MINUTES MERTON CLINICAL COMMISIONING GROUP GOVERNING BODY PART 1

Chair: Dr Andrew Murray In attendance: MINUTES MERTON CLINICAL COMMISIONING GROUP GOVERNING BODY PART 1 28 th September 2017 Time: 1.00pm 3.00pm 120 The Broadway, Wimbledon SW19 1RH Members SB Sarah Blow Accountable Officer JB James Blythe Managing Director PD Peter Derrick Lay Member: Audit & Governance CG Clare Gummett Lay Member: Patient & Public Engagement Lead JHa Julie Hall Nurse Member TH NM Dr Tim Hodgson Neil McDowell GP Member Local Finance Director AM Dr Andrew Murray Clinical Chair KW Dr Karen Worthington GP Member DZ Dr Dagmar Zeuner Director of Public Health, LBM Non-Voting Members JA John Atherton Director of Performance and Management JHe Julie Hesketh Director of Quality & Governance MJ AMc Marek Jarzembowski Andrew McMylor Chair, Local Medical Committee Director of Primary Care JP Josh Potter Director of Commissioning Operations Other Officers in Attendance TF DB Tony Foote Diane Bebbington Note Taker NELCSU Interim Board Administrator Apologies Prof. Stephen Powis Secondary Care Consultant James Murray Chief Finance Officer (Interim) Members of the Public in Attendance David Ash Keep Our St Helier Hospital (KOSHH) Sandra Ash KOSHH Colin Crilly Eileen Fairclough KOSHH MRHF No. AGENDA ITEM WHO 1. Welcome and Introductions AM welcomed all to the meeting and noted the apologies received. 2. Declarations of Interest The Governing Body APPROVED the Register of Interests as a full and accurate record. 1

3. Minutes of previous meetings The following amendments were requested: List of Attendees That one of the two attendees abbreviated as TH be differentiated. With the incorporation of the requested amendment the minutes were APPROVED as a full and accurate record. 4. Matters Arising and Action Log 4.1 Actions arising from the meeting of the Merton Clinical Commissioning Group Governing Body of 27 th July 2017. 9.3 Children s Safeguarding Report Q3: KW had requested a copy of the Terms of Reference for the review of the joint safeguarding arrangements. JHe commented that the Review had been undertaken in February but without any specific timeframe. JHe said she would look into this further. 4.1 Patient s Story: (i) JP to look into the variation of mental health services across Merton and Wandsworth; (ii) JH to look into how the CCG could be more visible in the area of mental health. (i) JP stated that he had met with the clinical leads for MH for Merton and Wandsworth. These had gone well and work continued. (ii) At the most recent meeting of the Clinical Quality Committee the focus had been on Children s mental health. There were also efforts to involved children in the Equality Plan with the aim of child-specific objectives. 11 - Any Other Business - Questions from the Public: (i) JP to look into recurring issued with IAPT service; (ii) a member of the public requested definitive population projections (but these had not yet been received). (i) JP said that there were now weekly monitoring calls and the Service had a recovery plan with regard to the backlog of patients. He was also assured by the rise in the number of patients being seen. (ii) JP replied that these had been emailed and apologised that this had not been received. He added that he would print these out and give them to member of the public. JHe 5. Chair s Update, Chief Officer s Report and SWL Accountable Officer s Updates 5.1 Chair s Update In addition to the contents of the update, AM reported that the CCG was currently in the process of appointing a lay and a secondary care member. PD the current lay member for Audit - was not reapplying for the role. AM stated his gratitude to PD for his invaluable input since the very start of the CCG, and his great experience gained from a number of other member-roles in the local NHS. He had always been supportive and his helpful challenges and sense of humour would be greatly missed. SP the current Secondary Care member unable to attend the meeting today due to his many other commitments was also an original Governing Body member and his expertise had been vital to the many challenging issues the Governing Body had had to consider. He thanked them both for their service to the CCG. PD thanked AM for his kind words and wished the Governing Body and the CCG the very best for the future. 2

