Minutes of the meeting held on Tuesday 5 Th December at 1.30pm, at Vassall Centre, Gill Avenue, Fishponds, Bristol

3 NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups Governing Body Meeting In-Common Minutes of the meeting held on Tuesday 5 Th December at 1.30pm, at Vassall Centre, Gill Avenue, Fishponds, Bristol Present Julia Ross Chief Executive, BNSSG CCGs JR Glyn Howells Interim Chief Finance Officer, BNSSG CCGs GH Peter Brindle Medical Director, BNSSG CCGs PB Lisa Manson Director of Commissioning, BNSSG CCGs LM Deborah El-Sayed Director of Transformation, BNNSG CCGs DES David Jarrett Area Director, BNSSG CCGs DJ Colin Bradbury Area Director, BNSSG CCGs CB Justine Rawlings Area Director, BNSSG CCGs JRa Martin Jones Clinical Chair, Bristol CCG MJ David Soodeen Inner City & East Bristol Representative, Bristol CCG DS Brian Hanratty South Bristol Representative, Bristol CCG BH Alison Moon Director of Transition, Bristol CCG AM Anne Morris Director of Quality & Nursing, BNSSG CCGs AMo Pippa Stables Inner City & East Bristol Representative, Bristol CCG PS Tara Mistry Lay Member, Bristol CCG TM Mary Backhouse Clinical Chair, North Somerset CCG MB Kathy Headdon Lay Member & Vice Chair, North Somerset CCG KH Miriam Ainsworth GP Representative, North Somerset CCG MA Ryan Richards Lay Member & Chair of Audit, North Somerset CCG RR Jon Hayes Clinical Chair, South Gloucestershire CCG JH Nick Kennedy Secondary Care Consultant, South Gloucestershire CCG NK Andrew Appleton GP Governing Body Member, South Gloucestershire CCG AA Kate Mansfield GP Governing Body Member, South Gloucestershire CCG KM Janet Biard Practice Manager Representative, South Gloucestershire CCG JB Jeanette George Chief Operating Officer, North Somerset CCG JG Danielle Neale Lay Member, Chair of Audit Bristol CCG DN John Rushforth Lay Member, South Gloucestershire CCG JRu Kirsty Alexander North & West Bristol Representative, Bristol CCG KA Martin Gregg Lay Member, South Gloucestershire CCG MG Alison Bolam North and West Bristol Representative, Bristol CCG AB Sara Blackmore Director Public Health, South Gloucestershire Council SB Apologies Lesley Ward South Bristol Representative, Bristol CCG LW David John GP Representative, North Somerset CCG DJo Kath Payne Practice Manager Representative, North Somerset CCG KP Sally Hogg Consultant in Public Health Bristol City Council SH In attendance Kate Rush Clinical Lead BNSSG KR Gill Ryan Delivery Director BNSSG GR Marie Davies BNSSG Head of Commissioning for Quality MD Louise Fowler Patient and Public Involvement Programme Lead LF Louise Rickitt Head of Strategic and Service Redesign LR

Sarah Carr Corporate Secretary, Bristol CCG (note taker) SC 1 Apologies Martin Jones (MJ) opened the meeting and the apologies above were noted. 2 Declarations of Interest Kathy Headdon (KH) had been appointed as a trustee of Voluntary North Somerset (VANS). Deborah El-Sayed (DES) was a trustee of the British Red Cross. 3 Minutes of the Previous Meeting and Matters Arising The minutes were agreed by the Bristol CCG, North Somerset CCG and South Gloucestershire CCG Governing Bodies as a correct record with the following amendments. Alison Bolam (AB) had attended the meeting Page two, item 2, should have read Ann Sephton had taken on the role of medical director at Sirona Page four, item 7, first paragraph, forth sentence should have read a three year recovery plan in place by February. Page six, item 8.1 fifth paragraph, final sentence should have read Only indicative activity plans could be agreed with providers. Page Six, second paragraph should have read the CCG was in discussion with NHSE Page seven, fourth paragraph, the Governing Bodies had discussed the recommendations and had agreed not to implement the recommendations relating to funding fertility treatment for couples where neither had a living child and the reduction in age limit. This decision was reflected in the recommendations, however not referred to in the discussion. Page eight, item 9.1, third paragraph, should have read JR highlighted it was the trust s responsibility to account for the action and the CCGs had an important role in supporting the delivery of the plan. Page ten, item 11.10 the second bullet point should be removed from the recommendations. The final bullet point should read the detailed assessment of the financial position, including the risk and mitigations, was undertaken. Page 14, item 12.1, the third paragraph, it was noted that the voting membership of the Strategic Finance Review committee would comprise of six non-officer members; each Governing Body would nominate two non-officer members to the committee, and one of each CCGs two nominees would have a financial qualification, expertise and experience. At least one of the six nonofficer members would be a clinician. A non-officer member was defined as either a Governing Body GP clinical representative or a Governing Body lay member. Page 13, item 15, A question had been received from a member of the public, Charlotte Patterson. It was noted that an action relating to the quoracy requirements of the Bristol CCG Remuneration Committee had not been recorded. Jeanette George (JG) confirmed that the terms of reference had been reviewed and the requirement was for three members including the Chair to be in attendance. 4 s from the Previous Meeting 2

