Report to the Sutton Clinical Commissioning Group Governing Body · 2014. 8. 28. · SCG GB 03.09.14 Att 15 Internal Audit Strategy and Internal Audit Plan 2014/15 GPr emphasised

SCG GB 03.09.14 Att 15

Report to the Sutton Clinical Commissioning Group Governing Body

Date of Meeting: Wednesday, 3rd September 2014 Agenda No: 8 Attachment: 15

Title of Document: Minutes of Committees for Note

Purpose of Report: For Note

Report Author: As per details on each attachment

Lead Director: As per details on each attachment

Contact details: As per details on each attachment

Executive Summary:

8.1

Executive Committee 21.05.14; 11.06.14; 25.06.14; 09.07.14

8.2 Quality Committee 15.05.14; 19.06.14; 17.07.14

8.3 Finance Committee 16.04.14; 28.05.14

8.4 Audit Committee 06.02.14; 29.05.14

Recommendation(s): The Sutton Clinical Commissioning Group Governing Body is requested to note the minutes.

SCG GB 03.09.14 Att 15

MINUTES OF

THE SUTTON CLINICAL COMMISSIONING GROUP EXECUTIVE COMMITTEE MEETING

Wednesday 21st May 2014

2.00 - 3.30pm Meeting Room 1, Priory Crescent

Present Geoffrey Price GPr Chief Finance Officer, Sutton CCG (Chair) Dr Farhan Rabbani FR Wallington Locality Lead / GP - Wallington Medical Centre Dr Jonathan Cockbain JC QIPP Lead-Urgent Care/ GP - Chesser Surgery Dr Dino Pardhanani DP QIPP Lead-LCCs & Service Redesign / GP - Mulgrave Road Surgery Karol Selvey KS QIPP Lead /Nurse Practitioner & Partner - Dr Grice & Partners Dr Simon Elliott SE QIPP Lead-Prescribing / GP - Dr Elliott, Grice & Partners Dr Jeffrey Croucher JJC Locality Lead, Sutton & Cheam / GP - Benhill & Belmont Surgery In attendance Megan Milmine MM QIPP Programme Director, Sutton CCG Sian Hopkinson SH Head of Performance, Sutton CCG Susan Roostan SR Director of Commissioning & Planning Elaine Oakley EO Senior Acute Contracts Manager, SLCSU Dr Brendan Hudson BH Chair, Sutton CCG / GP - Grove Road Surgery Julia Morosi JM Human Resources Business Partner, SLCSU Apologies Dr Ash Mirza AM Carshalton Locality Lead / GP - Faccini House Surgery Dr Chris Elliott CE Chief Clinical Officer / GP - Benhill & Belmont Surgery Jonathan Bates JB Chief Operating Officer, Sutton CCG Dr Chris Keers CK QIPP Lead-Mental Health / GP - Wrythe Green Surgery Dr Mark Wells MW QIPP Lead-Acute Contracts / GP - Wrythe Green Surgery Action

1 Welcome and Apologies The Chair welcomed all in attendance to the meeting.

2 Declarations of Interest

No items were declared.

3 Minutes of the meeting held on 14 May 2014

The minutes were approved. Matters Arising Joint Health and Social Care Strategy Plan SR confirmed the final version of the Joint Health and Social Care Strategy Plan will be submitted to One Sutton Commissioning Collaborative (OSCC) on 29 May for agreement and thereafter to 4 June Governing Board to approve the strategy documents. GP Referral Data SH restated this item will be added to future Executive Team agendas subject to improved data quality of practice referral reports being obtained.

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Internal Audit Strategy and Internal Audit Plan 2014/15 GPr emphasised that any comments are required by 19 May, to allow sufficient time to amend and present to the Audit Committee on 29 May. Performance Report - Quality Premium GPr stated that it is an overarching criteria for CCG to be in financial balance. Correspondence has been sent to NHSE seeking full clarification. The Executive were informed that the estimated QP payment is £600k. It is not known when this would be received but indications are for September / October 2014.

For discussion

4 Performance and Quality Report Month 12

SH reported that Month 12 CCG Performance Dashboard and Month 10 Quality Report by Provider will be submitted to the June Governing Board. SH went on to summarise that

Waiting times and lists - NHS England are seeking further assurance on 18 week performance, with waiting lists by provider being triangulated with CCG submissions. In general, the large teaching hospitals are experiencing the greatest challenge in meeting waiting time targets, particularly in tertiary specialty referrals. At ESH there are particularly issues in:

o Dermatology - An additional consultant has been appointed o Orthopaedics - insufficient capacity is causing waiting time delays

at ESH and an action plan is in place

52 week waiters - there are no patients currently exceeding the 52 week wait

Cancer waiting times - Details of breaches of waiting time standards for cancer were described within the report

Improving Access to Psychological Therapies (IAPT) - South West London & St George‟s Mental Health NHS Trust have an action plan in place to increase access and recovery rates in 2014/15. NHSE expect the 15% targets to be met by the end of the year which is of national interest

GP Out of Hours Service - is a good news story, SELDOC achieved green on every KPI in March

Recommendation The Executive Committee is requested to review the report prior to submission to the 4 June Governing Board meeting. Agreed

For Decision

5 HR Policies JM said the HR policies sets out the principles by which the CCG will agree to adhere to. Prior to submission to the Executive there has been liaison between MH on the following policies

Capability Procedure

Disciplinary Policy

Flexible Working Policy

Grievance Policy

Organisational Change Policy

Sickness Absence Policy

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Whistleblowing Policy JM asked members to take into consideration best practice and CCG can amend information with greater emphasis on a more informal approach. JM went on to say three additional policies have yet to be submitted, but awaiting feedback. It was noted that all HR policies are subject to change, except the Disciplinary Policy which would remain the same. Recommendation The Executive is asked to recommend the policies to the Governing Board for approval. Agreed

6 Assisted Conception Commissioning It was noted that CE/ MW / SR discussed the paper and that following approval from the Executive and Governing Board, there should be a caveat for 2014/15 to review our position at the end of the year. SR reported Sutton CCG is utilising a predecessor organisations policy to administer the commissioning of assisted conception services. It was reiterated the CCG does not routinely commission assisted conception from acute trusts locally. SR went on to say that as part of the operating plan the CCG to review the policy and take into account its position regarding the commissioning of IVF services locally. The IVF proposed budget for 2014/15 is £350k which equates approximately 58 patients if the costs per patient are £6k per patient. Recommendation The Executive is asked to

approve the revised clinical criteria and IFR referral process of cases requesting IVF treatment as depicted in Option 2

approve the amendments to the ECI documentation to reflect changes in commissioning and also advise GPs

note the CCG will converse with our lawyers on the clinical policy to ensure the mitigation of any risk of challenge

support the recommendation to contact previous applicants or complainants since the CCG became a statutory organisation to enable them to reapply against the revised criteria

agree and implement clear and stringent monitoring mechanisms via the CSU and IFR team to monitor approvals and spend

consider public health‟s supporting document when reaching an agreement on the recommendations

review the commissioning decision as part of the 2015/16 commissioning cycle to take account of additions to waiting list, spend against budget and consequences for the 2015/16 financial year. Also, needed is a further decision on re-commissioning in 2015/16

It was noted that a quality impact assessment needs to be addressed prior to submission to the Governing Board. SR agreed to undertake. The Executive thanked SR/MW for the work achieved thus far on the IVF paper. GPr said that a number of good questions and genuine concerns re clarity around qualifying criteria and potential cost had been raised and there was not a consensus to take the recommendation forward at this time. The Executive felt that the proposal should be submitted to the new Clinical

SR

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Effectiveness Group for discussion and then to the Executive Committee for decision and recommendation to the Board. This was now likely to be the September Board meeting.

