning plans and decisions in 2016/17 have been aligned to these initiatives. Sustainable Transformation Plan The involvement into the Sustainable Transformation Plan, both on a City and Hackney level as well as across North East London, has taken place in 2015/16 through our PPI Committee and at Programme Board level with input from Programme Board representatives. We take pride in the fact that due to regular involvement with our local communities we have access to on-going feedback from patients and members of public, both through our formal involvement events and the less informal meetings and discussions that take place on ad hoc basis. This has helped us keep our finger on the pulse and where possible, to try and embed the things that people have told are important to them, in the STP planning. More information on our involvement around STP can be found under section 5. Page 197 of 235

198 Hackney Devolution Pilot The devolution proposal for Hackney sets out a shared vision of delivering an integrated, effective and financially sustainable system that covers the whole range of wellbeing - from public health initiatives for school children, timely and appropriate access to GPs and community pharmacists, and top quality hospital treatment, to excellent mental health services and supporting people to remain independent in their community for as long as possible. Examples of how this new model could benefit residents include: o o o o Giving parents easier access to immunisations for very young children by providing more community-based services Tackling obesity through better co-ordinated services and greater local powers to create a healthy environment Quicker progress towards parity of mental health and physical healthcare services Providing tailored, more integrated support for people at the end of their life During 2015/16, we have been working together with local residents to understand how we can make the most of this pilot and ensure that it works for local residents. We are also conscious, that although City of London is not a part of the pilot it is crucial for us to keep involving them in the planning. The involvement and engagement for the Devolution Pilot is led and overseen by the Devolution Engagement and Communications work stream which is co-chaired by the CCG s Lay Chair and the Director of Hackney Healthwatch. The first stage of the involvement process was focused on ensuring that local people were informed about the pilot and what it means for Hackney. Devolution information sessions were built in to our Commissioning Intentions events which took place in January and February The next stage of the process included recruiting patient and public representatives for Devolution Pilot s work streams. The model planned for this was similar to our Programme Board structures; work stream representatives would have together as a Communications and Engagement Steering group and the chairs would then take discussions and feedback from this group to the Transformation Board. This work has continued into 2016/17 with further public events as well as targeted discussions with specific community groups in order to engage with a wide range of local residents. You can read more about this under On-going and future work in section 5. More information about devolution, what it means for Hackney and how people can have their say can be found on our website or at Quality of information, monitoring and acting on patient feedback We regularly monitor patient feedback and service quality. Feedback and quality concerns are raised and addressed through Internal quality processes (including clinical quality review meetings and contract monitoring meetings with providers) Page 198 of 235

199 CCG Quality Team Monitoring local and national patient surveys Quarterly quality reports from all providers to the CCG Board Biannual quality updates to the PPI Committee, including data from key providers as requested by committee members Feedback from patient and public involvement representatives (PPI committee, programme board representatives and NHS Community Voice) Feedback from Healthwatch Hackney and Healthwatch City of London. Healthwatch is represented at the CCG Board, Contracts Committee and Prioritisation and Investment Committee. Duty of Candour reporting Community and voluntary sector partners, other community intelligence and ad hoc feedback gathered at events, through outreach and events. Maternity Services Liaison Committee delivered by Social Action for Health (SAFH) (July 2015 on-going) Objective Activity Who was involved How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome This project aimed to engage more pregnant women and new parents in the MSLC. SAFH were commissioned to develop the MSLC with a focus on engaging women in the community and feeding their feedback into the MSLC. SAFH have engaged with over 400 pregnant women and parents (June 2015 to April 2016) and delivered various community events, outreach sessions and parent forums. The CCG, with input from clinical leads, PPI lead and MSLC chairs, developed a service specification and tender process to invite local services to provide the MSLC development project. SAFH delivered outreach work and community events to identify pregnant women and new parents who would like to share their experience of maternity services. We have received a considerable amount of feedback from patients and parents. The coordination of the MSLC has come back in house to the CCG but we have continued to commission outreach to engage patients and gather maternity care experience. Page 199 of 235

200 Holding Providers to account Patient involvement into CHUHSE (City and Hackney Urgent Healthcare Social Enterprise) Quality Review Meetings Objective The clinical quality and performance review meeting is a forum between City and Hackney CCG and the out-of-hours primary care service provider and Paradoc provider, City and Hackney Urgent Healthcare Social Enterprise (CHUHSE). The primary focus of the meeting is patient safety and clinical quality of services delivered by the provider. In addition to focussing on clinical quality, it will address matters of contractual performance, finance and activity. Activity Who was involved How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Bi-monthly meetings Lay Member, Independent GP lead, City and Hackney CCG Urgent Care Programme Board Director, Urgent care programme manager, Head of Quality, CHUHSE clinical lead, CHUHSE, Chief Executive, Paradoc clinical lead, CHUHSE Service Delivery Manager, Patient representative and Super PPG Chair, CCG Patient and Public Involvement subcommittee representative, Senior Finance Manager, Senior Contracts Manager PPI representatives were recruited through the existing PPI networks. They now co-chair the meeting. The clinical quality and performance review group will report to the CCG s urgent care programme board and escalate any immediate concerns to the urgent care board chair. Having PPI representatives involved ensures that patient views are included in decisions and actions regarding the following: o o o o o o o Monitoring contractual requirements Formally addressing quality issues and reports Quality assurance visit reporting Care Pathways Service Transformation: Provide guidance on service quality for future transformation of out of hours services. Clinical audit and benchmarking Addressing GP quality concerns Page 200 of 235