The action log was reviewed: 3 Oct 17 item 8.1 ref 01, 02, 03: the actions would be addressed in a single item to be presented to the Governing Bodies at the January 2018 in-common meeting. The actions would be merged to form one that remained open. 7 Nov 17 item 7 01: progress on the single Constitution was reported in the Transition paper to be received at this meeting. The Draft Constitution would be presented to the February 2018 in-common meeting. The action was closed. 7 Nov 17 item 11.1 01: performance data for community providers would be incorporated in future performance reports. The action was closed. All other actions were closed. 5.1 Update from the BNSSG Clinical Chairs Bristol CCG Martin Jones (MJ) reported that: The Bristol Localities had agreed to continue with the current clinical locality leadership unless vacancies arose The city plan developments in Bristol were firmly targeted at the determinants of health and it was encouraging to be part of the process and to see the involvement of private, public and third sector on behalf of the city in the longer term Information gathering around developing a plan for Healthy South Bristol had started and a plan for working with stakeholders to develop priorities for this piece of work was being put together 5.2 Update from the BNSSG Clinical Chairs North Somerset CCG Mary Backhouse (MB) reported: The North Somerset members met monthly and their agenda was increasingly aligned with that of Bristol and South Gloucestershire. The focus was on matters that were important to the whole community whilst maintaining a local focus. The Healthy Weston Project continued. The public dialogue meetings were being completed; an active programme continued and there would be on-going meetings with stakeholders. The Acute Frailty Network had visited Weston Area Health Trust (WAHT). Health Education England had also visited the Trust. MB continued as a member of the Clinical Senate and the Health and Wellbeing Board Network. 5.3 Update from the BNSSG Clinical Chairs South Gloucestershire CCG Jon Hayes (JH) reported: The membership was working well together, establishing a response to the Local Transformation Scheme and co-ordinating themselves as a locality provider of services. The proposal was that a single Commissioning Locality was formed. This would be confirmed with the membership. The joint work between Avon and Wiltshire Mental Health Partnership Trust (AWP) and the local authority, supported by the CCG had been nominated for a Dementia Care award 6.0 Chief Executive Report Julia Ross (JR) welcomed Deborah El-Sayed, Director for Transformation, to the meeting. 3

JR explained that there had been a constructive meeting with the Local Medical Committee (LMC) regarding the proposed Constitution for the single CCG. Helpful feedback had been received. JR highlighted that the term localities was used in both providing and commissioning contexts. For clarity the terms Provider Localities and Commissioning Localities would be used. Colleagues were encouraged to share the message that there were two distinct forms of localities. JR informed members that there would be a meeting with GP Practice Managers to discuss the development of Provider Localities; this meeting was also open to GP colleagues. 7.1 Update on Transition Alison Moon (AM) informed members that the work relating to merger and transition had come together. This was overseen by the Transition Group which she chaired that reported to the CCGs executive team. A detailed merger plan covering a range of key work streams had been developed that would be shared with members if requested. Louise Rickitt (LR) drew attention to the progress made. Positive discussions had been held with practices and the LMC regarding the proposed Constitution. Work was underway to develop the job descriptions and establish the appointments process for the new CCG Governing Body. A meeting would be held in February for the BNSSG CCGs membership to develop the shortlist of candidates for the Clinical Chair post. Progress had been made in relation to the proposed organisation structure and clinical leadership models. Work was underway to revise the financial recovery plan. The key areas of the merger action plan were highlighted. The creation of the single commissioning voice continued and an event for all staff members was planned for February 2018. The restructuring of teams and staffing across the three organisations was in progress. A Joint Consultative Committee had been established with strong staff representation. Work to develop and adopt a common approach to financial management was in place. LR invited questions. AM highlighted that this was an unsettling time for staff. A clear message from staff had been the need for clarity and transparency. The CCGs had established a number of communication mechanisms with staff and work continued to develop these. This included the setting up of all staff meetings, a BNSSG Intranet site, Team brief and a dedicated transition email address. Martin Gregg (MG) observed that the proposed Patient and Public Involvement Forum was the subject of item 11.2 on the agenda. MG noted that the membership would be developed and confirmed at a later point. MG asked if the proposed Constitution would need to be amended to reflect changes to the forum membership. JR explained that the intention was to establish a flexible Constitution that allowed the CCG to develop. The membership of the forum had not been stipulated in the Constitution. Governing Bodies noted the report 7.2 Clinical Leadership Model JR explained that the proposals had been developed in partnership with the current clinical leadership and the wider membership. Kate Rush (KR) explained that the 4