7 JSNA Fact Sheets MM informed members that the Sutton Joint Strategic Needs Assessment (JSNA) will be published in the public domain in June 2014 and will be accessible via the London Borough of Sutton website. MM said the submitted individual data and fact sheets on Cancer, Circulatory Disease, Diabetes, Long Term Neurological Conditions, Respiratory and Stroke will be arranged under the following sections:

1. Demographics 2. Children and Young People‟s Wellbeing 3. Adult Health and Wellbeing 4. The Wider Determinants of Health 5. Long Term conditions 6. Health Protection 7. Social Care Services

MM and Sylvia Godden, Public Health welcomed any feedback with a tight timescale of a week. KS stressed the circulatory, respiratory and diabetes factsheets required slight amendments prior to sign off. Recommendation The Executive is asked to review the documentation. The Executive agreed to the documents subject to modifications from KS.

KS

Standing Item

8 Monitoring Running Costs GPr said there is no item for discussion, but reiterated following the last Executive meeting there will be a more detailed Month 2 report on CCG running costs which will commence the financial reporting for 2014/15.

For Note

9 Annual Report 2013/14 GPr stated this is the 2nd draft of 2013/14 Annual Report and would welcome any comments by Friday 23 May, prior to submission to the June Governing Board. It was noted a summary of the Annual Report to be produced as a “public facing” document and made available prior to the CCG 2013/14 Annual General Meeting. Comment It was highlighted there is a significant use of “we” and “we know” on the Welcome page. Recommendation The Executive is asked to note the Annual Report. Noted

10 Any Other Business

KS is finally in receipt of Public Health “Cover” data on immunisation uptake. The Cover data and practice reported data use different timeframes and definitions, so cannot be directly compared. KS specified that it is the Cover data that is

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published nationally, and she will share this with localities. The 2013/14 Practice Engagement Scheme and Quality Premium Local Indicator both will use the practice data to assess achievement. Out of Hours SR reported that SELDOC is functioning satisfactorily. SW London CCGS have issued a performance notice to the 111 provider Harmoni. The performance notice relates to underperformance against KPIs on the contract, in particular at weekends. The contract is regularly monitored through monthly contract meetings held across SW London with the CSU. The GP led health centre contract is held by NHSE. If the contract is to be changed (it is not clear on plans for this) and this leads to a reduction in the OOH access element of the service. (8-8, 7 days per week) Then Sutton CCG and Merton CCG should receive some of those funds to resource urgent care services we would wish to commission to support additionally access locally. The Executive agreed that Out of Hours in relation to co-commissioning should be noted at the next Governing Board. GP IT SH had updated GPs at the Locality meetings that NHSE are indicating that they may not be able to allocate sufficient funding to complete the IT hardware and software update across Sutton in 2014/15. Members reiterated that the poor GP IT hardware continues to cause significant problems for practices, with the inability to run current systems efficiently. As there are many schemes coming online that require use of technology, such as Kinesis, risk stratification and case management, this is increasingly affecting the ability of practices to work effectively. This was affecting implementation of QIPP schemes and other initiatives. GPr stated that responsibility for GP hardware (ie capital) rested with NHSE but there was of course a knock on effect on the CCG. He undertook to look at the possibility of CCG capital being used to supplement NHSE spend and would talk to SLCSU (who manage GP IT capital for the NHSE) to get update on current position. Action - An update would be given at the next meeting. No further business to discuss. Date of Next Meeting: Wednesday 11 June 2014

SH

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MINUTES OF THE SUTTON CLINICAL COMMISSIONING GROUP

EXECUTIVE COMMITTEE MEETING

Wednesday 11th

June 2014 1.00 - 3.00pm

Meeting Room 1, Priory Crescent

Present Dr Chris Elliott CE Chief Clinical Officer / GP - Benhill & Belmont Surgery (Chair) Jonathan Bates JB Chief Operating Officer, Sutton CCG Geoffrey Price GPr Chief Finance Officer, Sutton CCG Dr Farhan Rabbani FR Wallington Locality Lead / GP - Wallington Medical Centre Dr Jonathan Cockbain JC QIPP Lead-Urgent Care/ GP - Chesser Surgery Karol Selvey KS QIPP Lead /Nurse Practitioner & Partner - Dr Grice & Partners Dr Jeffrey Croucher JJC Locality Lead, Sutton & Cheam / GP - Benhill & Belmont Surgery Dr Ash Mirza AM Carshalton Locality Lead / GP - Faccini House Surgery Dr Chris Keers CK QIPP Lead-Mental Health / GP - Wrythe Green Surgery Dr Mark Wells MW QIPP Lead-Acute Contracts / GP - Wrythe Green Surgery In attendance Adrian Davey AD Mental Health Commissioning Manager (Item 4) Megan Milmine MM QIPP Programme Director, Sutton CCG Sian Hopkinson SH Head of Performance, Sutton CCG Susan Roostan SR Director of Commissioning & Planning, Sutton CCG Ian Gordon IG Senior Acute Contracts Manager, SLCSU Dr Brendan Hudson BH Chair, Sutton CCG / GP - Grove Road Surgery David Jobbins DJ Better Care Fund Manager, LBS/Sutton CCG Caroline Jones CJ Designated Nurse Safeguarding Children and Vulnerable Adults

Lead, Sutton CCG Apologies Dr Dino Pardhanani DP QIPP Lead-LCCs & Service Redesign / GP - Mulgrave Road Surgery Dr Simon Elliott SE QIPP Lead-Prescribing / GP - Dr Elliott, Grice & Partners Action




3 Minutes of the meeting held on 21 May 2014

The minutes were approved. Matters Arising Performance Report - Quality Premium GPr stated that it is an overarching criteria for CCG to be in financial balance. Correspondence has been sent to NHSE seeking full clarification.