201 o o Analysis of trends in the feedback received from GPs and patients Reviewing provider quality reports including patient experience A summary of the quarterly performance reports will be provided to the finance and performance committee. Integrated Care Patient and Service User Experience Group Objective The Patient/User Experience Group (PUEG) is established as an advisory body to the Integrated Care Programme Board and One Hackney and City Programme Board. It is an effective body to represent patient and user views and advocate for service change and re-design. The group brings together a number of Patient Experts to advise on the further development of integrated health and social care services. Activity o Provide summary reports and recommendations for Integrated Care Better Care Fund (BCF) Programme Board o Ensure responses and requests from BCF board are reported back to the group o Request, collate and present requested information to the group as requested, in appropriate and accessible format o Ensure core representatives are engaged and able to contribute, by holding pre-meets or briefings outside main meetings o Recruit new reps as directed by the group o Work with CCG to ensure consistent and appropriate representation from statutory sector o Support the chair with briefing before meeting, information in meeting o Liaise with other community groups as directed by the Group o Provide link with updates from patient representatives on other relevant boards, if not able to attend (eg RICS, Patient Discharge Forum) Who was involved Healthwatch Hackney x 2, Patient Representatives x 2, Carers/Service Users x 4, Hackney Quadrant Navigators x 1, Homerton Hospital Patient Experience representative, City and Hackney CCG PPI representative, Integrated Care Programme board, London Borough of Hackney representative, City of London Quadrant Navigator x 1 (Age UK) Page 201 of 235

202 How were participants recruited and what were their roles and responsibilities Outputs, Impact &Outcome Participants were recruited through a number of routes including CCG s existing PPI groups, through Healthwatch and provider patient experience networks. Through the activities detailed above the groups will report its work to, and advise, the Better Care Fund Programme Board. Members of the group will sit on Better Care Fund Programme Board and will recommend service improvements and service re-designs based on patients experiences of the services commissioned under Better Care Fund. In light of data collected from patients experiences, the group s representation at the Better Care Fund Programme Board may hold relevant service managers to account. Using Information Technologies to support Collective Duty In 2015/16 we have continued use of information technologies, including social media, to engage and involve patients on both a collective and individual level. Our current IT work streams include o o o o o o o Developing our digital plan as part of our new Engagement Strategy On-going content management and development of the CCG s website, including the PPI focused Get Involved section Have Your Say section on the CCG s website CCG Twitter account followers have gone up by more than 1,000 from 2,581 to 3,959. We now use Twitter regularly to promote events, news and to connect with local residents. Electronic live PPI newsletter goes out quarterly to more than 250 recipients, including PPI networks, community and voluntary sector, and 43 GP practices. PPI Team and Programme Boards regularly use online survey tools such as SurveyMonkey and SurveyGizmo to involve patients, gather views and run application processes. All meeting papers available on CCG s website. 4. Involving people in their own care: meeting the Individual Duty Page 202 of 235

203 As well as ensuring that collective engagement and involvement takes place we have a duty to support people and enable patients to feel in control of their own health and the choices they make when it comes to the care and treatment they receive. This means making sure that information, tools and support are available so that patients can make informed decisions about their care. The priorities for the CCG around the individual duty are (1) Self-Management, (2) Shared decision making and (3) Personalised care planning and health budgets. In 2015/16 we have continued our work to embed these areas in the way that services are planned, but also in what we look for in terms of reporting from providers. Whether it is ensuring that information and advocacy services are available to people and making sure that those who are entitled to Personal Health Budgets can do so and have the appropriate support in place or ensuring that patients can feel that their care is well coordinated and focused around their needs, we are committed to involving our residents and patients in their own care. Self-management We recognise the role that people have in protecting their own health, making decisions about their care and managing their long term conditions. Self-management and making sure that the appropriate support is in place for patients to do this - is now a theme that features across all our Programme Boards. Five to Thrive (Oct 2015-ongoing) Evidence shows that regularly incorporating the five ways - being active; giving; connecting; taking notice; and engaging in learning - into daily life can help to improve mental health and wellbeing. In 2015/16 our Mental Health Programme Board have worked together with local authority and community and voluntary sector groups to launch Five to Thrive. Five to Thrive is a local programme aimed at helping people look after their mental health through making small changes in order to feel better and stay well. Rhiannon England, Clinical Lead for Mental Health at City and Hackney CCG said: "5 to Thrive is about really simple things that anyone can do to help keep themselves happy and healthy. In a world where we are increasingly juggling lots of things, it can be easy to neglect mental health. Stress is a massive factor for a lot of people and I hope that 5 to Thrive will demonstrate how everyone can tackle that by making small changes." In October 2015 a week of events took place to raise awareness of the programme. Funded by City and Hackney Clinical Commissioning Group (CCG), and delivered by voluntary and community sector organisations and Hackney Council, activities included mindfulness sessions from City and Hackney MIND, walks celebrating the borough's history, a mentoring information evening with Connect Hackney, a volunteer fair and sessions in Hackney's libraries. The week ended with a day-long extravaganza on World Mental Health Day, Saturday 10 October Page 203 of 235

