Meeting of NHS Bristol, North Somerset and South Gloucestershire s (BNSSG) Clinical Commissioning Groups (CCGs) Commissioning Executive

Meeting of NHS Bristol, North Somerset and South Gloucestershire s (BNSSG) Clinical Commissioning Groups (CCGs) Commissioning Executive Wednesday 3 rd January 2018, 11:30am-13:30pm CCG Conference Room, 5 th Floor, South Plaza Minutes Present Martin Jones (MJ) (Chair) Clinical Chair, Bristol CCG Mary Backhouse (MB) Clinical Chair, North Somerset CCG David Jarrett (DJ) Area Director for South Gloucestershire, BNSSG CCGs Deborah El-Sayed (DES) Director of Transformation, BNSSG CCGs Sara Blackmore (SB) Director of Public Health, South Glos Council Justine Rawlings (JRa) Area Director for Bristol, BNSSG CCGs Anne Morris (AMorr) Director of Nursing and Quality, South Glos CCG Jonathan Hayes (JH) Clinical Chair, South Glos CCG Lisa Manson (LM) Director of Commissioning, BNSSG CCGs Julia Ross (JRo) Chief Executive, BNSSG CCGs Colin Bradbury (CB) Area Director for North Somerset, BNSSG CCGs Attendees Margaret Kemp (MK) Senior Project Manager Recommissioning Item 5 Apologies Alison Moon (AMoo) Transformation and Quality Director, Bristol CCG Glyn Howells (GH) Chief Finance Officer, BNSSG CCGs Claire Thompson (CT) Delivery Director, Bristol CCG Peter Brindle (PB) Medical Director, Clinical Effectiveness, BNSSG CCG Notes Lindsay Sayers (LS) Project Support Officer, Bristol CCG 01. Apologies Lead Apologies were received from Alison Moon, Glyn Howells, Claire Thompson and Peter Brindle. It was noted that Justine Rawlings (JRa) would be late as she was taking part in the 11am System Escalation call. 02. Declarations of Interest 02a. To consider any changes to attendee interests since the last meeting None. 02b. To consider any conflicts of interest arising from this agenda Jon Hayes (JH) and Mary Backhouse (MB) declared an interest in respect of item 6, as they are both members of practices who are members of GP Care. Additionally, JH declared an interest in item 8 as his practice is a strategic partner with BCH in Inspire Better Health, which provides Primary Care services 1

to patients in custody in the local prisons. 03. 3.1 Minutes of the meeting and matters arising from 20.12.17 The minutes of the Commissioning Executive meeting on Wednesday 20 th December were approved as a true and accurate record. Action log from 20 th December and Forward Planner See item 03b. 04. Urgent Care Update 04a. A&E Delivery Dashboard Headlines and Executive Summary Lisa Manson (LM) circulated copies of the A&E Delivery Dashboard and summarised the position over the last month. It was noted that there was some improvement in late November, however, there was then a significant decline going into December. Various schemes came online around w/c 18 th December, which in turn improved the position, however, since Christmas there has been a significant deterioration across all providers, with the system escalating to Opel 4 within the last few days. It was noted that urgent care has been challenged in terms of demand but the ability to enact timely discharge has also had a big impact. Claire Thompson (CT) and JRa were noted as absent from this meeting due to 11am System Escalation call and it is expected that the system will remain on Opel 4 moving forward, in a very challenging landscape. Julia Ross (JRo) asked whether there were any other actions that the CCG, as part of the system, should be taking. JH advised that a South Gloucestershire GP colleague had queried whether it would be possible for a Comms piece to be put out advising the public to consider whether they needed to see a GP urgently before making an appointment, in order to ease pressure on primary care. LM felt that this could also build on the Choose Well work, while referencing NHSE comms regarding flu vaccinations. It was agreed that Deborah El Sayed (DES) would take forward the action around a comms piece on this and link with JH, Martin Jones (MJ), Peter Goyder and Mary Backhouse (MB) for a clinical voice. A link with SWASFT comms, particularly around ambulance prioritisation, was also suggested. Action DES. DES advised that there was a possibility of accessing extra primary support into some care homes by utilising existing capacity from Care UK and JH, MB and MJ were asked for their thoughts on this. DES explained that it could be stood up very quickly, in around 48 hours and costs would be about 14 for a telephone conversation. It could be run as a HOT pilot/pdsa cycle, which means that the CCG could also take learning from it. MB felt that it would need to be targeted where it s needed most and MJ added that it could have a positive effect in terms of admission avoidance. The Commissioning Executive agreed that DES should look to stand this up and MB, JH and MJ were asked to identify some care homes that would benefit most from this. Action DES will work with MJ, JH, MB and Care UK. LM also suggested linking in with SWASFT at a later time. JH suggested that it might be useful to target the smaller care homes where there might not be as much GP involvement. DES DES The group discussed the overall position and it was noted that there were issues both in attendances being over predicted levels as well as discharges not keeping up with admissions. LM added that an agreement had been reached the previous week with Bristol City Council to purchase some additional step down capacity, however this was under utilised as providers were unable to 2