5.2 Managing Director s Update JB presented this paper and summarised the main issues: Changes to Merton CCG Consultation Constitutional changes have been proposed to facilitate joint working. These changes have been discussed by the Governing Body and they will be considered for approval at the additional October meeting. Staff consultation Consultation with CCG staff is in process regarding limited changes to secure joint work across the LDU. Health and social care integration JB had jointly written with the Director of Communities and Housing (LBM), to local stakeholders proposing a multi-speciality community provider model (MCP). Subsequently, an MCP Programme Board has been established. Merton and Wandsworth Local Transformation Board The Board includes the Chairs of Merton and Wandsworth CCGs, major NHS providers, local authorities and GP Federations. Representation will be broadened to the voluntary sector and Local Medical Committees. Health and Wellbeing Board (HWBB) and related matters JB attended Merton HWBB last week and noted the following: - A strong collaborative approach amongst Borough agencies - The strong performance of Merton Borough s Children s Services rated Good by Ofsted, reflecting the joint working arrangements in place. - The Chief Executive, Epsom and St Helier Hospitals, presented on the engagement work underway on future estates options for the Trust. Regarding elective care over the winter period. JB confirmed that work was ongoing with fortnightly meetings with St George s concerning capacity. KW added that winter pressures would be discussed at the next locality meeting. CG asked whether the LTB would include patient representation. JB replied that both Healthwatch Chairs were members and there was a strong involvement presence in all aspects of transformation work. 5.3 SWL Accountable Officer Update SB echoed that work to manage winter pressures was underway, with a particular focus on flu jabs and other preventative measures. She would bring a more detailed report on this to the November Governing Body meeting. SB 6. Governance 6.1 Conflicts of Interest Policy JHe presented the updated Conflicts of Interest Policy, which had also been considered and recommended for approval by the Audit and Governance Committee. The key changes were as follows: - That the register must be updated annually. - That all outside employment must be declared. - That particular consideration must be given in the context of new care models commissioning, i.e. any Multi-speciality Community Provider or other arrangements that include primary medical services. - Conflicts of interest management to be part of the annual internal audit. - Raising concerns and breaches where interests are not identified, declared or managed appropriately and effectively. - All employees, Governing Body members, members of CCG committees 3

and sub-committees and Practice staff with involvement in CCG business should have conflicts of interest training. PD (Chair of the Audit and Governance Committee) said that the Committee welcomed the changes to this policy and also that for the declaration of hospitality and gifts. SB raised the issue of material interest and asked for further guidance to be obtained on this issue. MJ reflected the need for transparency at all times. The Governing Body APPROVED the revisions to the Conflicts of Interest Policy subject to further clarification, as stated above, being obtained. 6.2 Gifts and Hospitality Policy JHe presented the updated Hospitality and Gifts Policy, stating that this had also been considered and recommended for approval by the Audit and Governance Committee. The key changes were as follows: - That the register be updated annually. - Gifts up to 6 can be accepted and not declared. All other gifts from suppliers or contractors must be declined and declared. - Gifts under 50 can be accepted from non-suppliers and non-contractors and not declared. Gifts 50+ must be declared and can only be accepted on behalf of an organisation not in a personal capacity. - Hospitality under 25 can be accepted and not declared. Between 25 and 75 can be accepted but must be declared. When 75+ hospitality must be declared and refused unless senior approval is given. JHe added that, following the consideration by the Audit and Governance Committee, the potential need for a policy relating specifically to gifts and hospitality offered by pharmaceutical companies had become apparent and this was currently being looked into. AMc asked how this policy (and that for conflicts of interest) would be communicated to CCG staff. JHe acknowledged the importance of this and there was a training plan in place for all staff. SB welcomed this but also highlighted the need to raise awareness of both policies more immediately and JHe said she would bring both to the next Staff Forum. The Governing Body APPROVED the Gifts and Hospitality Policy. 7. Commissioning 7.1 Better Care Fund (BCF) JP presented his paper which provided an overview of the BCF, its aims, budget and expected impact on hospital admissions/discharges along with its proposed development for 2017/19. The BCF Plan was submitted to NHS England on 11 th September 2017, already having been approved by the Health and Wellbeing Board. NHSE had not yet provided formal feedback on the submission. JP highlighted the trajectory for Care Delayed due to Transfers of Care and that this was particularly challenging for Merton due to a nationally mandated baseline being used to calculate the target trajectory. The Governing Body NOTED the Better Care Fund Submission. 7.2 Commissioning Intentions Process JP explained that the document Developing our Commissioning Strategy outlined the process CCGs must undertake to develop its commissioning strategy in line with that of the SWL Alliance and STP. The Governing Body would be asked to approve a developed strategy at the November meeting. The refreshed strategy will: 4