aim was to establish a strong and consistent clinical leadership across the BNSSG CCGs with close links to management leads. The proposal was for four categories of clinical leadership roles: Commissioning Locality Leads, Provider Locality Leads, Pathway Leads, and Corporate Leads. With the exception of the Provider Locality Leads, the clinical leadership roles would sit on the Commissioning Executive. There would be a total of 15 clinical leads on the Commissioning Executive. KR explained the timescales for the appointment of the Commissioning Locality Leads, the Corporate and the Pathway Leads. The aim was to have all clinical leads in place for February 2018. John Rushforth (JRu) commented that there was no self-care and prevention role. KR confirmed that a specific lead role had not been developed. There had been discussions about how self-care and prevention sat within the clinical model. JR commented that self-care and prevention was a critical role and it was important that it was embedded in the role of all the Pathway Leads. Kirsty Alexander (KA) asked if other clinical lead roles such as the Macmillan role would continue. It was confirmed that these roles would continue. Brian Hanratty (BH) suggested that the Provider Locality Lead role was removed from the diagram depicting the Medical Clinical Leadership structure. Kathy Headdon (KH) asked if there were challenges related to the management of conflicts of interest that needed to be considered. KR agreed it was important to be clear on the role of Commissioning Locality Lead. It was asked where the Governing Body GP representatives sat in the structure. It was explained that the Commissioning Locality Leads would be the Governing Body GP members, with three members from Bristol representing the existing Localities, two members for North Somerset and two members from South Gloucestershire. David Soodeen (DS) noted that a clinical lead for health inequalities and inequalities had not been identified. DS acknowledged that this should be considered as business as usual and observed that there were occasions where a clinical lead was valuable. JR commented that this was an important principle that underpinned the work of the CCG. It was noted that the Commissioning Executive included public health representation. It was important to ensure that the roles included a clear description confirming the responsibility for inequalities and health inequalities. KR KR AM highlighted that the model would create resilience across the clinical leadership and provide support to the clinical leaders. The development programme that sat alongside the model was welcomed. Governing Bodies noted and endorsed the new model of Clinical Medical Leadership for BNSSG 7.3 Update on Plans for Improving Rehabilitation, Reablement, and Recovery Services for South Gloucestershire (the 3R s Programme) Lisa Manson outlined the background to the paper. The programme had commenced in 2013 and there had been slippage across a range of issues and providers. A business case for the redevelopment had been received from Sirona and had been tested by commissioners for the most likely date of occupation which was estimated as late 2019. The Sirona Board had clarified that it required a minimum contract of five years to ensure the project s viability. This would extend the contract term beyond the maximum term available through the existing 5

community services contract. Legal advice confirmed that the CCG could not offer to extend the contract within the legal framework. It was proposed that the CCG did not continue with model of procurement with Sirona; it was recommended that an options appraisal was concluded in quarter four and returned to the Governing Body in April 2018. JRu asked if the CCG was open to legal challenge by Sirona. LM explained that the CCG would not be liable to challenge. The issues had been discussed with Sirona who were disappointed and understood the position. Kate Mansfield (KM) observed that this had been a significant programme for South Gloucestershire CCG and an important issue for the local community however it was clear that the CCG had to work within the legal parameters. JR commented that the passion that underpinned the programme and the detailed history behind the programme were understood. Sadly the procurement approach was no longer legally viable. JR had committed to South Gloucestershire Council and Sirona that there would be a clear course of action in April 2018 and that this would be taken forward. It was important to reach a firm decision and take firm action to deliver against this decision. MB observed that it was important to maintain the confidence of the local population through communication and asked how this would be taken forward. LM explained that a communications plan was in place and developing; it was important to build on the work already completed. JR reported that she had written directly to the local MPs. It was important now to engage with people through the options appraisal to enable discussion. JH commented that it was embarrassing for the CCG to be in this position however the recommendation was the right course of action under the circumstance; it was important that, given the time that had already passed, there was an assurance that the information required to make a firm decision would be available for April 2018. LM confirmed that the intention was to undertake an options appraisal in quarter four and bring recommendations to the Governing Body in April. Governing Bodies: Approved that the current process in respect of the development of new health and social care facilities at Frenchay and Thornbury would be terminated based on the legal advice received Approved that a full options appraisal would be undertaken to identify an alternative approach to progressing this work in the context of providing rehabilitation, reablement and recovery services across BNSSG Noted that land at Frenchay and Thornbury remained the preferred locations for the development of health and social care services for the South Gloucestershire area. There was an agreement in principle with North Bristol NHS Trust that land at both sites would continue to be reserved for this purpose until the commissioner s work is concluded, and the CCG would continue to work in partnership with South Gloucestershire Council to optimise the resource for health and care provision 7.4 Re-procurement of Assisted Conception Services LM set out the background to the paper. The CCGs commenced a single provider procurement in 2017 and appointed a successful provider in October 2017. During the procurement a number of factors changed; feedback from the population highlighted concerns about patient choice and issues arose regarding the historic 6