identify patients in time. LM felt that there was work to do around how discharges can be enacted quickly when the system is under so much pressure. MJ asked about 111 dispositions and how the process could be aligned between 111 and the practice to ensure that the patient has the right experience in the right place. DES replied that the ability to transfer and book is one of the national initiatives and an action was noted for DES and LM to discuss this with 111. Action DES/LM. DES/LM 05. Smoking policy for patients on home oxygen Margaret Kemp (MK) presented this paper and explained that the purpose was to ask the Commissioning Executive to endorse the South West Region Policy for the prescribing of home oxygen to patients who are known to smoke. It was noted that a policy is currently in development at a national level, however, the decision has been taken to develop one as a region until such time that the national policy is complete. The draft policy is based one by Gloucestershire CCG, which has been in place for a number of years. Statistics show that only 1.6% of home oxygen households in Gloucestershire include smokers, which MK said appeared to show a positive impact from the policy. MK clarified that when talking about a definition of patients who smoke, young children would be included if their carer smokes. Under the policy, new patients wouldn t be prescribed home oxygen unless they agreed to stop smoking. MK confirmed that the policy has been seen by BCH Respiratory Nurses and there is support for a consistent policy across BNSSG. JRo asked about the impact on primary care and MK advised that as GP s should be referring patients to Respiratory teams for home oxygen prescriptions, there shouldn t be a big impact in that area. JRo proposed that the paper was approved and then taken to local leadership groups for information and SB felt that it would also be helpful to offer smoking cessation services. The Commissioning Executive approved the policy and MK will ensure that it is sent to the 3 chairs for the leadership groups. 06. AQP Audiology Reprocurement 2018-23 LM presented this paper, which is a request for the Commissioning Executive to approve a reprocurement of audiology services. It was noted that this had evolved from one the Turnaround plans and would offer the ability to improve pathways, strengthen choice and obtain better value for money. The existing contract has already been extended for 2 years, so it is felt that this is the right time to reprocure. The group discussed this, LM confirmed that the process would be to go out to advert and for interested parties to then go through pass/fail criteria. The Commissioning Executive approved the paper. 07. Bristol City Plan JRa joined the meeting during this item and MJ lead the discussion on her behalf until she was able to. It was noted that this had stemmed from a vision by the Mayor on what the city should look like and included long term and short term 3

plans that fit in to this. The CCG would agree with most of them, but MJ highlighted a change to Health and Well Being Board membership as the Mayor has suggested that providers should be included in this meeting. JRa joined the meeting at this point. The group discussed the value that could be added to the HWBB by inviting providers. As a whole, the plan was received positively by the group and there was nothing else that would be contentious or different from any other Local Authority plan. JRa said that the Mayor would like to bring in more resource and that there is ongoing discussion around funding a City Director role from the LA and including it in the Senior Manager structure as well as accountability from Public Health. In terms of supporting the work, they want to get resources from providers and are coming through with options with either a secondment model or to commission the work again. SB advised that she had sight of a draft structure and advised that she would circulate this to the group. Action SB. It was noted that this would be a good opportunity for integrated working, although it would be a challenge for the CCG to provide resource to this. JRa agreed to take an action to have a further discussion with Marvin Rees, SB suggested that a Public Health rep should be present as well. Action JRa. SB JRa 08. Any other Business LM asked the Commissioning Executive to consider a paper around the extension of the BCH Contract. She explained that it had attracted interest from the Department of Health and that the current contract has already been extended several times, with the position now being an 18/19 cessation. Consideration needs to be given about future contracting of community services across the whole BNSSG area, but in the meantime, a view needs to be taken around letting a new contract for a defined period of time as opposed to a further extension. The plan would be to align providers over the next 18 months with a view to reprocuring a full BNSSG service and LM proposed pulling together a paper on a single procurement for BNSSG for the next meeting. On the back of this we will need to issue a new contract for BCH. JRo felt that a reprocurement could be done in a shorter period than 24-36 months and LM advised that we would need to ensure alignment around termination points of all contracts, especially as NSCP have a contract until 2021. JR suggested reviewing termination clauses to check for the financial penalty. The timeframe is also an issue and the CCG will need to aim for a direct award for next year as well as understanding the contractual position and options available if this isn t possible or the financial penalties are too great. JRo asked about capacity for doing this work, LM didn t feel that this would be possible from the existing structure, but there may be resource in the budget to pull together a team to do it. JR stressed that this would be very high profile, so will be important to have a lead in place who will be able to see this through successfully. She added that it will also require a significant amount of clinical input and external input as it will be a big piece of work. LM advised that she was looking at pulling together a planner for future meetings in terms of helpful items for the Commissioning Executive to discuss. At the next meeting, there will be a big focus on Mental Health across BNSSG and advised the group that if there are items people want to bring in the future, to let her know. The meeting came to a close at 12.37 4