For decision

4 Primary Care Mental Health Model (CK/AD/SR) CK started by thanking Corinna White, Mental Health Programme Manager for her support in developing the proposed new primary care mental health model for

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Sutton. CK explained that the expiry of the current IAPT model had provided the opportunity to review new models of mental health provision beyond an IAPT service. Various models were reviewed, some of which included sign-posting, advice and information and others with more significant changes for example single point of referrals to all mental health services and treatment. The paper presented described the proposed primary care mental health services which is based on elements from the models reviewed would include:

- Single point of access for all mental health referrals; - Well-being arena - Support for patients under mental health cluster 5 & 11 - Talking therapies.

CK said that the model been presented to local stakeholders and carers and feedback received has been very positive and favoured a significant change model. 5 procurement options were considered:-

1. Do nothing and continue with the existing contractual arrangements 2. Re-procure an IAPT service only adding extra resource to increase

performance 3. Procure a psychological therapies service and include well-being resource 4. Procure a primary care mental health triage and assessment service, well-

being resource, psychological therapy service and a treatment service for patients under mental health cluster 5 & 11

5. Procure option 4 but apply a phased procurement process, procuring an IAPT service first and adding a wider mental health referral hub and a service for patients clustered 11 in 2015/16

Based on the feedback received and the need for changes to how patients in mental health cluster 5 and 11 receive treatment the Executive Committee were asked to consider two recommended options for approval – Option 4 and Option 5. Comments In response to a question on the risks and benefits of both options, AD said that Option 5 (phased) in relation to Cluster 11 patients would allow more time for discussions with SWLStG, however Option 4 (non-phased) although challenging would bring greater benefits to patients. BH was satisfied that the single point of referrals would bring the required benefits to patients but was cautious that there was insufficient capacity in GP Practices to see extra patients. AM said that whilst supportive of a central triage process, would want to know the impact on primary care in terms of extra patients. JJC said that all Locality Groups had been visited and there was a good level of support and confidence that GPs could refer patients at the right time, but would want more assurance that the assessment process is maintained to manage changes. In response to a request for the top 3 risks to Option 4, AD said that these were around the link between IAPT and secondary care to avoid gaps; patients understanding and ability to self-refer; and any referral issues with secondary care providers. CK referred to the perception that patient numbers would significantly increase in

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primary care. Work carried by Dr Stuart Adams, Sutton Consultant, SWLStG on the right setting for patients had found that the number of Cluster 11 patients who would require primary care support is low. JC said that whilst supportive of a single referral approach would want more understanding of the social care element and overlap with BCF. AD responded that the model proposed a „holistic‟ approach, including early identification of underlying issues with appropriate referrals to services for example „debt management‟ which may in some cases bring the same level of health benefits as a referral to a psychological service. JB supported Option 5 stating that existing IAPT contract has already been extended and the phased approach would allow more time for conversations with the Trust. In response to a question regarding funding for specialist procurement advice, SR said that the level of expertise required would be dependent on the Executive‟s decision. In summary CE said that the majority of clinicians, locality leads and practices would support Option 4 subject to the financial position, from a CCG and Trust perspective. SH said that the Quality Premium element £133k, which was underpinned by the CCG‟s financial position should not be factored into the model. . Next Steps AD to bring back the financial position and risks of both Option 4 and Option 5 to the Executive including:-

- Quality Risks of non-procurement - Unquantified Financial position - Performance risk in relation to delayed procurement

Recommendation The Executive committee is asked to:-

1. Support the broadest model for procurement Option 4 of Option 5; 2. Agree to the purchase of specialist procurement advice to support the

procurement process; 3. For the quality premium £133k (associated with IAPT target) to be directly

re-invested into primary care mental health provision The Committee would support option 4 but this was subject to review of the financial position as requested above. It was agreed that the Quality Premium would not be included and noted that specialist procurement advice would be determined when the final decision has been made. AD to bring back financial position to the Executive Committee.

AD

For discussion

5 Better Care Fund Update (DJ) DJ introduced a paper describing progress made in developing the BCF workstreams, reporting arrangements and governance in preparation for the introduction of pooled CCG/Local Authority Budgets from April 2015. The report to the HWB as presented has been discussed by the One Sutton Commissioning Collaborative and is due to be presented to the HWB in June. The final BCF plan was submitted to NHSE on 4

th April. Formal feedback is still

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awaited, however it is expected that a further submission will be required by 27th

June to describe the correlation between the BCF with the Operating Plan and SWL 5 Year Strategic Plan. Three distinct work streams have been identified:

- Planned Care - Unplanned Care - Mental Health

Each work stream will have a Lead and need to consider how it addresses the needs of people with dementia and those with complex health needs and also cross reference to the Care Act requirements. As enablers three other work streams have been chosen to support the implementation of the 3 main work streams. These are:-

- Workforce - Engagement and Communications - Finance and Performance

Four new posts called „Integration Facilitators‟ will be established; one for each Locality with a 4

th post at the hospital with the aim to manage hospital admissions

and discharge processes liasing with the Trust and Community Services. It is intended that existing staff, with local knowledge and expertise will be appointed to these roles to ensure that they are able work to progress at pace. The submission to NHSE included a set of performance metrics which are:-

- Permanent admissions of older people (aged 65 and over) to residential and nursing care homes;

- Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into Reablement/rehabilitation services

- Delayed transfer of care (delayed days) from hospital - Avoidable emergency admissions (average per month) - Patient/service user experience (national metric under development) - Local measure: Dementia diagnosis rate compared to estimated prevalence - Savings £3.2m target for 2015/16 – for Sutton this equates to £2.75m across

CCG/LA. Next Steps

- Final submission to NHSE by 27.06.14 - Work Stream Leads to be identified by end of June - Headline Delivery Plan to be presented to the OSCC at the end of July - Integration Facilitators to be appointed by end of July

Comments JC asked if the dementia work would be under the Mental Health work stream only. DJ said no, it has been agreed that dementia should run through all 3 work streams to ensure the needs of these patients are met in all settings. BH suggested a visit to Greenwich as an example of successful health economy, and to learn from. CE referred to the transfer of funds from CCGs to Social Care Budget in 2015/16 and asked how the CCG “savings gap” will be met. DJ said that reduction in number of unnecessary referrals to secondary care is where savings will be delivered and will be the focus for the unplanned and planned care work streams. CE then referred to the correlations between the BCF, Operating and SWL 5 Year Strategic Plan and asked how this will be achieved, recognising that each CCG will have own plans. DJ said that this has been considered and as a first step the

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Transformation Board have invited James Corrigan, BCF Lead for Merton CCG to join the Programme Board and invitations will be extended to the other SWL CCGs to have an overall understanding of each other‟s plans. JB cautioned that in working as part of the SWL Commissioning Collaborative the direct impact on Sutton must be clearly understood, with an agreed process for decision making with the Local Authority to mitigate risks. DJ finished by saying that it is important that all stakeholders understand that the community based work alone will not deliver savings and is reliant on other areas to realise the required savings as services are transferred from an acute to primary care setting. The Chair thanked DJ for attending the meeting. DJ left the meeting.