storage of samples. Subsequent to the contract award a legal challenge was made by an unsuccessful bidder and after significant consideration a decision was made to abandon the procurement. It was important to ensure that the service remained available. The North Bristol Trust (NBT) service was terminated on the 30 November. Patients were currently being treated by other providers through a commissioning process of non-contractual activity. The CCGs did not wish to continue with this. The recommendation was that an Any Qualified Provider (AQP) approach was adopted. This would enable the CCGs to offer patient choice and move quickly to this mechanism in February 2018. MJ asked about the proposed timescales. It was explained that the AQP nomination process would commence immediately, an assessment of providers against the criteria set out in the paper would be completed in January 2018, with the service starting on the 1 st Mach 2018. MJ asked if there were interested providers. A market review had been completed as part of the initial procurement which indicated a number of potential providers. JR asked why the AQP was the recommended option and not a full procurement. LM explained that one of the reasons for the original single provider procurement approach was storage of samples. This matter was no longer an issue as NBT had confirmed it would continue to provide storage for historic samples. Under the current commissioning mechanism the CCGs were negotiating with providers for individual cases. AQP would enable patients to choose providers and provided a more robust mechanism for commissioning. LM recommended to the Governing Bodies that an evaluation of the AQP process was carried out after one year to identify benefits and issues. BH observed that the patients involved were often well informed and that offering wider patient choice was to be welcomed. BH asked if there was national evidence of AQP being used for this service successfully. LM agreed that the offer of choice under AQP would benefit patients; AQP was used successfully for assisted conception services and it was noted that there was no local NHS provider for this service. DES commented that AQP was an agile procurement model. Janet Biard (JB) asked if the AQP model would be more costly. Gill Ryan (GR) explained that the AQP model would be a local tariff set by the CCGs. Available evidence demonstrated that AQP costs would be lower than current payments and the previous contract. GR explained that the process would be managed through Prior Approval, enabling commissioners to monitor providers. LM confirmed that the evaluation would consider costs. It was emphasised that the AQP mechanism was not being used to increase savings. Governing Bodies approved: the recommended commissioning option of Any Qualified Provider, and the formal advertisement and documentation 7.5 Update on the Consultation Process for the cycle 1 System Financial Recovery Process David Jarrett (DJ) explained that the paper provided an update and proposed recommendations based on the outcomes of the consultations with patients, carers and the public on a number of proposals related to the system financial recovery process. The paper also recommended that Bristol CCG agreed to a consultation regarding changes to gluten free prescribing. 7

DJ drew attention to page five of the paper and the recommendations that had been approved by the Governing Bodies and implemented and the recommendations that had not been approved by the Governing Bodies relating to fertility treatment. Members discussed the proposed Chronic Liver Disease Pathway. The proposal consulted on was for a consistent approach to testing for, and treating chronic liver disease across BNSSG. The proposal was for a chronic liver disease pathway and a non-alcoholic fatty liver disease (NAFLD) pathway. A web based consultation had been used and focus groups were held with specialist services. Feedback was generally positive. KR highlighted that patient feedback was for clarity of the pathway and a patient version of the pathway had been created in response. KA asked whether there had been a modelling of the costs of scans and possible impact on alcohol treatment and obesity services. KR confirmed that there had been close engagement with public health colleagues and the pathway led to healthy life style advice and ensuring that patients were able to access this. Alcohol and drug treatment services were clear that this would not be an increase in workload. KH suggested that in future papers described the financial benefit that proposed changes would deliver. DS welcomed the proposal and highlighted concerns that the prevalence of NAFLD could significantly increase resulting in increased in costs. KR agreed and noted that the pathway was for those patients already identified and did not extend to patients with other conditions and life style factors. BH raised the potential for an unfunded shift of work from secondary to primary care. JR commented that this was a patient group receiving treatment and the proposal was for additional resource and support. JR understood the concerns about the shift of work to primary care. KR highlighted the intention to address current inefficiencies across the pathway including the repetition of tests. There was a discussion about community Fibroscans and it was explained that a community pilot was planned in a small number of sites. It was understood that BH s concerns related to the potential of an increase in the primary care workload. Members discussed the matter. It was noted that best practice evolved and that at times this could initially impact on workloads. It was commented that the review of scans was relatively straight forward for GPs. It was noted that some patients would change lifestyle habits. The pathway and the guidance provided had been welcomed. It was also noted that resources needed to follow pathways. JR reflected that members were challenging the costing of the model and the financial implications. This modelling needed to be completed to understand the position and built into future proposals. Members were clear that the proposal was the right course of action. There was a principle being expressed that resources should follow the patient; the challenge was to understand if the proposal added to the primary care workload and if so why. BH clarified his concerns were related to the capacity of primary care. Alison Bolam (AB) observed that a robust evaluation would be needed in response to the challenges described. It was explained that there would be a detailed evaluation that would include secondary care. It was noted that there were also measures that could be used to understand any increase in primary care. KR Members discussed the proposal regarding the revised breast reconstruction after cancer policy. Peter Brindle (PB) gave the background to the proposal for further consultation on the revised policy. It was explained that the policy had been 8