Next meeting: Wednesday 17 th January 2018 5

Meeting of NHS Bristol, North Somerset and South Gloucestershire s (BNSSG) Clinical Commissioning Groups (CCGs) Commissioning Executive Wednesday 17 th January 2018, 11:30am-13:30pm Julia Ross Office, 5 th Floor, South Plaza Minutes Present Martin Jones (MJ) (Chair) Clinical Chair, Bristol CCG Mary Backhouse (MB) Clinical Chair, North Somerset CCG Sara Blackmore (SB) Director of Public Health, South Glos Council Jonathan Hayes (JH) Clinical Chair, South Glos CCG Justine Rawlings (JRa) Area Director for Bristol, BNSSG CCGs (12.37pm) Anne Morris (AMorr) Director of Nursing and Quality, South Glos CCG (12.38pm) Lisa Manson (LM) (12.38pm) Director of Commissioning, BNSSG CCGs Colin Bradbury (CB) Area Director for North Somerset, BNSSG CCGs (12.40pm) Deborah El-Sayed (DES) Director of Transformation, BNSSG CCGs (12.41pm) Peter Brindle (PB) (12.42pm) Medical Director, Clinical Effectiveness, BNSSG CCG Attendees Diane Beales (DB) Urgent Care Resilience Manager, Bristol CCG for Item 4 Emma Moody (EM) Deputy Director of Community and Partnerships, Bristol CCG for item 5a and 5b Julia Chappell (JC) Deputy Programme Manager for Mental Health and Learning Difficulties, Bristol CCG for item 5a and 5b Mark Hemmings (MH) Transformation Programme Lead, North Somerset CCG for item 5c Rebecca Cross (RC) Strategic Commissioning Manager (Children), Bristol City Council/Bristol CCG for item 5c Sue Moss (SM) Public Health, Bristol City Council for item 6 David Moss (DM) Delivery Director, South Gloucestershire CCG for item 7 Apologies Alison Moon (AMoo) Transformation and Quality Director, Bristol CCG David Jarrett (DJ) Area Director for South Gloucestershire, BNSSG CCGs Glyn Howells (GH) Chief Finance Officer, BNSSG CCGs Claire Thompson (CT) Delivery Director, Bristol CCG Julia Ross (JRo) Chief Executive, BNSSG CCGs Notes Lindsay Sayers (LS) Project Support Officer, Bristol CCG 1

01. Apologies Lead It was noted that due to an over-run of the Executive Team meeting, only Martin Jones (MJ), Jon Hayes (JH), Mary Backhouse (MB) and Sara Blackmore (SB) were currently present. As a result, this meeting was not quorate until approximately 12.40pm when other members of the group arrived. It was agreed that any decisions made in their absence could only be from a clinical perspective and would require full endorsement from the other members of the group via email following the meeting. Post meeting note Lindsay Sayers (LS) circulated an email to all Commissioning Executive members following the meeting to ask for their approval on items 3, 5a and 5b. 02. Declarations of Interest 02a. To consider any changes to attendee interests since the last meeting None. 02b. To consider any conflicts of interest arising from this agenda JH advised that his practice was a partner with AWP in a tender application to provide primary care services to a youth custodial unit in South Gloucestershire. This relates one of the papers presented under item 5. 03. Minutes of the meeting and matters arising from 3.1.18 The minutes of the Commissioning Executive meeting on Wednesday 3 rd January were approved as a true and accurate record other than a formatting error already corrected by LS in advance of the meeting. It was noted that these would need full approval from other members of the group. 3.1 Action log from 3 rd January and Forward Planner See item 03b. 04. Urgent Care Update 04a. A&E Delivery Dashboard Headlines and Executive Summary Diane Beales (DB) attended the meeting to present the A&E Delivery Dashboard. She advised that the whole system had been significantly challenged throughout the end of December and well into January. System calls have taken place on a daily basis and the system wide Opel score has fluctuated between Opel 3 and Opel 4, with NBT and Weston General Hospital in particular struggling and escalating to Opel 4 on occasion. A lot of extra demand in the morning is an issue, especially at Weston where the emergency department is closed overnight, meaning that any patients who have been bedded in the department the previous night will have breached by the following morning. There has been a lot engagement with NBT from community services colleagues and a MADE event has been planned in the next few weeks. The same event took place at UHB at the beginning of this month. The team are very keen to bring GP s into the NBT event. The group discussed the importance of the hospital being able to take forward and put in place any changes agreed at the event and it was suggested that it may also help acute teams to get a better understanding of how community and primary care worked. 2

DB advised that teams at the event would be GP led with support from community services across BNSSG (Sirona, BCH, NCSP), as well as clinical staff and commissioning representatives. MJ suggested that it would be helpful to look at how a joint discharge care plan could be put in place for patients so all health professionals know what s going to happen to that individual. It was noted that clear challenge is needed, along with clear actions and output and there is an expectation that this will facilitate 100 additional discharges. DB felt that if the event was to work for the system as a whole, the right people needed to be invited and will contact MJ, MB and JH if there is any ask to practices around support to the event. SB also offered support from the local authority, which DB noted and will discuss with Kate Hannam at NBT. DB moved back to system performance and advised that it had dropped further since the latest reporting had been done. Community providers are now starting to see the effects of the system actions, such as increased referrals and there has also been an impact on the local authority. In terms of individual trust performance, UHB performance has slipped since October and November but they still seem to recover well, NBT fell to 86%, with the figures now being in the 70 s and Weston General Hospital has fallen to the 50 s at points. There was a query around whether this might indicate that UHB were seeing patients with lower acuity than the other trusts and DB felt that there was further work to do in terms of looking at what was coming through the door in each of the ED s. It was noted however, that UHB figures included Bristol Children s Hospital, Bristol Eye Hospital and Bristol Dental Hospital, so it may just be that there is less potential for admission for patients visiting the emergency departments at these hospitals. MB asked about the current position with MH DTOC s and DB advised that these were progressing in a positive direction and are also being picked up within one of the Mental Health Control Centre plans. In terms of DTOC s in general, the main bulk of these seem to be due to Social Care and placement delays and this appears to be more of an issue in Bristol than South Gloucestershire. NBT have also been challenged to provide more placements as there was unfilled community capacity but backed up discharges. The group thanked DB for this update and she left meeting following this item. 05. Mental Health: Emma Moody (EM) and Julia Chappell (JC) attended the meeting for this item. It was agreed that the paper listed on the agenda as item 5b would be discussed first, with item 5a following afterwards. Proposal for extension of Bristol Mental Health Contracts: EM presented a paper proposing the extension of contracts until 2021, explaining that this would be an interim arrangement while the BNSSG transformation of mental health services was taking place. The contracts are currently due to expire in 2019, so an extension would provide reassurance of stability during the implementation of the transformation strategy. The Bristol mental health contract would be put into the main AWP contract but this wouldn t stop things being done jointly. JC confirmed that procurement advice had been sought and the proposals were deemed to be at low risk of challenge. The paper was approved from a clinical perspective by those present, on the condition that confirmation of approval from other members of the group was 3