204 Supporting people with long term conditions Supporting people with long term conditions and enabling self-management is one of our priority areas. Examples of the services we commissioned in 2015/16 to ensure support is place include Long Term Conditions contract Long Term Conditions contract is in place with local GP practices to ensure those diagnosed with long term conditions have access to support. This includes extended appointments for those newly diagnosed with, and for those living with, a long term condition. The contract also includes annual reviews for people with long term conditions, including self-management support, lifestyle advise etc. Targeted support for Sickle Cell patients Hackney has a relatively high number of patients diagnosed with sickle cell disease. We have funded a targeted service which works with and supports sickle cell patients, who are often high users of A&E services due to the characteristics of their condition. Self-Care Event 2015 (November 2015) To mark the National Self Care week (16-22 November 2015) we teamed up with London Borough of Hackney Public Health team and organised an event to raise awareness of services and support that are available locally to help people stay healthy and well, and to self-manage their conditions. The event took place at Hackney Central Library on Thursday 19 November, with stalls, refreshments, information, health checks and taster sessions available for attendees. Shared decision-making Making patient pathways accessible (March 2016 on-going) We are committed to ensuring that patients have access to clear information that enables them to play an active role in their care; to stay well, self-manage health conditions and make decisions about the care and treatment they receive. Plans for making patient pathways more accessible begun to take shape early in They include work streams that will aim to deliver both better clinical outcomes and improved productivity. We want to ensure that both current and new pathways are patient friendly and include information about relevant services and support. Work will include o o Ensuring that the patient pathways used by clinicians to map out the treatment route for patients are developed in a way that enables them to be used and understood by both the clinician and the patient. Ensuring that the pathways are patient friendly and that the patient facing information included in them is in line with the Accessible Information Standard. Page 204 of 235

205 o o o o o o o Ensuring that the pathways have links to local and national information and services that are relevant to the patient and that the patient can access for additional support. These include services provided by statutory as well as community &voluntary sector organisations. Maintaining an oversight of local and national services, support and information that are available and are of relevance to the pathways in question. Ensuring that this information is included in the pathways in a format that is accessible and easy to understand, taking into consideration the diverse community. Ensuring that all patient information included in the pathways is of good quality, in line with NHS guidelines and has been signed off by the clinical teams. Involving local patients and members of public in shaping the patient information, making use of the CCG s Patient and Public Involvement groups, readers groups, community networks and more. Gathering feedback and questions from patients, ensuring that their views are shared with the clinicians and that these views inform the patient information included in the pathways. Ensuring that use of patient information and patient decision-aids is embedded in the pathways, in local clinical practice and across all relevant local platforms. To support this work and ensure clinical insight into it we have appointed a new clinical lead, Dr Anita Coutinho who is a local GP at Lower Clapton Practice. She said: "It is an honour to join the Patient Participation Involvement team. As a GP and through working at the CCG I feel that patient involvement is crucial to the success of our health service. In particular, I will be reviewing patient involvement in clinical pathways. All of our services, pathways and clinics are used by patients so it is our job to make sure that patients are at the heart of their creation. Patients need to be at the centre of all our decisions and every voice should be listened to. It is important for us as a team to make sure patients of all ages, backgrounds, and hard to reach groups are heard. Thank you for this opportunity and I look forward to both working with and for patients." Personalised care planning and personal health budgets At home medicine reviews for vulnerable patients (July 2015 on-going) Lots of us take medicines and some people worry about them. Through our Home Based Medicine Review scheme we wanted to give patients an opportunity to discuss with a healthcare professional any issues relating to their prescribed medicines. The aim is to talk about and find solutions to any problems and ensure the patient feels they are supported and more confident in managing their medicines. Following on from discussions with patient representatives in City and Hackney at our Commissioning Intentions the CCG has implemented a new service that will give patients the opportunity to have a medicines review with a specialist pharmacist, in their own home. PPI Committee receive regular updates of the progress of this service which aims to Page 205 of 235

206 o o o Empower patients to manage their medicines through greater understanding Reduce the risk of preventable medicines related problems Avoid unnecessary hospital admissions The service takes a holistic approach to reviewing medicines. Patients with long term conditions, those with complex care needs living in the community, housebound patients or people recently discharged from hospital are some of the key groups of patients that will be offered a medicines review, as a priority, by the new service. For the service to make a real difference, it s vital that patients are engaged and understand the benefits to them. The review is intended to give patients the opportunity to openly discuss any aspect of their medication and to talk about issues which may be affecting their access to certain medicines, or their adherence to a treatment plan. Targeted antenatal classes In order to expand local antenatal class provision and increase access and engagement for pregnant women who may not access generic NHS or private classes we have commissioned 4 providers to deliver targeted antenatal classes to pregnant women including : Turkish speaking women including those with limited spoken English Orthodox Jewish women Women with current or previous substance misuse problems Women on the public health midwifery caseload 94 pregnant women attended (with another 34 family members or partners). The MSLC reviewed antenatal education in2014/15 and prioritised extension of current provision to better meet the needs of diverse groups of women. The CCG, with input from clinical leads, Public Health, Safeguarding and MSLC chairs, developed a service specification and tender process to invite local services to provide targeted classes. The four providers recruited local women via midwifery and health visiting services and also through voluntary sector networks. All classes were extremely well evaluated by women with 3 classes evidencing improved levels of knowledge, confidence and healthy behaviours pre and post classes. Classes also evidenced reaching women who would not ordinarily access antenatal education. Funding for classes has been secured for 16/17 and 17/18 onwards and provision is being extended to reach new groups including trafficked women and women with no resource to public funds. Personal Health Budgets (October 2014 on-going) Since October 2014 anyone who receives continuing healthcare has had the right to have a personal health budget. This offer has now been extended to children and adults with Page 206 of 235