6 Children Services Inspection Team Safeguarding and Looked After Children Review The Chair welcomed Caroline Jones, CCG Safeguarding Lead to the meeting. From April 2014 the CCG has taken on the new responsibility to host the next inspection for children service‟s in Sutton. MH advised that CJ is leaving in two weeks time and over the summer the CCG will be without a Designated Safeguarding Nurse. The role has been appointed and will be in place by September. However, an interim Designed Safeguarding Nurse will be available to the CCG in the event an inspection takes place over this period. CJ presented and talked through a short presentation describing the role of the CCG, stating that the CCG itself will not be inspected but will be expected to host the Inspectors. The CCG will receive 2 working days notice that an Inspection is to take place. This will be received on a Thursday before a 5 day Inspection commences the following Monday. Inspectors will decide on the first day which 6 out of 12 provider cases to review and who they would like to interview. This is likely to include GPs and Specialist Nurses amongst others. CJ gave assurance to the Executive all Providers are aware of the CQC inspection framework and are prepared for the visit and all the CCGs processes are in place to support such an Inspection. Comments RF asked how much notice GPs would receive that they are to be interviewed. MH said that once the CCGs have received notification of a visit it will be communicated to GP Practices immediately. CE asked that a letter is sent to GP Practices to raise awareness and to re-emphasis their responsibilities in relation to Safeguarding, i.e. staff training numbers. JC welcomed the opportunity for Practices to feedback concerns to the Inspectors. On behalf of the Executive, CE thanked CJ for her work with the CCG and wished her well for the future. CJ left the meeting.

CJ/MH

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7 Update on Carbapenemase – Producing Enterobacteriacae The Chair welcomed Penny Spence, Infection Control Specialist, SLCSU to the meeting. PS presented a paper to provide the Committee with information on the emergence of Carbapenemase – producing Enterobacteriacae (CPE) and the potential impact on Provider Trusts and the actions required of Providers to mitigate the risks. PS informed the Committee that ESH have completed the Public Health toolkit and are compliant with the recommendation in terms of identifying and screening patients in A&E, but unable to comply with the recommendation for Isolation due to a lack of single rooms at the Trust. The Committee were asked to note that ESH are not alone in this and concerns about the practicalities are currently being raised across the Country and it is the general consensus of opinion of the microbiologists within the acute trusts that the toolkit in its current form is not implementable. PS asked the Committee to note and support the actions taken by ESH and this was agreed by the Executive. CE asked PS to draft a short paper for circulation to all GP Practices to raise awareness. The Chair thanked PS for updating the Committee and noted that it will be discussed and monitored through the CQRG. PS left the meeting

PS/MH

8 Finance Report Month GP provided a verbal update and the following was noted:- 2013/14

- Annual Report and Accounts have been submitted to NHSE within deadline and posted to the CCG web-site. This effectively closes the Financial Reporting for 2013/14.

- The CCG received an „Unqualified‟ Auditors Report 2014/15

- The CCG are reporting on plan - Acute data will be reported in Month 3 - SWL 5 Year Plan and BCF Plan submitted within deadline - Financial Plan to be submitted on 20.6.14 - In relation to £5.5m over-activity at ESH in 2013/14 - GP has invited Sarah

Cottingham to attend Executive Committee (date to be confirmed)

9 SWL 5 Year Plan and Addendum CE introduced this item. SWL 5 year plan: The document set out the 5 year strategic plan for South West London Strategic Planning Group. It covers 8 clinical areas, setting out initiatives in each which will collectively form the response of the SPG to the case for change for south west London. There are 4 key drivers for change in south west London that must be addressed:-

- The quality of care - The workforce gap - Financial sustainable - Rising demand for healthcare

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There is clear clinical consensus around the quality of care that all acute hospitals need to meet the London Quality Standards represented by 7 day working to be implemented by 2015/16. It is important to address the workforce gap and this cannot be achieved by recruiting more consultants. Page 17 describes the workforce gap in south west London. The case for financial sustainability is presented on Page 19, and demonstrates that if there were no improvements in productivity, commissioners in south west London would be faced with a total QIPP savings target of £209m in 2018/19 in order to meet the 1% surplus requirement. CE introduced the 5 Year Plan Addendum - Implementation challenges. CE then referred the Committee to Item 2.3, which states that at the current time it is not possible to demonstrate financial sustainability as part of the strategy without support from NHS England and agreed collaborative support. This is due to the collaborative position forecast for 2018/19. Price Waterhouse Cooper (PwC), who are supporting the process have stated that changes may be required in a shorter period of time than previously expected, to achieve the level of savings reviewed. Comments JB said that whilst recognising that the financial position is very challenging, there is a way forward with NHSE. In terms of Governance and how much to devolve to a joint group in SWL it is important that whilst recognising the need to move forward this needs to be balanced with the needs of Sutton. BH concurred that the issues are extremely challenging, and that more work will be required following the Governing Body decision.

10 SCCG 360° Stakeholder Survey 2014 JB presented the stakeholder feedback to the Committee for information. Following brief discussion and to improve engagement with GPs it was agreed to consider a summary paper from the Executive on discussions which have taken place to improve engagement and to allocate as a standing agenda item, Locality Lead feedback.

Standing Item

11 Monitoring Running Costs There are no costs to report.

For Note

There are no items for note.

Any Other Business

12 GP IT An update on the implementation issues was received by the Committee. GP said that the CCG have agreed to guarantee £150k so that the implementation can move forward.

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Taking into account the strong views of the Executive, CE asked that an Implementation Timeline and explanation for the delays in implementation is presented to the next meeting of the Executive Committee. SH to feedback to the CSU to action.