given via email. Post meeting note it was agreed that this paper would be presented to the Executive Team on Wednesday 24 th January for further review before full approval can be agreed. Risk to short term funding of Mental Health services in BNSSG from March 2018: EM explained that this paper had been brought to the Commissioning Executive to highlight those mental health services across BNSSG with an element of non recurrent funding due to end in March 2018 and to seek approval for proposals to mitigate this. The services affected are Control Room and Street Triage, Psychiatric Liaison services at UHB and NBT, Assertive Contact and Engagement (ACE) service and The Sanctuary. They were originally funded on a short term basis so that commissioners could evaluate their effect and also because of the challenged financial position. EM outlined the proposals for each service: Control Room and Street Triage: there is funding in the baseline to continue the service on a BNSSG basis and a 6 month bridge funding arrangement is requested while a business case is worked up. It was confirmed that Street Triage is currently funded until midnight, while Control Room Triage is a 24 hour service, although the information and advice element is only available in hours as the Mental Health team are not there out of hours. The business case would look at combining these services, which could potentially create efficiencies meaning that a full 24 hour service could be offered. Assertive Contact and Engagement Service (ACE) and The Sanctuary: there is funding in the bottom line for these services. The proposal is to extend them until 2021 and include them in the strategy for mental health transformation. The Sanctuary operates within the BRI, seeing patients between 7am and 2pm with the aim of diverting them to alternative services to the emergency department. They have just received funding of 50k from NHSE to extend the service and base a member of staff in the BRI. Work is also being done to look at whether NBT could be covered by this as well. The funding proposal would also involve extending the service across BNSSG. The ACE service works with complex patients and staff visit them in their own surroundings. It was previously joint funded with the local authority and there is agreement from Bristol City Council for this to continue for one year. Psychiatric Liaison services: South Gloucestershire have funded NBT on a non recurrent basis and Bristol have funded UHB. There is recurrent funding across the three acute emergency departments, however, there have been problems with the two non recurrent sums. Investment in these would put the CCG s in a worse financial position, so the proposal is to try and negotiate with the trusts for them to put funding in, along with reviewing the entire recurrent funding budget to look at whether it could be pulled forward to the ED. This would present a large degree of risk, in terms of a poorer experience for wards if funding is pulled out of ED. Funding has just been secured for Core 24, which will be a BNSSG hub and spoke model, so this is a driver and EM advised that if the decision is not to fund then something different needs to be done. The recommendation in the paper is to continue with the service that has funding and renegotiate and remodel the BNSSG service. This paper was approved from a clinical perspective by those present, on the 4

condition that confirmation of approval from other members of the group was given via email. Post meeting note it was agreed that this paper would be presented to the Executive Team on Wednesday 24 th January for further review before full approval can be agreed. The remaining members of the group joined the meeting following this discussion. Child & Adolescent Mental Health Services Transformation On line Support & Counselling for 11-25 year olds: Mark Hemmings (MH) and Rebecca Cross (RC) attended the meeting to present this paper. MH explained that the purpose of bringing this paper to the Commissioning Executive was to recommend that online emotional wellbeing and counselling services for young people are made permanent. MH and RC explained that 1 in 10 young people have a mental health condition, with many adult conditions starting before a person reaches the age of 18. Furthermore, the NHS Five Year Forward View also states that effective early intervention can prevent deterioration and avoid issues in adulthood. It was noted that the Kooth online support and counselling service has been piloted successfully in Bristol for 19 months. It provides 24 hour access, 7 days per week and offers support via information, forums, chat rooms and face to face counselling which can in turn then trigger a local service. The format appeals to young people as it is accessed online and it provides a swift response and early intervention. It can also meet unmet need at a lower cost and is highly valued by schools and GP s. MH explained that the risk of not commissioning it would mean the removal of a highly valued and successful service and could also be potentially unsafe as it may leave vulnerable young people without a service. In North Somerset, complexity is increasing and is very unsafe, so the recommendation to Commissioning Executive is to continue the service in Bristol and extend it into North Somerset. There was a discussion around this and it was felt that there was further work to be done in terms of being able to evidence the quality of the service as well as more engagement and having a BNSSG specific service. There was concern that the proposal did not include extension of the service into South Gloucestershire and it was discussed that funding had been a major factor in this in the past. LM felt that there needed to be assurance that this service was not Tier 1 or 2 CAMHS support, as that is not the responsibility of the CCG to fund but the local authority and Public Health. The Commissioning Executive members felt that further actions were needed to look at how the service could cover the whole BNSSG area as well as exploring the funding in more depth. It was noted that Glyn Howells was currently working through 18/19 planning and LM proposed that this is taken through a priority setting exercise, particularly in terms of extending it to cover South Gloucestershire and tailoring it to services that are already in place. SB felt that there also needed to be a link with Public Health. MH and RC were asked to put together some further information about the costs of the service, as well as what the financial implications could be if there was no service so that an informed comparison could be made. DES felt that case studies would also be useful and assurance that the CCG are responsible to funding this service was requested. It was agreed that this would need to come back to the Commissioning Executive in February for further discussion and review. Action LM to take 5