207 learning disabilities and children and young people with a health component of the new SEND plans. Through personal health budgets we want to support people to better plan their care, to use the budget to buy services and equipment that best meets their needs. The budgets will also give people more choice and control over the support they receive allowing people to think of new ways to meet your health and wellbeing needs. Patient qualifying for a personal health budget can now have their health needs assessed by their continuing healthcare team who will then develop a care plan for them. Patients will receive advice on how much money they will receive. They will also have access to a support worker who will work with them and patient s carers to decide how to best use the budget. The support plan sets out how the budget is to be used to support patient s health and wellbeing needs and it must cover the following points o The health and wellbeing outcomes you want to achieve o How your outcomes will be achieved o The risks to your health, wellbeing, safety and independence o How you will manage your personal health budget o Contingency arrangements you will have in place should support arrangements fail Different options are in place for patients to choose how they would like to receive their payments. This includes direct debit, a notational budget (where NHS staff will arrange and pay for the services for you or an arrangement where a third party holds the budget for you. Six personal health budgets have been issued so far in City and Hackney. Working with our providers We work with our providers to help patients feel in control of their condition and their care. We commission and contract in line with NHS policies and regulations, including NHS Standards Contract Service Conditions: Personalised Care Planning and Shared Decision Making (SC10) and Service User Involvement (SC12) Homerton University Hospital, Shared Decision Making CQUIN (2015/16) Shared decision making is about patients and clinicians reaching decisions in partnership. It contributes to a more patient centred way of delivering care. To pilot and evaluate relevant elements of a person centred care scheme within in three different specialties a shared decision making CQUIN was agreed with Homerton University Hospital for 2015/16. The areas chosen for this were Page 207 of 235

208 Respiratory Chronic condition COPD (Chronic Obstructive Airways Disease) is a lung condition that patients have to live with for life once acquired. o o o o o Trialling of Tools (OPTION and CollaboRATE) that measure how involved patients feel in decisions that get made during a consultation. Trialling of in clinic Observation with subsequent structured feedback on the presence or absence of SDM features within the consultation. Key Clinicians in the process of completing the Whittington Advanced Development Course Review of patient information provided pre appointment, and consideration of the use of a National Patient Decision Aid. Reflection tool piloted for use with clinicians carrying out consultations Musculoskeletal Elective Hip and Knee Replacements - Surgical Osteoarthritis of joints has a number of management options. o o o Evaluation of patient involvement Measurement Tools OPTION, CollaboRATE Trial of decision outcome quality measurement Tools SURE, Harvard DQI Trial the introduction of a patient decision aid into the pathway OPTION Grid Treatment Escalation Planning (TEP) This is the concept of making a plan in advance, so if the hospital Emergency Team is called they have the best chance possible of acting in accordance with a patient s wishes/best interests. o o o o Develop/adapt a questionnaire asking patients to report how involved they have felt in the process of the creation of their TEP plan Develop a patient support tool/patient information leaflet to facilitate TEP discussions Examine the concept of Futility, due to the legal role with regards to SDM in this field Develop (IT) infrastructure that facilitates sharing of conversations between Hospital and Community. Value Based Standard at Bart s Health We are the lead organisation for East London s Cancer Board s Patient Experience work stream. Through this work we are involved in feeding into the new Macmillan Value Based Standard project which aims to address areas of poor patient experience. Value Based Standard is based on MacMillan s research and it highlights 8 focus behaviours which equated to a positive care experience for staff and patients. Although the framework is not cancer specific, it has been applied to cancer services at Bart s Health. So far the project has feedback on the project has been positive. The key themes identified for the work in the cancer context at Bart s are detailed below. Work is on-going and regular updates are provided both at the East London Cancer Board Patient Experience meetings as well as at City and Hackney Cancer Patient Experience group. Macmillan Values Based Standard Naming I am the expert on me Page 208 of 235 Private communication My business is my business Communicating with more sensitivity - I m more than my condition Clinical treatment and decision making - I d like to understand what will happen to me