- Build on existing engagement. - Build on existing strategy and delivery in Merton. - Be part of an overarching SWL Commissioning Strategy supporting the goals of the STPs. There followed questions and comments from the Governing Body. Regarding specific engagement JP confirmed that some would be via the Health and Wellbeing Board. CG welcomed the overall approach towards engagement but would like more detail of which forums would be involved. JP said that if any Members had specific forums in mind they should let him know outside of the meeting. TH commented that the round of practice visits would soon be commencing and this could be another way of engaging on this issue. DZ highlighted the role of the Local Authority and that she was eager to discuss this further with JP outside of the meeting. JB welcomed this as supporting the need for a joined up strategy. AM then asked for questions and comments from the public gallery. Question 1 Could this document please be emailed to the Keep Our St Helier s Hospital Group? JP said he would do this. JP Question 2 We are led to believe that CCGs, Trusts and Local Authorities are all working together on a plan. However, with its current engagement it appears that Epsom and St Helier s is now going it alone. SB responded that the engagement was solely regarding estates and not related to the Commissioning Intentions. SB added that there were shared Commissioning Intentions and joint working across SWL involving the STP, AM suggested that the CCG s website could feature a clear description of the work being done by the various groups involved. The Governing Body DISCUSSED and NOTED the Commissioning Intentions Process. 8. Finance 8.1 Summarised Minutes of Finance Committee: 15.06.17; 18.07.17 NM informed the Governing Body that the summarised minutes were for note and invited PD (Chair of the Finance Committee) to give his thoughts on recent financial issues discussed at these meetings. PD commented that the challenges of the very tight budget for 2017/18 and the QIPP target had been the Committee s chief concerns. There was a significant challenge to the break even control total and the Finance Team was engaging with this. The Governing Body NOTED the summarised Minutes of Finance Committee meetings 15.06.17; 18.07.17. 8.2 Finance Report Month 4 NM summarised the CCG s financial position in Month 4 as follows: - The overall year to date position and forecast outturn in-year was breakeven as planned. - The year-to-date position for acute commissioning is an overspend of 1,309k, principally due to overspends at St George s and Kingston. 5