this through the priority setting exercise before it comes back to the group. LM 06. Social Prescribing Link workers for Bristol This paper was presented by Justine Rawlings (JRa) and Sue Moss (SM), who had joined the meeting from Bristol City Council Public Health team. The Commissioning Executive were asked to approve the proposal for the procurement of a social prescribing link worker service across all Bristol GP practices as well as a standardised approach across BNSSG. It was noted that a great deal of work has been done in Bristol around social prescribing to try and clarify the key components, focus on what the offer should be and to try and ensure that it is consistent across BNSSG and gaps are filled. Funding in Bristol could potentially be available through Better Care, although it is limited to one year in the first instance, with a possible two year extension. Local Authority funding in Bristol currently covers about half of the GP practices and the business case for Better Care funding was to fund link workers in other GP practices and suggest that CCG s should procure a link worker service so that it is shared. JRa advised that a pilot had already taken place and that services in BNSSG are currently delivered and funded in different ways and it was felt that a comprehensive, standardised approach was needed. The group discussed the implications of not extending the service beyond Bristol and whether to carry on with it here if it isn t possible to cover BNSSG. It was felt that further work needed to be done to explore the funding streams and LM agreed to take this through the priority setting exercise, which will be reviewed by the middle of February. Action LM. LM 07. Acute Contract Refresh 2018/19 David Moss (DM) attended the meeting to present this paper and explained the that purpose of bringing this to the Commissioning Executive was to get approval to reopen/refresh elements of the BNSSG 2 year acute contracts, recognising local and national must do s. DM advised that a national variation had come out, which included no dispute resolution in year 2 and no penalties for never events from February this year. Also, as of 1 st October 2018, all referrals need to be made through the e-refferal system and there are implications around non payment of activity where this isn t done. This will also go into GP contracts. Wider national guidance is still awaited, but should be published soon and any decision today will need wider consideration in the context of this. It was noted that the contract values across all three acute providers are significantly in excess of what is affordable for the CCG. In 16/17, the contract value was a total of 535m and this has risen to 573m for 17/18. Despite the fact that there was an underspend in month 8, all three remain outside of the window of affordability and significant reductions are required. LM added that the CCG s were expecting a marginal uplift for growth, but remain so far from the allocation that any adjustment would become negligible. It also not known how the additional money allocated in the budget will come through. The recommendation to the Commissioning Executive is a renegotiation of 6

activity and finance within the financial envelope. In terms of dispute resolution, DM advised that other than UHB there isn t any activity and finance information in the contracts, so the CCG could be eligible in cost and volume terms if this isn t agreed. DES and DM discussed the ERS paper switch off and concern about NBT not being where they need to be with this. DES advised that she would pick this up with them. DM offered to send DES a list of services on ERS, as well as timelines for those still to go on. Action DES and DM. DES/DM DES and DM will discuss offline. 08. Any other Business LM asked for some future agenda items to be noted, which were Community Reprocurement and the Governing Body proposal, Enhanced Services prioritisation planning in terms of the system, National guidance and proposal of prioritisation at a subsequent meeting. The meeting came to a close at 1.30pm approximately. Next meeting: Wednesday 31 st January 2018 7