209 Source: Update for ELCB Patient Experience subgroup. Individual Duty and Information Technology There is no doubt about the role that new technologies play in helping people find and access information, make decisions and look after their health and wellbeing. It is also planned that by 2018 all patients will have access to their digital care records and by 2020 health and care systems are paper-free at the point of care. Making the best use of digital technologies is one of the national challenges all CCG s need to address over the next five years. We see the use of digital technologies as having the potential to o o o o o o o Help patients make the right health and care choices Enable patients to have more control over their health and wellbeing Give patients access to view and comment on their health records Help health and care professionals by giving them access to all the information they need to look after their patient Improve communication between GPs and hospitals, health and social care, patients and services Increase transparency by making quality information about services available online Save money for the NHS What s already available in City and Hackney? o o Patients can request access to their digital health records Patients can book GP appointments and renew prescriptions online Page 209 of 235

210 o o People have access to national and local websites to find health information and information about local services (NHS Choices, Hackney i-care, City Health website, myhealthlondon.com.) Clinicians have access to DSX where they can find out about care pathways and relevant support services for their patients and print out leaflets etc. (More on pathway development under section 4 and Shared Decision Making.) During 2015/16 we have engaged patients and local residents in discussions about how our digital offer might be best expanded so that it meets people s needs. We are also aware of the digital divide that can exist between groups and are committed to supporting equitable access to information technologies where gaps and training needs are identified. IT and managing demand in primary care We recognise that primary care is currently under unprecedented demand and are keen to explore the potential of IT in offering some solutions. A Primary Care Demand Management scheme is being developed together with City and Hackney GP Confederation to identify and pilot a suite of demand management activities over the course of 2016/17. We envisage that this will deliver patient benefit in terms of increased overall satisfaction with primary care whilst maintaining a fair access to all. The broad aim of the scheme is in line with our principles and aims for primary care as set out in its Primary care Strategy: o o o o o o Supporting the delivery and future development of high quality services for patients Supporting the use of well designed, robust, high quality IT to facilitate patient and public empowerment of self-care Having services that are resilient by being productive, efficient, safe and value for money Having services that are of high quality and offer comprehensive patient support Having services that are accessible Reducing health inequalities Page 210 of 235

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215 5. On-going and future work Equality and Diversity We contract and commission in line with national policies and guidance on equality, including NHS Standard Contract Conditions. In our 2014/15 report we recognised the significant overlap that exists between the equality agenda and many other aspects of social value and sustainability. We have therefore incorporated our Equality and Diversity work stream into our Sustainable Development Management Plan. In 2015/16 Equality and Diversity Training was delivered to Programme Directors and Clinical Leads, covering areas such as use of Equality Impact Assessment (EIA) Toolkit when designing and redesigning services. We are in the process of following this up with training on carrying out Equality Audits and will be delivering a separate training session for PPI representatives as well as identifying a PPI representative with specific interest in the topic, to work alongside the group. We recognise the need for this work stream to be formalised and embedded into our processes in a similar manner to PPI. We have therefore identified a designated CCG Equality and Diversity lead who is taking this work forward together with the CCG s Lay PPI Chair and a working group with representation from Programme Boards. The group reports to the CCG s Clinical Executive Committee. The key areas of work for 2016/17 include Implementing the Equality Delivery Standard 2 (EDS2) framework by applying across number of services we commission as well as internally, to our workforce and leadership structures. Reviewing progress against our Equality and Diversity Objectives using the EDS2 as a framework Reviewing existing Equality and Diversity objectives and setting up new ones for Carrying out a stocktake of internal processes around Equality and Diversity in order to identify and address gaps. Equality and Diversity work will be underpinned by the following policy context: o NHS Constitution o Human Rights Act 1998 o Health and Social Care Act 2012 o The Equality Act 2010 which includes the protected characteristics o The Public Sector Equality Duty o FREDA principles (Human Rights in Health Care benchmarking tool for Fairness, Respect, Autonomy, Dignity, Autonomy) A report on the progress of the work stream will be available in Q1 of 2017/18. City and Hackney CCG Equality and Diversity Strategy and Objectives are available here. Page 215 of 235

216 Equity of our PPI structures In addition to the above, we will continue ensuring that our PPI activities are inclusive and accessible to the diverse population we serve. To do this, we will o o o o o o o o o o Continue funding the NHS Community Voice with specific focus on involving groups that are considered hard to reach and seldom heard. Work closely with Healthwatch Hackney and Healthwatch City of London who are able to provide valuable information and insight into local communities Maintain a close relationship with the community and voluntary sector in the area Commission targeted projects, such as those delivered through the Innovation Fund and the CCG s non-recurrent funding stream, aimed at hearing from vulnerable groups and raising awareness of service provision and involvement opportunities. Make sure that documents are accessible and free from jargon Ensure that the membership of our involvement forums is reviewed regularly and that it reflects the local population Make sure we meet the diverse linguistic needs of our communities. Our website uses a translation tool and translation services are available on request at all our events and meetings Undertake a specific piece of work to make patient pathway information relevant and easy to understand Continue working closely with local disability groups including Hackney People First, The Huddleston Centre and POhWER. An involvement forum with specific focus on children and young people with disabilities was set up in 2015/16. Work to ensure equal opportunities for involvement for those groups identified under the protected characteristics sections of the Equality Act. Our work in 2016/17 and beyond During 2016/17 we have continued to maintain and develop PPI structures that are inclusive and enable involvement from the wide range of populations that we serve in City and Hackney. The work of our Programme Boards reflects the wider priorities set out in the NHS Five Year Forward View, NHS Planning Guidance and the four domains identified in the CCG Improvement and Assessment Framework (IAF). As mentioned in the sections above, Hackney Devolution Pilot will enable us to deliver these priorities and work towards the four domains of the IAF with a local focus and in partnership with local authorities, service providers and patients. NHS Improvement and Assessment Framework 2016/17 In 2015/16 a number of key service areas in City and Hackney were identified for improvement under the IAF four main domains. These included Diabetes, Maternity, Learning Disabilities and Cancer services. We are developing action plans to address these areas and are working together Page 216 of 235