significantly revised following response to the initial engagement where 95% of respondents disagreed with the proposal. The recommendation was for a further four week consultation on the new policy. It was explained that the policy had been developed in discussion with the onco-plastic surgeons. The public engagement exercise would be targeted and thorough. It was proposed to commence the engagement process in mid-january and further details of the proposed approach would be discussed with the CCGs Commissioning Executive. It was planned to hold face to face interviews and telephone discussions with individuals as part of the consultation to ensure that views were heard and understood. JR asked why a four week consultation period was recommended given the high profile of the initial consultation and the feedback received. It was important to be assured that the policy was correct. PB explained that the aim was to conclude an excellent consultation in a four week period to provide certainty for patients and clinical services. JR asked for clarification of what was meant by an excellent and focused consultation and whether stakeholders expressed a view that this was appropriate. PB explained that the previous consultation had been web based and the proposal was for face to face discussions and focus group work. Louise Fowler (LF) explained that local patient groups would be contacted alongside members of the public who had expressed an interest in the policy. JR highlighted responses to the previous consultation included the view that the consultation period had been too short. Tara Mistry (TM) sought clarification of the major change to the policy. PB explained that surgery on the contralateral (unaffected) breast would be offered. It was explained that previously there were different approaches and no clear policy. TM asked if the Bristol local authority Women s Commission had been consulted. LF agreed to add the Commission to the stakeholder list. LF MB noted that usually consultations took 12 weeks. There did not appear to be a compelling reason for a shorter consultation period. It was commented that given the high profile of the issue greater assurance would be provided by a 12 week consultation period. KH noted that the CCG Patient and Public Involvement Leads were involved in a number of significant pieces of work and a longer consultation period would reduce capacity issues. It was agreed that a 12 week consultation was appropriate. Members discussed the proposal to recommence the consultation on ending the contract for homeopathy services. The initial consultation had generated significant feedback. There was strong support for the proposal although there were comments opposing the proposal from service users and the service provider. NHSE had recommended to the Department of Health that homeopathy was no longer provided through the NHS. The proposal was for a focused 12 week consultation. Nick Kennedy (NK) noted that there was no clear evidence supporting the commissioning of homeopathy services. JR agreed that evidence based commissioning was the right approach. It was known that users of homeopathy reported a benefit and it was important to maintain a balanced view. Members discussed the proposal for a Bristol wide consultation on the prescribing of gluten free products. The background to the proposal was explained. BH asked if guidance for prescribers on discretionary prescribing had been issued. This was confirmed. It was noted that national guidance was now available and that this would be reviewed. The proposal would bring Bristol into line with North Somerset 9

and South Gloucestershire. KH commented that foodbanks had been approached as part of the consultation process in North Somerset. PB observed that Bristol CCG spent approximately 13,000 per month on gluten free products with 80% for adults. There was therefore a potential saving of 10,000 per month. David Jarrett informed members that a 'You Said, We Did' report would be published. The paper highlighted some of the learning. Martin Gregg (MG) noted that the report should be published through the websites and asked that a more proactive approach be used. JR asked that the report was shared with people who had provided comments where possible. JR asked that the report be called an Outcomes Report. Danielle Neale (DN) requested that indicative costing be included in future consultations. KA asked if consultations placed proposals within the context of the challenge facing the CCGs. JR commented that the CCGs would in future need to consider difficult decisions and how to best involve people in these decisions was important. LF Governing Bodies: Approved the chronic liver disease pathway Approved a new 12 week consultation on the revised post breast cancer reconstruction policy Agreed to delegated responsibility for implementation to the Commissioning Executive following the consultation on the new breast cancer policy Approved the recommendation to recommence the engagement process for homeopathy by delivering phase 2 of the Communication and Engagement Plan The Bristol CCG Governing Body approved a move to consult with patients, public and our stakeholders with a proposal to limit prescribing of gluten free products only to those patients with a diagnosis of coeliac disease under the age of 18 years and remove gluten free products from the formulary for patients over 18 years 8.1 BNSSG Finance Report as at Month 7 Glyn Howells (GH) presented the BNSSG finance report and explained that at Month 7 the CCGs had delivered in line with the forecast reported to NHSE at Month 6. The CCGs continued to report a forecast outturn position of a 30 million deficit, a variance of 22 million from plan with a further 5 million unmitigated risk relating to savings delivery and prescribing costs. To achieve this position required the delivery of full year savings of 42 million. At Month 7 the CCGs had achieved savings of 20 million. GH explained that annualising the Month 7 position took the expected savings to 35 million and that the challenge was delivering the incremental savings above that to achieve the required 42 million. GH drew attention to the risk regarding No Cheaper Stock Obtainable NCSO price concessions on the financial position. It was explained that additional costs had been incurred as a result of NCSO concessions granted where products were not available at the Drug Tariff price leading to the dispensing of equivalent products at prices above the set Drug Tariff. The year to date position for additional costs incurred was 2.7 million with a further potential risk each month of additional costs of 0.5 million - 0.7 million. It was noted that this was a national issue. It was 10