- The forecast outturn acute position is an overspend of 3,220k. This is driven by St George s, ESH and and Kingston. - A risk that QIPP will not deliver the fully planned savings required to deliver the planned breakeven position. It is planned to mitigate this with stretching existing QIPP and other one-off opportunities. - Running costs are still planned to be achieved. - Delegated primary care budgets are assumed to provide a small forecast underspend. - The 0.5% non-recurrent reserve remains uncommitted as per NHSE requirements. There followed questions and comments from the Governing Body. With regard to difficulty in forecasting acute outcomes and risks, NM said this was due to the differences between anticipated and actual earnings and the fluctuations in the price element. AM asked about the QIPP and how many were likely to bring savings and how many were transformational. CG was particularly interested in the mental health QIPP. JP said that any benefits from QIPP should come from improving the quality of services and that with mental health the aim was to ensure the right placements for people. The Governing Body APPROVED the Finance Report Month 4. 9. Primary Care 9.1 Summarised Minutes of Primary Care Commissioning Committee (Pt 1): 25.05.17 CG (Chair of the Primary Care Commissioning Committee (PCCC)) informed the Governing Body that the summarised minutes were for note and gave her thoughts on issues discussed at the meeting. Rowans Surgery Procurement The procurement process was approved and the contract awarded to AT Medics at its meeting on 27 th May. Ravensbury Park Medical Centre The CQC inspected Ravensbury Park in January and gave an overall rating of inadequate, placing it in Special Measures. The following actions are in place: - The Royal College of General Practitioners (RCGP) have drawn up a Special Measures Action Plan with scheduled monitoring meetings; - East Merton Locality Lead has offered ongoing clinical support to the Practice; - NHSE and the CCG have met with the Senior Partner and Practice Manager. Two questions from the public were put to the PCCC: Question 1 How many of the CCG s GP Practices are running unsupported versions of Microsoft Windows such as Windows XP which makes them vulnerable to ransomeware and malware attacks? CG responded that she had been assured that there were no GP computers on the system that we are aware of that are running XP software. Question 2 Is it/should it be a contractual requirement for Practices not to run unsupported software and keep their software up-to-date and apply relevant patches? CG responded that it was the responsibility of commissioners of GP services to also ensure that the GP systems are compliant with the latest NHS policies of 6

which supplier supported software replacement is needed, for example XP is now unsupported. The commissioners also are requested to replace the old Computers in practices to allow for the new up to date software to be installed. Both questions will also receive written responses. The Governing Body NOTED the summarised Minutes of Primary Care Commissioning Committee (Part 1): 25.05.17. 10. Quality and Performance 10.1 Summarised Minutes of Clinical Quality Committee: 05.07.17; 02.08.17 CG (Chair of the Clinical Quality Committee) informed the Governing Body that the summarised minutes were for note and gave her thoughts on issues discussed at the recent meetings. The main issues were the IAPT targets, the PMS Review and the Primary Care Hubs. CG commented that she had had cause to use one of the Hubs recently and found them very helpful and accessible. CG added that at the most recent meeting the provider of Children s Services and the Mental Health Trust had attended for a very positive discussion, particularly with regard to the transition from children to adult s services. JHa commented that she was particularly interested in mental health service users who are hospitalised and what is the best course of action for them and their carers. She said she would take this issue up with providers at a future meeting. 10.2 CCG Governing Body Assurance Report and Scorecards JA presented the Assurance Report and Scorecards and highlighted the following areas: Positive performance had been seen in the following areas: - London Ambulance Service response times - Diagnosis of Dementia rates - Delayed Transfers of Care More challenging areas were: - A&E admitted/transferred/discharge performance - Utilisation of e-referral service Some improvement is being shown here but Merton remains considerably below the London average of usage. Risks and Exceptions were: - IAPT number of people entering 1 st treatment JA commented that this remained a significant concern. There were now weekly telephone conferences and an action plan in place. Additional staff had been recruited and the aim was to be rid of the backlog by mid- October. - Cancer: 2 weeks wait - Cancer: 2 weeks wait (breast symptoms) - Cancer: 31 day wait JA also highlighted the CCG s Improvement and Assessment Framework rating that had improved from Requires Improvement in 2015/16 to Good in 2016/17. There followed questions and comments from the Governing Body. St George s appeared to have difficulties with listing clinics on the e-referral system. What is the reason for this and how do other Trusts compare? JA said 7