SH/CSU

13 Date of Next Meeting:- Wednesday, 25th June 2014, 2-3.30pm, Priory Crescent

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MINUTES OF


Wednesday 25

th June 2014

2.00 - 3.30pm Meeting Room 1, Priory Crescent

Present Dr Chris Elliott CE Chief Clinical Officer / GP - Benhill & Belmont Surgery (Chair) Jonathan Bates JB Chief Operating Officer, Sutton CCG Geoffrey Price GPr Chief Finance Officer, Sutton CCG Dr Farhan Rabbani FR Wallington Locality Lead / GP - Wallington Medical Centre Dr Jonathan Cockbain JC QIPP Lead-Urgent Care/ GP - Chesser Surgery Karol Selvey KS QIPP Lead /Nurse Practitioner & Partner - Dr Grice & Partners Dr Jeffrey Croucher JJC Locality Lead, Sutton & Cheam / GP - Benhill & Belmont Surgery Dr Ash Mirza AM Carshalton Locality Lead / GP - Faccini House Surgery Dr Simon Elliott SE QIPP Lead-Prescribing / GP - Dr Elliott, Grice & Partners In attendance Adrian Davey AD Mental Health Commissioning Manager (Item 5) Megan Milmine MM QIPP Programme Director, Sutton CCG Sian Hopkinson SH Head of Performance, Sutton CCG Susan Roostan SR Director of Commissioning & Planning Ian Gordon IG Senior Acute Contracts Manager, SLCSU Dr Brendan Hudson BH Chair, Sutton CCG / GP - Grove Road Surgery Sam Green SG Service Redesign Manager (Item 4) Mike Conlon MC Service Redesign Manager (Item 4) Paul Sarfaty PS SCCG Board Lay Member – Governance and Audit Sarah Cottingham SC LBS MDT Lead - Acute Contracting NHS CSU (Item 4) Di Carter DC LBS MDT Lead - Acute Contracting NHS CSU (Item 4) Apologies Dr Dino Pardhanani DP QIPP Lead-LCCs & Service Redesign / GP - Mulgrave Road Surgery Dr Chris Keers CK QIPP Lead-Mental Health / GP - Wrythe Green Surgery Dr Mark Wells MW QIPP Lead-Acute Contracts / GP - Wrythe Green Surgery

Action




3 Minutes of the meeting held on 11 June 2014

The minutes were approved with two amendments Page 3 - replace BCF element with Quality Premium element in fifth paragraph Page 5 - replace hold in second paragraph with host the next inspection

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For discussion

4 External Review of 2013/14 Financial Overspend at ESHT and CCG Initial Response (SC/SR/MM) SC was asked to write a full review of the end of year 2013/14 ESHT performance which included the over performance drivers, reported position and gain an understanding of the contractual levers available to the CCG. Looking at the three main issues of non-elective admissions, outpatients and excess bed days. To establish a robust start line was very complex and challenging given the movement to CCGs. Unfortunately the Trust was also not reporting accurately until near the end of the year making the underlying position difficult to understand. The end of year over performance of £5.5m was a negotiated position with three main areas of over performance being non-elective admissions, outpatients and excess bed days. The areas are quite complex with the combination of underlying increases in activity, case mix complexity and apparent changes in recording and charges. This was clearly a significant over performance. Financial settlement did not resolve all the contracting issues and are going to have to keep monitoring the significant issues in 2014/15. Currently all the risks with QIPP sit with the CCG with no incentive for the Trust to be involved and nothing formally in the contract. SC stated that other CCGs had looked at this and had linked QIPP to the contract to incentivise the Trusts. The CCG needs to look at levers required with ESHT. National guidance and policies do put CCGs at risk this needs to be down to local negotiations and working more collaboratively with the Trusts to encourage them to participate more. The CCG needs to think more tactically on how to manage the Trust with more stringent contract management over 2014/15 and to work on the relationship between the Trust and the CCG. CCG, CSU and the Trust need to work better together to think tactically how to manage the contract in 2014/15 and to relook at risk stratification with regards to QIPP delivery. CCG need to start the discussion early with the Trust for the 2015/16 contract on a Board to Board level along with senior manager meetings looking at what the Trust want too. JB thanked SC and DC for all their work. If we repeat the £5.5m again the CCG will not reach financial balance this year. CCG need to be looking to see if we are doing what is needed to be done both as an exec and individually. The early signs for 2014/15 so far are showing financial pressure. The CCG at Board, Executive and Operational Team level need to take this priority very seriously. GP stated that they have started working on the relationship with the Trust and working with CSU on more robustness of work with the Trust. Year end settlement was the same as the actual outturn position which was a good result. BH stated he saw this as a wake-up call and we need to focus more on our relationship with the Trust. JC feels that a lot of this depends on the data inputting being accurate and they had started to employ people to look at this but it was shown not to be value for money. We should have a better insight of the recording issues for this year which requires robust contract management. SC advised that data is always analysed sometime after the activity occurred. The biggest issue was data being recorded accurately and there are new PBR changes which need to be carefully considered. DC advised that a lot of what happened last year was due to staff changes in the Trust.

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AM asked with excess bed days what can be done? DC stated the Out of Hospital strategy (Joint Health and Social Care Strategy) implementation would help develop community alternatives. JB advised that One Sutton Collaborative Commissioning committee has expanded to include the local three main NHS providers as well as the voluntary and community sector. SC stated that the CCG/CSU needs to be more assertive and robust in contract negotiations and ongoing managing including monetary withholding elements until key information is available. SE asked would an awayday be a good idea for the Trust and the CCG to assist in working more collaboratively. SC agreed that this would enable frank discussions to happen. DC feels that clinically there has always been a good relationship but contractual liaison definitely needs more work. CE closed this item off stating that this should come back to the next Executive Committee and for all to look at the three columns on the action plan document sent. CE also stated that there have been high level discussions with the Trust at the Strategic Partnership Group but currently with there being an interim CEO this may prove more difficult to change approaches.

ALL

5 Primary Care Mental Health Proposed Model Update (GP/AD) This paper is presented again following the comments from the last Executive Committee in relation to the development of a Primary Care Mental Health Care Model. SR advised that the purpose of presenting this again was for the Executive Committee to decide whether to go for Option 4 which is a redefinition of the service specification for IAPT services and procure a stand-alone service for Sutton CCG or Option 5 which is to procure the broadest model but to take a phased procurement process by re-procuring the talking therapy and health & well-being service first then adding the wider referral hub and service for cluster 11 patients at a later day. SR advised that for Option 5 the timeline was set for procurement completion and start of October 2015. AD advised that the element needed is the disinvestment from our current provider. GP made contact with the secondary mental health provider and primary mental health provider and has some previous information from other CCGs but GP still needs further information to determine the impact of this financially. SR advised that CK has done a lot of work on how this will impact primary care and felt it would not be immense. JB has concerns around the timeline and other procurements going on at the same time. As the present timeline presented to the Executive was inaccurate he requested another timeline to be created and an exploration of whether the implementation date could be brought forward to 1

st April 2015. SR advised that this

has to fit in with the coterminous of Merton to end the link between Sutton and Merton. Executive Committee need to decide on one of the two options (4 or 5). SR also advised that this needs to be done correctly and felt the October 2015 timeline is more feasible. AD stated that the timeline also takes into account mobilisation being made easier and also the staff TUPE. CE stated that TUPE would be a provider issue. JC stated he still didn‟t have confidence with understanding the impact on general practice as this could be quite time consuming. SR feels this will be less time consuming as the single point of access will be the GP so patients will not

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continuously be returning to the GP to complain about not being in the right service. JCr recommended this went to the workshop for all localities taking place in July to ascertain the practices views. KS feels with the amount of resource available the timeline put forward would be the best option of October 2015. If brought forward there is a chance of something being missed and this needs to be done properly. SE agreed with KS. CE closed this item with the following :

Look at the concerns of primary care workload – numbers need identifying and fed to workshop for all localities

Bring the result to August Executive Committee

Aim for financials to be completed in one months time

Timeline to make sure this process is completed properly CE then finalised with once financials have been worked through this will help to decide whether to go with full programme and in the timeline specified. If financials do not work for full programme then bring timeline forward to go with IAPT option. Meeting was asked if the decision of this could now be delegated and not brought back to Executive Committee. Meeting agreed this did not need to come back and that CE would make the final decision.