explained that the CCG Medicines Management team were actively pursuing all possible mitigations. It was noted that there was also a risk in relation to primary care workload where products at the Drug Tariff were not available in the UK. DS noted that there was significant variation between the prescribing costs for Bristol and South Gloucestershire compared to North Somerset which had reported lower costs. It was explained that the impact of the NCSO issues was the same across the three CCGs however the North Somerset position should over deliveron savings schemes which mitigated the impact. It was noted that all three CCGs performed better than average on spend however the Bristol and South Gloucestershire positions had moved closer to the national mean. Work was under way to understand the position and the potential mitigations. DS highlighted that this position would not be identified in an aggregated BNSSG report and asked how this would be addressed. GH explained that the reporting team had been asked to identify the appropriate level of detail for future reports. JR observed that data at Locality level would be appropriate. NK asked if there were patient safety issues. PB explained that there were directly comparable medications and that the issues related to finance and work load. MJ it was noted that there were patients for whom swapping mediations was complicated. NK asked if there was an issue if medications were not available. The issue was that it was not clear how long products at the Drug Tariff would be unavailable; therefore it was not clear whether it was worth switching patients medication. DN informed the Governing Bodies and members of the public that the three audit chairs and members of the executive team sat on the Strategic Finance Committee and reviewed the information provided in detail. DN noted that the schedule of risks and mitigations was not included with the report. This would be reinstated in future reports. JR asked how the CCGs would be assured that there was no harm to patients. PB clarified that if a decision not to switch was made the patient remained on the current medication which was more expensive. It was explained that GPs would discuss issues with the Medicines Management team. It was agreed that the Medicines Management team would review whether there were patient safety issues. KA commented that communications to patients explaining why medicines were switched would be helpful. GH GH JR observed that there were a number of areas of overspend in the report that were within the CCGs scope to resolve and asked for further information. GH explained that the budget lines had been adjusted to account for savings programmes and variances occurred where savings plans were under target. JR sought confirmation that within all these areas work was in place to stop over expenditure. This was confirmed. Governing Bodies noted: the financial position, the key risks, issues and mitigations that the detailed financial assessment of the financial position including the risks and mitigations undertaken at the Joint Strategic Finance Committee in November the BNSSG forecast outturn for 2017/18 is a deficit of 29.9m. the requirement of the external auditors to write to the secretary of state for health of the likely breach by each CCG to spend more than its 11

revenue resource limit the forecast position reported to NHS England 9 BNSSG Performance Report, including Quality LM drew attention to the following key performance indicators. The A&E performance target remained challenged. September s performance was 87% against the 95% national standard. The position continued to be challenging in October and November. The CCGs were working closely with providers to ensure a resilient service and the ability to manage surges in demand. 18 week elective referral to treatment times were being delivered at 90.29%. The Governing Bodies noted that the CCGs had taken the decision not to commission providers to deliver the 92% standard to support the financial position. It was noted that there had been a fluctuation in referrals recorded; this was due to changes in counting methodology. This was not reflected in reported first outpatient appointments. There had been a reduction in the number of patients waiting over 52 weeks to 78% and the CCGs remained on target to reduce to zero the number the patients waiting over 52 weeks by March 2018. Performance against the 62 day cancer standard was at 82.29%. NBT continued to maintain delivery of the standard and commissioners were working with WAHT and University Hospitals Bristol Foundation Trust (UHB) to improve performance. This focused on late referrals from other providers and internal pathway issues. Attention was drawn to South West Ambulance Service Foundation Trust (SWASFT) category 1 performance. SWASFT was part of the Ambulance Response Programme (ARP) and reported through this national pilot. Clear reporting from the Trust would not be reached until the ARP standard was implemented nationally from 1 st April 2018. It was proposed that a presentation on ARP was made to the Governing Bodies to explain the national standard. LM The 111 service and AWP reports were highlighted. The 111 service was not achieving the CCGs standard. Key issues included recruitment and action had been taken by Care UK to ensure that sufficient clinical and non-clinical staff were in post before the Christmas period. AWP was performing against indicators; the CCGs were aware of other issues including the four week response target in South Gloucestershire and the level of Delayed Transfers of Care (DToC). Marie Davies (MD) presented the Quality report. Three cases of MRSA had been provisionally assigned to the CCGs in September. Following review one case had been identified as a contaminated specimen and removed. The two remaining cases had been put forward for arbitration. A report from the Elizabeth Blackwell Institute regarding MRSA in injecting drug users and a briefing paper would be shared with GPs. No Never Events had been reported in September; the CCGs had been notified of Never Events in October/November and contract levers were being issued in response. One mixed sex accommodation breach had been reported concerning a Bristol patient being treated at Northern Lincoln and Goole NHS Foundation Trust. A backlog of Serious Incidents reported by AWP was highlighted; contractual levers were being exercised with the Trust. AM asked if the CCGs would report mixed sex accommodation breaches in specialised commissioning services. Anne Morris (AMor) agreed these should be reported and further clarity from NHSE specialised commissioning would be sought. AMor 12