that work was ongoing to understand the particular issues involved, with an action plan to follow. Most other Trusts were performing better. SB emphasised the need to learn from these Trusts as the system was vital in improving the availability of appointments for patients. AM asked what should GPs say to their patients about the IAPT Service? JA suggested that the backlog would be cleared by mid-october and improvements should follow. TH said that he hoped that, from then, the wait from triage to appointment would be in line with the current contract. The Governing Body APPROVED the Assurance Report and Scorecards 10.3 Complaints PALS Annual Report 2016-2017 JHe presented this report, noting the information about standard performance targets for complaints and PALS enquiries and that, with regard to response targets the CCG did well and that the number of complaints and enquires received was higher than most other CCGs. However, JHe added that she would like to see more evidence of lessons learned and quality issues. SB agreed and emphasised the importance of having evidence of complaints both local and South West London-wide. TH added that data from complaints could be used to inform the Primary Care CQRG and AM stated that it would be good to get Practices to confirm they have Complaints Policies in place, and carry out regular monitoring of complaints showing learning from these. MJ commented that Practices were obliged to have a Complaints Policy and should be able to provide information about the general these emerging. SB requested that JHe discuss this with the LMC. JHe The Governing Body Approved the Complaints PALS Annual Report 2016-2017 adding that the improvements requested should be incorporated inti future reports. 11. Any Other Business AM invited further questions from the public gallery. Question 1 The risk of not meeting targets is very high and the STP wants huge savings. Where will these come from and will any cuts impact on patient welfare? SB responded that the CCG was not intending to make cuts but looking at increasing efficiency. The CCG was required to adhere to the Nolan Principles regarding patient welfare but also faced significant financial challenges. The CCG will be talking with people about what is needed locally and this will feed into a refreshed plan that will be available for view on the website in November. Question 2 The key to the plan is the overall reduction in the number of hospitals. Who is responsible for this plan and how does it relate to Epsom and St Helier s current engagement? SB responded that the plan had been created by commissioners and clinicians and that its view was that all current hospitals would still be needed, although they may be used differently. If the final decision was to move/consolidate services, and this was considered to be a major change, a formal consultation process would be held. Question 3 Epsom and St Helier s is currently putting a bogus argument for new premises. This is a trap. The CCG should be providing additional funding to update the current premises. 8

AM replied that all at Epsom and St Helier s were focused on providing high quality services but it had to be recognised that there were significant constraints. Question 4 Would the Governing Body welcome a presentation by the Keep our St Helier Hospital Group AM said a presentation as part of any formal consultation would be welcomed. 12. Meeting close The meeting closed at 3.30pm. 13. Date of next meeting 30 th November 2017, 1.00pm - 4.00pm, 120, The Broadway, Wimbledon, SW19 1RH. Signed as a full and true record of Part 1 of the Merton Clinical Commissioning Group Governing Body Meeting on the 28 th September 2017. ---------------------------------------------------- --------------------------------- Dr Andrew Murray Clinical Chair Date 9

MERTON CLINICAL COMMISIONING GROUP GOVERNING BODY MEETING PART 1 26 th October 2017 Rooms 6.2/6.3, 120 The Broadway, Wimbledon, SW19 1RH Chair: Dr Andrew Murray In attendance: Members SB Sarah Blow Accountable Officer JB James Blythe Managing Director CG Clare Gummett Lay Member: Patient & Public Engagement Lead JHa Julie Hall Nurse Member TH Dr Tim Hodgson GP Member JM James Murray Chief Finance Officer (Interim) SP Prof. Stephen Powis Secondary Care Consultant KW Dr Karen Worthington GP Member Non-Voting Members JHe Julie Hesketh Director of Quality & Governance MJ Neil McDowell Local Finance Director MJ Dr Marek Jarzembowski Chair, Local Medical Committee Other Officers in Attendance MW Michelle Wallington Communications and Engagements Lead, NELCSU TF Tony Foote Note Taker, NELCSU Apologies Peter Derrick John Atherton Andy McMylor Dr Dagmar Zeuner Members of the Public in Attendance There were no members of the public present. Lay Member: Audit and Finance/Vice Chair Director of Performance and Management Director of Primary Care Director of Public Health, LBM No. Item Resp. 1. Welcome and Introductions AM welcomed all to the meeting and noted the apologies received. He announced that the meeting was not being live-streamed due to technical issues. However, the recording of the meeting would be posted on the website tomorrow. 2. Declarations of Interest The Governing Body APPROVED the Register of Interests as a full and accurate record. No other declarations of interest were made. 3. Governance 3.1 Constitutional Changes 10