217 with the relevant patient and public involvement groups to ensure that these plans include the things that matter to people. Decisions about these plans are made at Programme Board level and at CCG s Governing Body. Both bodies include patient and public representation and the latter is attended by our PPI Lay Chair. NHS Improvement and Assessment Framework 2016/17: four domains Better Health Better Care Delivering NHS Five Year Forward VIew Sustainability Leadership Plans to improve Maternity IAF rating in 2016/17 Support with choice in pregnancy, labour and birth o Information regarding choices for antenatal care and place of birth is given verbally by midwives and supported by information leaflets, parent education classes, early pregnancy place of birth drop in sessions, tours of the unit, support sessions (for women who want to have a vaginal birth after C-section), Wednesday club for women with high Body Mass Index including discussing birth options and additional support from supervisor/consultant midwives for more complex discussions around choices. o Maternity Services Liaison Committee input into identifying what choice means in practice for women, to further develop birth plans as tools to start choice discussions and to support GPs to describe women s options at pregnancy appointment and 16w antenatal check. o Care in labour and birth to be improved through reducing the number of inappropriate referrals to triage to reduce waits and developing care bundles that will enable midwives to discharge more women. Women booked for birth centre flagged with a sticker on their hand held notes and referred directly there when in labour, bypassing triage entirely. Additionally, a pilot will take place to extending the maternity helpline hours to 24/7 and including telephone triage service. Being treated well after the birth Page 217 of 235

218 o 2016/17 CQUIN to increase continuity (and therefore consistency) of care provided to women in the ante and postnatal period. HUH implemented partners overnight project to enable birth partners to stay with mum and baby, which has been anecdotally reported as well received by parents. Support with feeding o o The Homerton developed a set of actions to address key areas raised in the CQC survey; this included improving skin to skin support to help with bonding and breastfeeding from birth. The CCG also commissions two breastfeeding support services (peer support and tongue tie) and we have secured further funding for 17/18. Hackney Devolution Pilot Hackney s bid to become one of the five areas in London to take part in a health and social care devolution pilot, has been approved by government. Hackney Council, City and Hackney Clinical Commissioning Group and local organisations delivering health, social care and wellbeing services have signed up for the initiative. The vision for Hackney Devolution Pilot is to work together with our patients and providers to deliver an integrated, effective and financially sustainable service that meets the population s health and wellbeing needs. Through the pilot we want to increase the independence and choices of local residents, improve the quality and timeliness of care and use our common infrastructure to deliver modern and responsive services. Partners involved in the pilot include City and Hackney Clinical Commissioning Group, City and Hackney GP Confederation, City and Hackney Pharmaceutical Committee, City and Hackney Urgent Health Care Social Enterprise (out of hours GP), East London NHS Foundation Trust, Hackney community and voluntary sector providing services to Hackney Council, London Borough of Hackney, Healthwatch Hackney, Homerton University Hospital NHS Foundation Trust and City of London Corporation. Devolution Engagement and Communications Devolution Engagement and Communications work stream has been set up to ensure the involvement of local patients and residents in the pilot. The aim of the work stream is o o o To inform Hackney resident about devolution and be a critical friend to the programme of activity and other workstreams To ensure and facilitate regular and meaningful service user, stakeholder and public engagement and involvement at all stages of the project To encourage, support and enable the widest range of patients/service users and the public to engage with the project by participating in workstreams and other relevant and accessible activities Page 218 of 235

219 o o o o o To design and commission a programme of engagement with patients/service users, the public and other stakeholders that meets the aspirations of the Health and Wellbeing board for citizens being at the centre of service redesign and decision-making and meets the policy and statutory requirements and achieves best practice for consultation on service changes on local authorities and the NHS. To maintain an active log of all engagement activity and make sure that the results are fed into other workstreams To establish principles of patient/service user and public involvement that underpin the design of any new model of healthcare delivery that comes out of the project To develop and implement a detailed plan for stakeholder communications about the project To oversee the communications that are issued to ensure they are relevant, meaningful and accessible They work stream will adopt a co-production approach that sees local communities as an asset and an integral part of service provision and health improvement. The desired outcomes from consultation and public engagement include o o o o Co-design and implementation of best practice evidence based models of care which ensure a productive health and social care economy both locally within Hackney and with surrounding areas A local health and care system that offers choice and control to patients and service users and reduces or eliminates health inequalities and waste. Citizens of Hackney are fully informed about the proposals and have had opportunities to ask questions, contribute ideas, be part of the design and decision-making process People of Hackney are more engaged in their health and care and feel more confident about their role in managing their own health and wellbeing Other things that we will be working on Events Public events will continue to form an important part of our involvement work. Since April 2016 our events have covered topics such as people s views on the quality of primary care (June 2016), exploring how IT can be used to support self-management (June 2016),health and homelessness (Oct 2016) and Sustainable Transformation Plan (Oct 2016). In May and June 2016 we ran a series of meetings and events with focus on the Devolution and City and Hackney Five Year Plan. We are currently planning for a Men s Health Event (Oct 2016), Health and wellbeing in pregnancy event (December 2016) and a Hackney Refugee Forum focus group on mental health needs within the migrant and refugee community (Nov 2016). We are also involved and represented in events Page 219 of 235