6 GP IT - Timetable (SH) SH advised that a person from the CSU team will be attending the next meeting to provide a comprehensive update. Sutton CCG have agreed to underwrite £150k to get practice IT upgrades underway now. CSU are employing a new Project Manager to take on the stock take, statement of works, practice priorities, steering group meetings who includes Trevor DeSa from Carshalton Fields and Dr Raza Toosy from Park Road. GP advised that the risk to this would be if NHSE decide not to refund the capital but this is a very low risk.

7 Primary Care Co-Commissioning - Expression of Interest (SH) The expression of interest has been submitted directly to NHSE and as part of the SW London proposal involving all six local CCGs.

Any Other Business

8 Community Services Procurement KS, SR and Carol Lambe working through the community services procurement but need far more clinical engagement to redesign service specifications. CE will add a temporary post around this onto the appointments of clinical leads process.

CE

9 Date of Next Meeting:- Wednesday, 9th July 2014, 1pm - 3.30pm, Priory Crescent

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MINUTES OF


Wednesday 9

th July 2014

2.00 – 3.30pm Meeting Room 1, Priory Crescent

Present Dr Chris Elliott CE Chief Clinical Officer / GP - Benhill & Belmont Surgery (Chair) Jonathan Bates JB Chief Operating Officer, Sutton CCG Geoffrey Price GPr Chief Finance Officer, Sutton CCG Dr Farhan Rabbani FR Wallington Locality Lead / GP - Wallington Medical Centre Dr Jonathan Cockbain

JC QIPP Lead-Urgent Care/ GP - Chesser Surgery

Karol Selvey KS QIPP Lead /Nurse Practitioner & Partner - Dr Grice & Partners Dr Jeffrey Croucher JJC Locality Lead, Sutton & Cheam / GP - Benhill & Belmont

Surgery Dr Ash Mirza AM Carshalton Locality Lead / GP - Faccini House Surgery Dr Dino Pardhanani DP QIPP Lead-LCCs & Service Redesign / GP - Mulgrave Road

Surgery Dr Chris Keers CK QIPP Lead-Mental Health / GP - Wrythe Green Surgery Dr Mark Wells MW QIPP Lead-Acute Contracts / GP - Wrythe Green Surgery In attendance Adrian Davey AD Mental Health Commissioning Manager Megan Milmine MM QIPP Programme Director, Sutton CCG Mary Hopper MH Director of Quality Ian Gordon IG Senior Acute Contracts Manager, SLCSU Neil McDowell NMcD Acting Head of Contracts for SWL, SLCSU Mike Conlon MC Service Redesign Manager (Item 8) Dawn Chamberlain DW Director of Operations SWLStG (Item 5) Andrew Dean ADe Director of Nursing SWLStG (Item 5) Barry Holland BHo Support Services Manager, LBS (Item 12) Avtar Ubbi AU ICT Support Manager, SLCSU (Item 6) Dick Daby DD ICT Support, SLCSU (Item 6) Observer Dr Brendan Hudson BHu Chair, Sutton CCG / GP - Grove Road Surgery Apologies Dr Simon Elliott SE QIPP Lead-Prescribing / GP - Dr Elliott, Grice & Partners

Action



The SLCSU holds a register of interests which is available upon request. No addition declarations were made in relation to the items on the agenda.

3 Minutes of the meeting held on 23 June 2014

The minutes were approved without amendment.

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Action 4 Acute Commission Review - response to action plan

JB introduced the action plan developed in response to Sarah Cottingham‟s review of ESH contract over-performance in 2013/14. The action plan sets out the recommendations for robust performance monitoring in 2014/15 with actions aligned to the CCG, CSU and the Trust. The Executive Committee were asked to review the action plan and agree the proposed recommendations and alignment of actions. Comments NMcD (CSU) supported the proposal for robust monitoring and agreed the alignment of actions with a recommendation for a stronger description of the CCG‟s relationship with the Trust to ensure that the Trust sees the CSU and CCG as one body. Regarding clinical engagement which is already captured with the contract, it is important that the Trust is clear on their responsibilities. JB said that a Board to Board and Executive to Executive are planned for the Autumn to formally agree the management approach and monthly meetings on top of those already in place have been agreed with the Trust at a meeting with Jackie Sullivan (Chief Operating Officer) and Peter Davies (Director of Strategy and Performance); to address concerns that the Contract Management meeting membership needed to be strengthened in terms of decision making. IG added that at a meeting with SR and the Trust, the CCG had requested sight of the Trust‟s governance structure to understand the internal decision making process. In response to a comment from FR on the changes from last year, GP said that the process this year is that over-performance is managed and agreed with the Trust quarterly to avoid miss understandings at year-end. In 2013/14 although over-performance was known and reported throughout the year an agreed year-end position was not agreed until Q4. JC said that not all clinical discussions with the Trust are „negotiations‟ and asked for clarity on decision making. CE responded that no decisions are confirmed until they have been agreed by the Contract Management Group. In response to a request for support in clinical discussions, CE asked that a paper describing Key Performance Indicators (KPIs) and the financial management process be presented to the Executive meeting in August. It was also agreed to add “Acute Activity against plan” as a standing item to the Executive Agenda from August. Recommendation The Executive Committee were asked to agree the action plan and to note the robust approach to performance management. Agreed

NMcD/IG (SLCSU)

5 SWL London & St George’s Mental Health Trust Presentation - Update on Foundation Trust Application Process and Estates Strategy Consultation The Chair welcomed Dawn Chamberlain (Director of Operations) and Andrew Dean (Director of Nursing) to the meeting. DC started by saying that the presentation today would be in two parts:- a. Estates Strategy Consultation b. Application for Foundation Trust Status update a. Estates Strategy Consultation

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Action DC introduced a presentation on the estates strategy advising that the proposal was based on the knowledge that the existing in-patient buildings are old and not suitable for modern mental health care, in addition the transformation programme for community services has led the Trust to undertake a fresh look at the future needs for inpatient services. The proposal is for two centres of excellence with new and modernised buildings at Springfield and Tolworth. The proposals were developed with input from clinicians and mental health professionals and there is clear evidence of the clinical benefits of modernisation, including improved staff morale, fewer serious incidents and will in addition result in no isolated units which are known to be vulnerable to safeguarding issues. The development of community mental health services with the introduction of the Home Treatment Team has had a positive impact in Sutton and Merton with the number of avoidable and unnecessary hospital stays reduced by 50%. Engagement started in 2014 with services users on the need to modernise Springfield. Since that time there have been a number of events held including a workshop held in April 2014 attended by local stakeholders, service users, carers and HealthWatch to give their views on the proposed plans. Timetable