JB explained that the primary purpose of the proposed changes to the constitution was to enable a new way of working as part of the South West London Alliance, allowing the CCG to make decisions with other CCGs under a Committee in Common (CiC). Additionally, the creation of a Managing Director post as a voting member would assist the Accountable Officer in giving leadership and control for the CCG. The Constitution had also been updated to reflect the following: - A third Lay Member (voting) to be added to the Governing Body - The addition of a Primary Care Commissioning Committee - Updated Standing Orders, Prime Financial Policies and Scheme of Delegation and Reservation approved in December 2016 - Establishment of a Conflicts of Interest Guardian - New national Conflicts of Interest Guidance (June 2017) JB reminded the Governing Body that it was being was asked to support the proposed changes for formal recommendation to the CCG Membership, and then invited questions and comments from the Governing Body. AM asked about consultation with Member Practices. JB confirmed that there had been discussions with the Local Medical Committee and then all Practices had been written to, adding that all Practices had confirmed their support of the proposed changes. JHe asked whether decisions made by CiCs had to be unanimous and SB confirmed that they did. In light of the three person delegation actually attending CiC meetings, CG asked if there would always be an opportunity for the whole Governing Body to discuss these issues prior to decisions being made. SB confirmed there would, although the process for this may differ between CCGs and be dependent on the prevailing circumstances. SB said that constitutions need to be reviewed on a regular basis and there was a need to build in an annual review to avoid the need to changes being made on an ad hoc basis. The Governing Body SUPPORTED the proposed changes to the constitution and that it now the formal recommendation to the CCG s Membership should be sought. 3.2 Corporate Objectives 2017/18 JHe reminded the Governing Body that at a Joint Governing Body seminar with Wandsworth CCG on 5 th September 2017 it was agreed that a common set of objectives should be adopted. The objectives were further discussed and reviewed at a joint meeting of the CCGs Executive Management Team on 11 th October 2017. The draft objectives were as follows: 1. Improving Outcomes and Reducing Inequalities: Ensuring access to high quality and sustainable care. 2. Leading with ambition for our communities, driving transformation through innovation: Delivering better care and a better patient experience. 3. Working Together: Continually improve delivery by listening to and collaborating with our patients, members, partners, communities and other stakeholders. 4. Meeting our performance and financial objectives: Make the best use of our resources to benefit our patients and communities. 5. Supporting Our People: Provide the tools and environment for a healthy workplace and support our staff to do a great job. Be a learning organisation that encourages continuing improvement. There followed questions and comments from the Governing Body. The issues of how to embed the objectives in all aspects of the CCG s work, including the Governing Body, was raised. JHe suggested that they be flagged up at 11

the beginning of each Governing Body meeting to ensure that all business related to the objectives. They should also form a framework for commissioning intentions. SB added that it was necessary for processes to flow from the corporate objectives. AM said that the objectives had been crafted to be comprehensive and that the Governing Body needed to remind itself what they meant in practice. JHe suggested that some background text should be added to each objective and that Directors should ensure their teams are working to the objectives. JB proposed that said that the objectives should be part of the staff induction pack and included in the annual report. The Governing Body approved the Corporate Objectives 2017/18. 4. Any Other Business AM read out a question received via email - from a member of the public: How much is the proposed restructuring costing to deliver and how much will it save? How long is the structure expected to remain in place before a further reorganisation? How many and what has been the cost of reorganisations of Merton CCG and CCGs across South West London in the last 10 years? How will all these organisational changes improve delivery of frontline services to patients? AM said that, due to the complexity of the issues raised, a written response would be provided. AM/ SB 5. Meeting Close The Meeting closed at 1.25pm 6. Date of the next meeting The next meeting of the Governing Body will be held at 120 The Broadway, Wimbledon, SW19 1RH on 30 th November 2017, 1.00pm 4.00pm. Signed as a full and true record of Part 1 of the Merton Clinical Commissioning Group Governing Body Meeting on the 26 th October 2017. ---------------------------------------------------- --------------------------------- Dr Andrew Murray Clinical Chair Date 12