220 organised by local organisations, including City Healthwatch Annual Event (Oct 2016), Big Do (organised by POhWER for people with learning disabilities, Oct 2016) and Carers Event (Nov 2016). Four quadrant based events will take place in November 2016 to mark the next stage of the involvement into the Hackney Devolution Pilot. Supporting practice based patient participation groups Practice based patient participation groups are crucial for our PPI structures to work effectively. Ongoing work is taking place to look at how we can best support practices in making the most of these groups. We would like to see our existing involvement forums such as Older People s Reference Group, Health and Social Care Forum and Hackney Refugee Forum take an active role in working more closely with the practice based participation groups and are formulating a proposal for what this might look like. North East London 111 service procurement We are involved in planning the engagement for the North East London wide 111 procurement process and our PPI representatives will take part in this. Working with Hackney Refugee Forum to better understand the needs of migrant and refugee populations. A grant agreement is in place with Hackney Refugee Forum in order to better understand how we can better meet the needs of our local migrant and refugee populations. As part of their work the refugee forum will be attending CCG s events and meetings to advocate for the migrant and refugee community, gather and share feedback and encourage participation in other involvement forums. Innovation Fund As described in section 4, we are pleased and proud of the work that has taken place through the City and Hackney Innovation Fund. Our vision for the fund going forward is to align projects that are funded with mainstream services, thus improving their fit with existing services as well as encouraging partnership working between them and the smaller Innovation Fund providers. The third round of the fund is due to launch in early November 2016 and all projects that have previously received funding will be able to apply for additional money to help them take their service to the next level. As before, the selection process will be supported by PPI representatives, commissioners and clinicians and we will be looking for projects that can demonstrate that they have met their objectives and have a clear plan for scaling their project up. Page 220 of 235

221 SECTION SIX - Healthwatch Statement Building effective partnerships is an essential element of meeting the statutory obligations; Local Healthwatch organisations play a central role in acting as a patient and consumer champion for health and social care services. This section of the report provides an opportunity for your local Healthwatch to comment and reflect on the content of your report. Please indicate in this section if Healthwatch has been commissioned to undertake any engagement work for the CCG, and if so for which activities. Submission date Please send your completed template to ENGLAND.qualityhub@nhs.net by the 4 th November 31 st October Page 221 of 235

222 FINANCE & PERFORMANCE COMMITTEE (FPC) Report to CCG Governing Body on meeting held on 28 September 2016 For information Page 222 of 235

223 Month 5 Finance & Performance Report The month 5 year to date surplus declared was 519k with a net 23k in-month surplus movement. Whilst cost pressures were contained within the acute portfolio and breakeven declared, the CCG is working with NELCSU to review and challenge providers over key performance issues. Outside of the acute portfolio, cost pressures of 807k have been identified in Continuing Healthcare and Funded Nursing Care, although this is offset by underspend in financial reserves and running costs. The CCG has plans for delivery of non-recurrent investments in a range of schemes and the CCG is also funding the Hackney Devolution project and associated transformation workstreams. All these areas are continually reviewed and risk-assessed, and any deviation will be managed and mitigated accordingly. The risk-assessed Forecast Outturn remains unchanged at 38.19m. 2016/17 Quarter 1 Performance Report The Committee reviewed CCG performance against constitutional standards, and on key target areas: A&E Waiting times; Referral to Treatment times, CQUINs, IAPT and Dementia. This report was presented to the Governing Body in September. Maternity Tariff In 2015/16 there had been a significant increase in deliveries with complications and co-morbidities at Homerton University Hospital Foundation Trust (HUHFT) compared with 2014/15 levels. This had prompted a benchmarking exercise which showed HUHFT to be a significant outlier in this area, and it was believed this related to coding practices. The Committee agreed to challenge the data received from HUHFT and to discuss carrying out an audit of HUHFT maternity services with commissioners in Waltham Forest. Page 223 of 235

224 Outpatient Referrals The Committee received a report on planned care activity and action planning in relation to over-performance at Homerton. It was agreed that consultant to consultant referrals would be scrutinised in greater detail. The Committee also received an Urgent and Emergency Care Demand Management Plan. Programme Board Reports The Committee received updates from the Prescribing and Mental Health Programme Boards, as part of the standard cycle of pro gramme board reports to the FPC. Prescribing The Committee noted progress on key aspects of the PPB work plan for 2016/17 and proposals to recurrently fund medication review services (Domiciliary & Respiratory) and the prescribing aspects of the CCE. Mental Health The Committee noted the report on performance against targets in the year to date, and key risks around agreeing a capitated model for contracts, re-basing, and funding gaps affecting service provision. Page 224 of 235