Meeting of NHS Bristol, North Somerset and South Gloucestershire s (BNSSG) Clinical Commissioning Groups (CCGs) Commissioning Executive Wednesday 31 st January 2018, 11:00am-13:00pm CCG Conference Room, 5 th Floor, South Plaza Minutes Present Mary Backhouse (MB) (Chair) Clinical Chair, North Somerset CCG Martin Jones (MJ) Clinical Chair, Bristol CCG Mark Pietroni (MP) Director of Public Health, South Glos Council Jonathan Hayes (JH) Clinical Chair, South Glos CCG Justine Rawlings (JRa) Area Director for Bristol, BNSSG CCGs Lisa Manson (LM) Director of Commissioning, BNSSG CCGs Colin Bradbury (CB) Area Director for North Somerset, BNSSG CCGs Deborah El-Sayed (DES) Director of Transformation, BNSSG CCGs Peter Brindle (PB) Medical Director, Clinical Effectiveness, BNSSG CCG Glyn Howells (GH) Interim Director of Finance, BNSSG CCG s Julia Ross (JR) Chief Executive, BNSSG CCG s David Jarrett (DJ) (from 11.30am) Area Director for South Gloucestershire, BNSSG CCG s Peter Brindle (PB) (from 11.43am) Medical Director, Clinical Effectiveness, BNSSG CCG s Anne Morris (AMor) (from 11.45am) Director of Nursing and Quality, South Glos CCG Attendees Andy Newton (AN) Planned Care Lead, Bristol CCG (item 5) Pippa Stables (PS) Inner City and East (ICE) GP LEG Member (Item 5) Helen Wilkinson (HW) Deputy Head of Medicines Management, South Gloucestershire CCG (item 7) Debbie Campbell (DC) Deputy Director Medicine Optimisation and Primary Care, North Somerset CCG (Item 7) Rachel Anthwal (RA) STP Diabetes Programme Lead, Bristol CCG (Item 8) Anna Collinette (AC) GP Clinical Lead for Diabetes, Bristol CCG (Item 8) Ro York (RY) BNSSG Primary Care Workforce Lead (Item 9) Marie Davies (MD) Head of Commissioning for Quality, Bristol CCG (Item 9) Apologies Alison Moon (AMoo) Transformation and Quality Director, Bristol CCG Notes Lindsay Sayers (LS) Project Support Officer, Bristol CCG 1

01. Apologies Apologies for absence were noted from Alison Moon (AMo) and Anne Morris (AMor). Apologies had also been received from Mark Pietroni (MP) and David Jarrett (DJ), who had advised that they would be late for the meeting. Lead 02. Declarations of Interest 02a. To consider any changes to attendee interests since the last meeting No new interests noted. 02b. To consider any conflicts of interest arising from this agenda Mary Backhouse (MB) and Joh Hayes (JH) both declared an interest in item 5, DVT pathway as the surgeries where they are partners could be involved in delivery of the service. Additionally, JH advised that his practice are part of GP Care and will be merging with Almondsbury surgery who provide the scanning services. Julia Ross (JR) agreed that she would take on the chairing of the meeting for the duration of this item, so as not to cause any conflict of interest for MB or JH. Glyn Howells (GH) advised that he would shortly be leaving his role as Interim Director of Finance for BNSSG CCG s and may then commence work with the Healthy Weston project so agreed that he would not take part in discussions around item 6. 03. Minutes of the meeting and matters arising from 17.1.18 JH asked for an update on the progress of the Mental Health papers that were presented at the last meeting, particularly the Psychiatric Liaison paper. Lisa Manson (LM) advised that these had subsequently gone to the Executive Team meeting and that commissioners were currently working through a programme plan to identify all funding sitting behind Psychiatric Liaison services. It was agreed that LM would bring an update paper back to a future Commissioning Executive meeting. Action LM. LM The minutes of the meeting on 17 th January 2018 were approved as a true and accurate record. Lindsay Sayers (LS) advised the group that there was no documented record of the minutes of the meeting on the 3 rd January 2018 being approved, as the group had not been quorate when these were reviewed at the last meeting. The group agreed that these represented a true record of the meeting on the 3 rd January and these were also approved. 3.1 Action log from 17 th January and Forward Planner See item 03b. 04. Urgent Care Update 04a. A&E Delivery Dashboard Headlines and Executive Summary LM advised that the overall A&E position had stabilised in the last 2 weeks and the system was currently at Opel 2. Clear challenges remain, particularly flow at NBT and a CQC warning notice was issued to them in draft, although it was noted that NBT have challenged this. The current status relating to this notice LM 2

isn t clear, so LM took an action to obtain an update. Action LM. Anne Morris (AMor) and members of the Quality Team have made visits to all 3 ED s so that the CCG can be assured of patient safety and LM advised that this assurance has been given. The opening of additional beds at a nursing home in Yate is currently in the go live phase, with full occupancy expected by the end of February 2018. NBT and UHB are going through a process to look at how to improve flow and an issue in terms of length of stay at Weston now requires a piece of work to be done to look at how this can work better. JR queried the shift in admissions between UHB and NBT as the total emergency and elective figures appeared to show that UHB figures are higher. Action LM to check this. LM 05. Deep Vein Thrombosis options paper for pathway implementation Andy Newton (AN) and Pippa Stables (PS) joined the meeting to present this paper. PS explained that, with1 in 1000 people getting DVT s and suspected DVT s, there is a benefit if this can be managed close to home. Currently, there are 5 differently funded pathways across BNSSG, so an integrated pathway would be much easier for GP s as the actions they need to take will be clearer. AN added that this had come out of the System Financial Recovery Plan work and the intention had been to put this out for tender for a single provider. However, this didn t go ahead because of the option to embed it in primary care instead. This would be an opportunity to move from a secondary to primary care service and would allow localities and practices to think about how they work in that way. The Commissioning Executive were asked to confirm their preferred approach to the implementation of the pathway across BNSSG, out of three possible options: Option 1 would be for the CCG to facilitate the new pathway implementation and contracts with each practice. It was noted that this would require resource of around 2 days a week from the CCG for approximately 6 months as well as some assistance across all contractors in Bristol. Option 2 is to allocate funding to the localities for one year to enable them to set this up themselves. They could then choose to use a provider such as One Care to facilitate this or a group of practices could lead on it. It was noted that the CCG wouldn t have a contractual relationship with One Care for this and that this might carry a risk. Option 3 is to wait for the Locality Transformation Scheme to be up and running in around 6 months time before handing it over to localities to take forward. Julia Ross (JR) asked whether it would be possible to combine options 1 and 3, to form an approach where implementation of the integrated pathway is put out as a locality initiative but with recognition from the CCG that at this point, they may require a significant amount of support. JH asked whether there was assurance around access to scans and coverage for patients from BNSSG presenting at the RUH in Bath as well as out of hours support. AN advised that this has been considered and discussions have taken place with Brisdoc, who would be able to provide a service out of hours. He added that there hadn t yet been a conversation around the RUH, but said that 3