- 17 July 2014 - Joint HOSC - 1 August five CCGs to authorise start of public consultation - 4 August for 12 weeks: public consultation and start of planning

process - Outline Planning Submission for Tolworth and application for

Springfield by end of August/September 2014 - Planning approach to Richmond and Barnes to be developed - OBC development now to end of November 2014 - CCG‟s letter of support – November 2014 - November 2014-early 2015 taking decisions - 2015-17 detailed planning - 2017-22 construction of new buildings

Comments CK said that service users and carers concerns were historical and around the loss of the local Sutton services following the transfer to Springfield, issues with public transport links and an overall a preference for Queen Marys Hospital which is linked to other healthcare services as opposed to a standalone service. AD said that he supported new facilities, but agreed that public transport links were a key concern for Sutton and must be assured. DC said that it is envisaged by offering 2 equitable services (Springfield and Tolworth) patients will be able to access the one closest to home. In addition, ADe said that an options appraisal of transport links must be undertaken as part of the OBC. In relation to the link to other healthcare services, DC said that work was already underway to establish a link between acute and mental health services. JJC asked about the numbers accessing Ward 3 to understand the 50% reduction as a result of the introduction of the Home Treatment Team.

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Action ADe responded that in 2013/14 there were 300 admissions from Sutton, with 23 at Tolworth, 19 at Queen Mary‟s Hospital and the remainder at Springfield. The proposal is to reduce Ward 3 to 18 beds which is in line with national guidance. MH was supportive of the proposal but highlighted two areas for further assurance. The first related to the public‟s confidence of community services and the need to clearly describe how community services will be different in 2017. Secondly recognising that inpatient numbers will reduce, but acuity will increase, staffing levels and skill set must be transparent. DC said that as the numbers reduce the staffing numbers will remain the same. ADe said that currently staff ratios are correct, however at the moment there are number of patients on the wards currently who when community mental health services are in place would be treated in the community. JB noted that he had received a letter from the Trust responding to Sutton CCG‟s issues prior to the launch of formal consultation. Legal advice had been taken on the powers of the Executive Committee to launch a consultation, as the Board did not meet again until September. This advice confirmed that it was constitutionally appropriate to start a consultation if supported by the Executive. JB insisted that the Board would have the final say as they would consider the consultation responses and make the ultimate decision as to whether they support on behalf of Sutton CCG. In concluding the discussion CE said that the CCG would be influenced by feedback from Carers and Service Users on the benefits of two rather than one hospital. Recommendation The Executive were asked to support the start of a public consultation into inpatient mental health services, noting that all CCGs in Southwest London would be asked and that the consultation would be led by the six CCGs. The Executive agreed the recommendation. To support the request for clinicians to attend local public events, BHu asked that the Trust confirm the date of the event in Sutton. DC to feedback. b. Application for Foundation Trust Status ADe provided an overview of the timetable advising that the Trust is on track to achieve FT status by April 2015. The next step is a Board meeting with the Trust Development Agency to agree that the Trust is ready to proceed with a final decision to be taken by Monitor informed by letters of support from the CCGs. ADe said that Integrated Business Case for each Borough is being developed with CCGs and the full IBC will be circulated in August for review and to inform the CCG‟s decision to support the Trust. CE said that the CCG‟s decision will be based on the views of service users, carers and local stakeholders. CE thanked DC and ADe for attending the meeting. DC and ADe left the meeting.

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Action 6 GP IT Refresh Project (AU and DD)

The Chair welcomed Avtar Ubbi and Dick Daby (SLCSU ICT Team) to the meeting to update the Committee on the project and capital allocation progress to date. The following was noted:-

- Following a meeting last week it was indicated that the capital funding allocation will be available in early August;

- SCCG have underwritten £150k of the total cost to allow the project to start;

- The first Steering Group meeting was held on 3rd

July; - Due to significant IT failure, the Chesser Practice refresh started on 7

th

July. JC reported an improvement was already being seen at the Practice;

- 17 practices have been audited to date. The remaining 10 will be audited before the next Steering Group. The Project Briefing Document will then be updated to allow the CCG to make an informed decision on which Practices to migrate first and to support budget management;

- A communications plan and strategy is being developed (SLCSU to CCG to Practices) and will be put in place when agreed.

Comments GP asked if the allocation of funding from NHSE would enable all Practices to be upgraded. AU confirmed that it would and the aim was that all Practices would be upgraded to Windows 7 by the end of March 2015. KS referred to „new‟ and „upgraded‟ PCs and asked about future proofing to allow Practices to manage the demands of the “new world” for example all referrals are now by email. AU said that once the allocation was known it would be the responsibility of the CCG and the Project Board to make decisions on how the funding is utilised both in terms of the roll-out to Practices and future proofing equipment. MW referred to the long term effectiveness of items such as printers and BHu asked if in the future it would be possible to use IPADs for clinical care. AU said that the CSU are looking into collective purchasing options to get the best deals for CCGs. DP referred to Co-Commission with the IT solution providing an opportunity for CCGs to gain latitude with NHSE. AU responded that the priority is the roll-out to Practices, and then more work will be required to ensure Practices have access to required data both in terms of co-commissioning proposals and BCF. Recommendation The Executive Committee is asked to note the progress to date. Noted Action The Chair asked for an update on ICT Progress for the next meeting. SH to action.

SH

7 Finance Report Month 3 GPr provided a verbal update.

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Action At Month 3 the CCG are reporting a year to date and full year performance on plan. In Month 2 year-to-date under-spends were reported at ESH, however as data is not robust at this time of year the CCG is taking a prudent approach and reporting performance in line with contract. A full financial report will be presented to the next meeting of the Executive.

8 111 Contractual Arrangements The Chair welcomed Mike Conlon (Service Re-design Manager) to the meeting to present the re-procurement options for the NHS 111 service. Following a review of NHSL‟s 111 learning to date and in consultation with the other CCG 111 commissioners, the following options were generated for consideration:-

1. Pan London and/or South London contract 2. South West London 111 service with a bolt on for OOH if the CCG

agrees 3. Individual CCG Integrated 111 and OOH contract 4. 111 and OOH Integrated Services across CCGs

Option 2 is the recommended option for approval. Contractually the CCG is working successfully with SELDOC, our OOH provider, until 2015 and they are currently providing a service that meets the contract requirements and have a good relationship with ESH. The timetable is as follows:- September 2014 Pre-market engagement event October 2014 Specifications refresh and sign-off by each

CCG January 2015 Issue the final specification for ITT May 2015 Successful bidder is confirmed September 2015 to April 2016 A staggered implementation of services