225 LOCAL GP PROVIDER CONTRACTS COMMITTEE (LGPPCC) Report to CCG Governing Body on LGPPCC meeting held on Friday 30 September 2016 Page 225 of 235

226 The LGPPCC approved the following payments for the delivery of contracted services: Contract details Amount approved Confederation 2016/17 Q1 service fee payment 100,000 Enhanced Primary Care & DEPOT Payment 2016/17 Q1 9,525 Maternity & Children s Programme Board 59,320 Vulnerable Children Payment 2016/17 Q1 22,674 Nursing Homes Payments 2016/17 Q1 - Acorn Lodge 18, Nursing Homes Payments 2016/17 Q1- At Anne's 5,999 One Hackney Payment 2015/16 Q4 438, Frail Home Visiting Payment 2016/17 Q1-Q2 670,929 End of Life Care Payment 2016/17 Q1 10,450 CHUHSE KPI Payment 2016/17 Q1 47,361 Duty Doctor Payment 2016/17 Q1 366,250 Enhanced Access Payment 2016/17 Q1 74, Post-Operative Wound Care Payment 2016/17 Q1 4,800 Phlebotomy Payment 2016/17 Q1 64, Ear Nose & Throat Community Service Payment 8,655 Primary Care Anticoagulation Service Payment 2016/17 Q1 45,129 Non-Recurrent Investment - Accessible Information Standard 45,000 Page 226 of 235

227 Child Immunisation proposal: The Children s Programme Board presented a report asking the committee to approve a proposal plan of 235,000 to provide additional support to primary care to increase the capacity for child immunisation. The Committee approved the clinical case and approach as set out in the report but requested that an addendum be drafted to show the case for delivery by the GP Confederation and provide detail regarding the mechanism and legal process for transferring funding to the Local Authority. Long Term Conditions (LTC) 2017/18 Contract: The LTC Programme Board presented a report seeking approval from the Contracts Committee for the LTC contract to be made recurrent. The committee approved the contract subject to the overhead not exceeding the value of 200,000 as stated in the report. The LTC report will go to the January 2017 Contracts Committee meeting with details of the reconciled overheads figures. Coordinate My Care Non-Recurrent Proposal: The Integrated Care Programme Board presented a report asking the committee to approve 171,900 to allow GP practices to transfer existing care plan records onto another system. Committee members approved the request in principle subject to further justification of the 50 fee for each care plan transferred onto CMC. The Committee required the Confederation to demonstrate the need for clinicians in this role and for a summary of this to be shared with the Committee membership for approval. Since the meeting on 30 September 2016 a virtual discussion has been carried out by committee members in which they scrutinized the information provided in support of the 50 per patient fee. The members have approved the proposal as set out in the report. Page 227 of 235

228 CLINICAL EXECUTIVE COMMITTEE (CEC) Report to CCG Governing Body on CEC meeting held on Wednesday 12 October 2016 For information Page 228 of 235

229 The CEC discussed the closure of adult day-care centres in Hackney. Members of the CEC are being encouraged to share stories from any of their patients who are negatively affected by these closures with the Public Patient Involvement (PPI) Committee. Stories will be used to demonstrate the impact of closures to LBH. The CEC discussed the challenges signposting Turkish speaking patients to appropriate translation / advocacy services in Hackney. Positive progress has been made updating Coordinate My Care (CMC) plans, Hackney is now half way to completion (when compared to other London boroughs), and Hackney s CMC Lead has confirmed that all the completed plans are of good quality. The CEC discussed a risk regarding CMCs and London Ambulance Service (LAS); it has been reported that LAS frequently do not check patient CMCs. The CEC heard key issues from the Mental Health Programme Board (MHPB): regarding CAMHS, the CEC was asked to feedback comments re how the CCG could deliver further support to young people in crisis specifically regarding home delivery of services. Another key MHPB issue under discussion included Dementia diagnosis, and the push towards ensuring each Alzheimer s / Dementia patient has a CMC produced by ELFT at diagnosis. The CEC discussed a Public Health Outcomes data graph measuring patient outcomes, patient complexity, and spend per head across North East London CCGs. Hackney has a complex patient composite [largely due to high instances of psychosis], high spend and good outcomes. C&HCCG s performance was praised by the CEC. Re Devo / STP work stream: The CEC heard how multidisciplinary quadrants are being created to support each general practice in Hackney with the management of high risk patients. Quadrants will include representation from: mental health, voluntary sector, Geriatrics, Social Work, the Community Matrons as well as a Team Leader and GP Lead. East London Foundation Trust (ELFT) was inspected in June 2016 by the Care Quality Commission (CQC), the Trust was rated outstanding overall. This was praised by the CEC. The CEC discussed introducing Biosimilars to the HUHFT, and agreed that the CCG should support HUHFT with this initiative going forward. Page 229 of 235

230 AUDIT COMMITTEE (AC) Report to CCG Governing Body on meeting held on 13 October 2016 For information Page 230 of 235