he would pick this up. The group discussed the proposals. It was felt that further work on this was needed in terms of ensuring that the pathway proposed was the best one for patients rather than what practices would prefer. There will also need to be patient engagement, involvement from Healthwatch and assurance around patient safety and continuity of care. The risk of challenge needs to be considered so there will need to be transparency in how this is commissioned. The committee were supportive of the proposal in principle, however, felt that there was more to do as outlined above, before this could be approved. It was agreed that the preference would be for a locality initiative, supported by the CCG rather than involving a provider. PS and AN were asked to work with LM to ensure that commercial aspects of this were resolved. 06. Healthy Weston Update Colin Bradbury (CB) presented this paper, the purpose of which was to provide an update on the progress and developments of the Healthy Weston work. It was noted that an issue has been identified in the Primary Care at Scale and Integrated Community work being behind schedule in moving beyond the conceptual stage of the process and a plan has been put in place for this. Further work is also needed around self care, with feedback being given at co design workshops. There now needs to be consideration to how this is taken forward. An opportunities evaluation has now started which is linked to the partnership work around Weston and UHB and CB highlighted that the UHB Board will today receive a strategic outline case putting forward a plan for the trust to acquire Weston Area Health Trust (WHAT) under a merger via acquisition. An external agency, Carnall Farrar, have been appointed to deliver a programme of work for this. A specification was written by LM and UHB to identify if there was a more efficient way running of the site and it was identified that certain acute services could be delivered in a better way, with an opportunity to also think about how the site is used in the most effective way. CB advised that it is really important that the Carnall Farrar work is embedded in the programme. In terms of timelines for the completion of the Opportunities Evaluation, it was agreed at the North Somerset Sustainability board 2 weeks ago that these would be harmonised with the Healthy Weston Plan and a paper will be going to the BNSSG CCG Governing Body private session to request support for this decision. There will be a checkpoint at the end of March where an update on work will be published and an event is being planned to support this. It was noted that as well as the UHB Board meeting today, there would be an extra ordinary meeting in private taking place at WAHT and staff are also being briefed. There was a discussion about this and JR advised that an announcement with intent to go forward was expected today and the CCG have a press release drafted in the event that we are asked to comment. LM added that there is a placeholder on the next Governing Body agenda to ask for support for them to release this information publicly as we are not allowed to put anything out at the moment. CB advised that finance is progressing on the basis of the modelling and a number of issues have been identified which need to be resolved. Implications within BNSSG are the work Justine Rawlings (JRa) is leading on for Healthy 4

South Bristol and it was noted that consideration needs to be given to how the locality roll out is prioritised. CB proposed that a further paper is presented at the next Commissioning Executive meeting, to give an update on a particular element of Primary Care estates capital. David Jarrett (DJ) asked for this to be BNSSG wide and CB agreed to work with him on this. Action CB and DJ. It was agreed that the specific North Somerset piece would come to the next meeting, with a wider scope to follow at a later date. CB/DJ 07. Working with an industry partner to optimise continence prescribing through training delivery Helen Wilkinson (HW) and Debbie Campbell (DC) attended the meeting to present this paper. HW explained that the purpose of bringing it to Commissioning Executive was to seek approval for joint working with an external pharmaceutical partner to develop a training programme in continence care for delivery to community and care home staff. Work would also be done with the pharmaceutical provider to review CCG s current prescribing of continence products and advise of opportunities where prescribing costs could be reduced and patient care improved. HW advised that nearly 15% more was spent on continence products in the last financial year than the previous one and it had been identified via the System Financial Recovery Plan that there was a potential to make savings in this area. Upskilling staff in this way could also result in a reduction in the risk of a UTI and subsequent hospital admission. Work has already been done with community providers to develop some guidelines but the specialist teams don t have the capacity to deliver training in house, hence the reason for an approach to pharmaceutical partners for their support with this. HW emphasised that the CCG policy for working with the pharmaceutical industry had been consulted, as well as the formulation of an agreement setting out principles and values for delivery. AMor asked if Public Health had been engaged with this process and expressed some concern about how the CCG would be assured of the quality of the training as well adherence to BNSSG infection control guidance. She added that there would need to be very clear guidance about what the training would look like. JR said that absolute assurance would be required from the pharmaceutical partner providing the training that they would not be selling their products at all. Furthermore, all training materials would need to be fully branded by BNSSG CCG s with no provider branding whatsoever. The group then discussed the continence prescribing review part of the proposal and significant concern was raised about using a supplier to identify savings. It was felt that there would be an inevitable conflict of interest and it would be extremely difficult to assure ourselves that decisions and recommendations made by the supplier weren t driven by this. JR said that working with them to deliver training was a very sensible idea as external providers often have access to high quality training approaches (although we will need to make sure that it is appropriately branded) however, her concern was the proposed prescribing review. AMor added that a question needed to be raised in the regular community performance and quality meetings around what the role of the community nurses was in terms of checking value for money when continence equipment is prescribed. DC emphasised that there would be no clinical review of patients and that it would be purely to look at whether cheaper products were 5