DS commented on the deteriorating position of AWP in South Gloucestershire in relation to four week waits. DS commented that the percentage figures would not indicate an increase in the number of patients and if an increase could influence the deteriorating position. LM agreed to provide more data on referral demand in the January report. LM explained that the Trust had experienced difficulties in recruiting to the Primary Care Liaison service which impacted on the ability to respond. Further information on this would be included in the January report. LM DJ asked where the fluctuation in referrals originated. LM explained the increase appeared to relate to a change in recording practice. Further work was required, particularly in relation to the number of first outpatient appointments to validate the data. JR commented it was important to understand whether the plan was correct. LM highlighted the position relating to follow up appointments and noted that there were a number of factors. The initial plan had removed activity from provider plans, and was not supported by a programme of work to reduce that activity; this was changing. It was important to understand the outpatient profile and ensure that patients were seen at the right time in the right place. KH highlighted the reported Summary Hospital-level Mortality Indicator (SHMI) score for WAHT. This had improved and KH asked if the contract penalty notice would be removed only when the Trust reached a score of 100 or better. This was confirmed; the Trust was not expected to remain an outlier. It was noted that the comparison data was no longer provided. MB asked what had caused the increase in the number of AWP reported DToCs in North Somerset. LM apologised that she was unable to explain the deterioration and would investigate and report this back. It was explained that, in line with arrangements for other providers, there were twice weekly phone calls with AWP to identify each patient with a delayed transfer of care and identify a suitable discharge route. DS commented on the work undertaken jointly by Bristol City Council and AWP to reduce the number of DToCs. LM TM highlighted the backlog of complaints reported by NBT. AMor commented that this was an ongoing issue; the Trust had tried a number of approaches to reduce the backlog of complaints however a sustainable position had not been achieved. Contract levers were in place and a recovery action plan established. It was understood that the backlog sat with the corporate directorates. JR asked that AMor and LM raise this matter with the Trust. JR commented on the number of patients waiting for more than 52 weeks noting the number of orthopaedic patients. JR asked if there was an outsourcing policy to reduce the number of patients waiting. LM explained that an outsourcing policy had been in place however this had ceased. A targeted approach could be adopted for these patients. These were complex cases where there was a limited choice of providers. It was agreed that a targeted approach should be adopted. JR voiced concern that the 111 service position would not be improved until March 2018 and asked what mitigations were in place. LM explained that there was a national contingency for 111 services and the CCGs were working with the service on a pilot to improve clinical validation. There was also a focus to recruit additional call handlers. 13

JR asked what specific action was in place to address the AWP performance against the four week wait to assessment target in South Gloucestershire. LM agreed that further information would be provided. LM Governing Bodies noted: the performance position of the CCGs and that of key providers, including the risks, mitigating actions and responsibilities as appropriate the addition of performance information for Avon & Wiltshire Mental Health Partnership Trust and NHS 111 (Care UK) 10.1 BNSSG CCGs Governing Body Assurance Framework (GBAF) and Corporate Risk Register (CRR) JG set out the background to the development of the GBAF and CRR. It was noted that the previous CCG CRRs had been reviewed and revised and used to develop the papers presented. Sarah Carr (SC) highlighted the GBAF and the application of risk appetite and the description of current performance. JR commented on the risk set out on page six of the GBAF that the CCG would not develop the required financial plan. JR asked if the risk was delivery of the plan. GH explained the risk was that there would not be the level of detail in the plan to enable it to be credible and achievable. GH commented that the risk would change to be delivery of the plan; it was important to move the current ideas into a deliverable plan. JR asked if there were actions that colleagues could take to help mitigate the risk in addition to the control centre work. GH explained that the control centres were the main focus. A positive workshop with control centres had been held to develop the three year plan. It was felt that the three year planning timeframe and better relationships with providers allowed for better planning. It was confirmed that clinical leaders had participated in the workshop. JRu asked if the statement used on the GBAF there are no risks currently relating to this objective was correct. It was agreed that the statement should be amended to there are no risks rated at 15 or above currently reported. JRu asked whether there were risks reported in relation to the delivery of constitutional standards. JR noted that the GBAF contained risks reported at 15 or above and that there were risks reported with lower scores on the CRR. JR noted that where there was under performance against constitution standards this was an issue (rather than a risk) and reported through the performance report. SC The Bristol, North Somerset and South Gloucestershire CCG Governing Bodies commented on and approved the GBAF and the CRR, noting the risks, controls, assurances reported 10.2 Further Transition Aligning governance across BNSSG Jeanette George presented this item; the Patient and Public Involvement Forum terms of reference had been developed with the Governing Bodies Lay Members for PPI and the CCGs PPI leads. There was further action needed to develop the Forum and therefore approval in principle was sought. MG welcomed the involvement of the Lay Members. The best elements of the local arrangements had been brought together. The chair of the Forum would be a Lay Member from the Governing Body which strengthened the relationship. There was broad community representation although it was not possible to represent the whole community through the Forum. It was important not to lose the local voice. JR highlighted that 14