available on the formulary, but agreed that they could look at another way of carrying this out. JR agreed that it was a necessary step, but that a different approach needed to be found. She added that in terms of the training, an additional clause needed to be included to state that the agreement with the provider would be immediately terminated if any practice which was against guidance came to light. JR also asked how a 15% rise had happened and DC responded that the reasons for this needed to be explored. JR agreed to pass across further comments offline and LM said that she would like to look into the community contracts a little more to establish the role of community nurses in this work. The Commissioning Executive supported the proposal to implement the training programme. The prescribing review was not approved and commissioners will need to find another way to approach this. Further work now needs to be done on the pathway and training and this should come back for approval when the issues have been wrapped up. HW and DC were advised that they could go forward with the training. 08. Diabetes Transformation Programme Briefing Paper Rachel Anthwal (RA) and Anna Collinette (AC) attended the meeting to provide an update on the progress of the Diabetes Transformation Programme (DTP). The Commissioning Executive were also asked for their agreement that the priority areas identified were the right ones and the actions being taken were appropriate. The tracking of patient outcomes will begin in April 2018 by linking secondary and primary care data, with community services data hopefully following later in the year. An issue with resourcing to the project was flagged by RA and AC and it was noted that a plan would be required in order to keep momentum and delivery going. JRa added that governance on the project to date has been relatively informal and less than required and that better oversight on risks and how things are being reported externally is needed. They have managed to secure 1 day per week resource but don t think this is enough to do what s required, however, there is really good clinical engagement with the project. DES advised that the work done by Outcomes Based Healthcare has given us a framework and there is then an opportunity for further work to be done, although this hasn t yet been committed to a specific provider. She agreed to meet with RA and AC for further discussion around outcomes. Action DES. The group discussed patient education for diabetes and it was agreed that this was a key priority, which needed to be addressed. JR added that we need to ensure that we are maximising our existing resource as well, such medicines optimisation and primary care teams. DES RA and AC were thanked for this work and it was recognised that more support was needed in the future. 09. Workforce Update Ro York (RY) and Marie Davies (MD) attended to present this item. AMor explained that this was an overview of work being done by the STP and BNSSG Local Workforce Action Board (LWAB). There are several recommendations that the Commissioning Executive are requested to give a 6

steer on. National Health and Care Workforce Strategy and Consultation this will be launched on the 70 th anniversary of the NHS and will include consultation feedback. Healthier Together Local Workforce Action Board to include sign up to an STP Memorandum of Understanding which will allow baseline data to be shared. A privacy impact assessment has been completed and statutory and mandatory training would need to be aligned. Apprenticeships to look into opportunities apprenticeships could offer the CCG, it was noted that this could also be an opportunity if there were staffing gaps in appropriate areas following phase 3 of the restructure. There is some scoping to be done around this and it can then come back to a future meeting. JR welcomed this proposal and added that apprenticeships are a missed opportunity for the organisation. BNSSG Health and Care Workforce strategic priorities and development of strategy and delivery plan18/19 MD is looking at workforce baselines data and RY advised that the Clinical Senate will tomorrow see a paper reporting results of a survey of GP s that suggests 2 in 5 will leave general practice in the next 5 years in the South West. Workforce planning and modelling a subgroup has been formed to look at workforce analysis, RY is currently holding the role in terms of primary care as it hasn t been yet been established who this should be. BNSSG Healthier Together Primary Care workforce plan on a page asking for this to be agreed so that it can be baselined at this stage with other stakeholders. Delivery is dependent on a range of stakeholders and a narrative strategy and delivery plan will need to be developed. JR expressed her concern at the movement of the same staff around the system she explained it felt like different organisations were poaching staff from each other and she would like to push back on how this can be addressed and how new staff can be brought into the workforce. MP also queried whether there was any analysis of staff being paid at or near minimum wage and felt that ways needed to be found of retaining those staff as they are likely to be attracted into much less stressful roles with the same salary. CB asked whether thought had been given to opportunities in the community and voluntary sector, is there anything about how clinicians can work across agencies in a blended model and finally, how are staff being engaged on their views. RY responded that the LWAB is focussed on the health and care workforce and community and voluntary sectors aren t included in baseline, although it has been recognised that this is an untapped resource. Additionally, clinicians working across agencies was one of the key enablers about how we allow people to work across organisations, so there are two workstreams for this, one being a recruitment passport but also looking at aligning stat/mand training. The Commissioning Executive group thanked RY and MD for this update and it was agreed that this would come back to the meeting in April. 10. Any other Business Primary Care Budget statement LM advised that the Commissioning 7