the Forum would be established from April 2018. The Forum would be informed by Commissioning Locality stakeholder groups and each Locality would have a PPI manager ensuring the local voice continued to be heard. The Forum s purpose was to assure the Governing Body that engagement was being done effectively across the organisation. Governing Bodies: Considered and discussed the draft terms of reference for the Patient and Public Involvement Forum Approved in principle these terms of reference and agreed the commencement of work to establish the Forum in preparation for the formation of a merged CCG 10.3 Emergency Preparedness, Resilience and Response (EPRR)Core Standards Assurance Assessment 2017-18 JG explained that the annual assurance process was undertaken by NHSE on the CCGs arrangements. It was noted that the CCGs had been assessed as partially compliant. The action plan agreed with NHSE was presented with the paper. The paper also reported on the assessment of providers where the CCGs were lead commissioner. It was noted that Care UK was included in the assessment for this year and the paper highlighted a number of concerns regarding the organisation s ability to respond to an emergency. The CCGs were working with NHSE to set out clear expectations of the service. There would be quarterly with Care UK to review their progress of their action plan. JH asked what assurance was available regarding the primary care out-of-hours service and primary care in general. JG explained that NHSEs assurance process was not undertaken for primary care services. Issues relating to the preparedness of primary care had been raised with NHSE. The GP Out of Hours contract also did not fall within the scope of the process. However, it was noted that BrisDoc had responded well in previous incidents and played a full part as system responders and participated in exercises. NK commented on the requirement for a non-executive director lead for EPRR. It was explained that this was primarily aimed at NHS providers. TM commented that it could be helpful to have this within a lay member role. JG noted that EPRR was within the remit of the Audit, Governance and Risk Committee which included Lay Members. The Bristol, North Somerset and South Gloucestershire (BNSSG) Governing Bodies: Received the report on compliance for the BNSSG CCGs against the EPRR Core Standard Received the report on compliance for NHS Providers for whom the CCGs were lead commissioner Approved the CCGs action plan 10.4 BNSSG CCG Lay Member Cross Cover Arrangements It was noted that the arrangements refreshed the existing agreements. JR highlighted the comment that it was not anticipated that there would be frequent 15

requests.. JR noted that the CCGs did not know what the frequency of requests would be and the comment should not have been included. The Bristol, North Somerset and South Gloucestershire CCG Governing Bodies approved the proposed Lay Member Cross Cover arrangements 10.5 CCG Administrative Office Updates GH explained this provided an update on progress. DS highlighted the office requirements of the clinical leaders. It was explained that arrangements for clinical leaders had been included in the plans. JR asked about the notice period for the Castlewood accommodation. JR asked about the financial implications and whether greater detail could be provided. GH explained that further detail would be presented when details of the Locality offices were more developed. PS asked about the Locality Offices. JR explained that these would be small offices to maintain a local presence. The Bristol, North Somerset and South Gloucestershire CCG Governing Bodies noted the progress in moving towards a single administrative office and area offices for BNSSG CCGs 10.6 BNSSG Managing Conflicts of Interest and Gifts and Hospitality Policies JG set out the background to the policies presented. There were no comments or questions on the policies. The Bristol, North Somerset and South Gloucestershire CCG Governing Bodies approved the BNSSG Managing Conflicts of Interest and Gifts and Hospitality policies 12.1 Joint BNSSG CCG Quality and Governance Committee Minutes September 2017 Governing Bodies received and noted the minutes 12.2 BNSSG Sustainability and Transformation Plan Sponsoring Board (August 2017 DN sought clarity of the figures provided on page two, section two for the digital programme progress. MJ explained the background which had involved a request to fund the development of the business case. JR explained that the Sponsoring Board had received a detailed paper that had requested further investment. The Sponsoring Board had asked for further work to be completed. This would be picked up by DES. A further paper would come to the Governing Bodies in February 2018. Governing Bodies received and noted the minutes 12.3 BNSSG Strategic Finance Committee Minutes October 2017 Governing Bodies received and noted the minutes 12.4 North Somerset CCG Clinical Commissioning Leadership Group Minutes September 2017 16