The risks are due to procurement weighting issues. Wandsworth and Kingston CCGs may need to go into a separate pool which will result in 2 contracts for 111 across SWL and due to technical issues if there are two contracts, Richmond would have to be included in the Wandsworth and Kingston contract. Comments FR asked for clarification of impact on the existing OOH contract in supporting the option to „bolt on to OOH‟. MC said that the option is for the future when the existing contract with SELDOC expires in 2015. Recommendation The Executive committee is asked to approve Option 2. Approved

9 CSU Contractual Arrangements Post September 2014 (JB) The CCG‟s contract with South London Commissioning Support Unit ends on 30

th September 2014. The CCG has discussed with the CSU a number of

services it wishes to continue to procure, the services it wishes to move in-house (including Financial Management Reporting, Infection Control, Clinical Procurement and elements of Governance and Communications); and services

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Action where a different “draw down” is required such as procurement expertise. The SLCSU, at the request of SEL CCGs, is proposing to remove the „smoothing‟ factor that reduces costs in six areas to smaller CCGs. The impact for SCCG is £230k which the CCG has stated must be neutralised. All CCGs are requesting a 5% tariff reduction for 2014/15 and 10% in 2015/16 which have been agreed with the SLCSU. Comments In response to a question on „testing the wider commissioning support services market”, JB advised that from an original 28 CSUs in the Country there are 8. SLCSU have expanded with the merger of Kent and Medway CSU and are also taking on the remaining services of NWL CSU. GP responded to comments on the need for localism, and said that CSU will be providing commissioning support to Surrey Downs in 2014/15 and this will benefit SCCG in terms of the ESH contract. DP asked for the rationale for an 18 month contract. JB responded that the 3 options were:-

1. 6 months with no price reduction 2. 18 months with price reductions agreed 3. 5 years. This option was not support by the CCG and has not been

developed. CK asked about the mental health service hosted by Kingston CCG. JB said that at the Chief Officers group there had been no desire to move away from the host commissioner though measurements to improve this arrangement were always welcome. Recommendation The Executive Committee were asked to:-

- agree that CCG enters into a further 18 months contract with South London CSU;

- agree the precise range of services commissioned, is devolved to the COO and CFO;

- note the contract will require Governing Body sign-off of the final SLA on 3

rd September 2014.

The Executive Committee agreed the recommendation.

10 Non-recurrent funding for operational resilience and referral to treatment 2014/15 (MM) MM introduced this item. Funding will be made available to CCGs to support planning and operational resilience for 2014/15. This goes beyond planning for winter planning and links to planned care across the whole healthcare system to provide year-round resilience, with an immediate focus to reduce the number of patients waiting over 16 weeks. RTT for patients waiting more than 16 weeks CCGs are asked to work with local providers to develop plans across the admitted, non admitted and incomplete pathways for both CCG and NHSE commissioned activity by September 2014. Providers are asked to submit a plan by 30

th June outlining the number of additional pathways against each

speciality, their related costs and delivery schedule. It is important that plans

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Action demonstrate additional activity over and above that already commissioned as part of existing plans. Timeline

- By 30th June conversation with Providers, CCGs and area teams

- 30th June providers submit templates to Unify

- 2nd

July assurance and sign off by CCGs - 7

th July assurance by area teams

- July delivery commences Winter funding A bid has been made through the ESH Urgent Care Working Group for winter funding agreed by all three CCGs (Merton, Sutton and Surrey Downs). The deadline for templates from Providers is 17

th July for review by the Urgent

Care Working Group on 22nd

July with agreed plans submitted to NHSE by the end of July. Comments and Questions BH requested that the template is forwarded to Primary Care JB commented that the allocation of winter monies in June is an improvement on previous years, whilst recognising that the timeframe for submission is still challenging. CE asked if the information had been sent to OOH providers and Community Services. MM confirmed that it. GP said that funding for Primary Care would be held by NHSE as the host commissioner. Recommendation The Executive Committee is asked to note the allocation of additional funding, application process and timeframe. Noted

11 Community Services Re-Procurement (CL) The 2014/15 contract for provision of SMCS is provided by the Royal Marsden and is hosted by MCCG on behalf of 4 commissioner organisations, MCCG, SCCG, Public Health Sutton and Public Health Merton. It is agreed that SCCG and Public Health Sutton will form a commissioning partnership to re-procure community services together for Sutton with SCCG hosting the arrangement. Merton CCG and Local Authority are taking the same approach for Merton. The provider has been formally notified of this decision and an additional one year extension to the contract until March 2016 has been requested but not yet agreed. Next Steps

- Establishment of a Project Board - Agreed Governance arrangements – it is proposed that the Project

Board will report to Executive Committee with ultimate responsibility held by SCCG Governing Body.

- Project Board to link to the Better Care Fund - Appointment of Project Manager for 1 year to support the clinical lead

and commissioning lead in the redesign/procurement process. The

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Action appointment will be funded from the 2.5% transformation fund. The availability of funding has been confirmed by the CFO

- Clinical Membership x 2 of the Project Board to be confirmed Recommendation The Executive Committee is asked to agree the reporting and governance arrangements for the community services re-procurement and membership of the Project Board and the appointment of a Project Manager for 1 year funded from the transformation funds. Agreed CE asked that Clinicians able to commit to December as Members of the Project Board contact CL.

12 Draft Outline Integrated Digital Care Fund bid application (Barry Holland, Support Services Manager, LBS) The Chair welcomed BHo to the meeting to present this item. SCCG were asked to consider a proposed bid for Integrated Digital Care Funding which would allow GP Practices to have access to Adult Social Care and Community Services data. The deadline for submission of bids is 14

th July 2014.

Comments MW asked if social care and community services would have access to health records. BHo said that this was not envisaged at this stage. MW referred to patient consent. BHo said that it was anticipated that in most cases the patient would be with the GP and able to give consent in real-time. Where this was not the case patient consent would be required. KS said that in the past patients have rejected data sharing, BHo said that he believed that this related to a “national spine” but it was expected that the majority of patients would be agreeable to data shared locally with their own GP Practices. BHo said that the proposal was to give Practices access to existing data held by Community Services and Social Services via a link to their existing PCs. In response to access to Acute data, BHo said that the project is divided into Phases and Acute data sharing will be phase 3. JJC said the consent of Patients will be key and suggested that contact is made with the Patient Reference Group to support communication and understanding with patients. Recommendation The Executive Committee is asked to support a bid for funding to be submitted by the deadline of 14.07.14. Agreed

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Action 13 Locality Lead Update/GP Engagement (JJC)

JJC asked that the Locality Lead Update and GP Engagement Scheme assessment process and achievements of 2013/14 be taken as one item and the following points were noted:-

- Mental Health Workshop is replacing Locality Lead meetings in July; - GP Engagement assessment process for 2013/14 was presented and

noted by the Executive. - JJC said that all Practices have been notified of the outcomes for

2013/14 and have all signed up to the 2014/15 scheme. On behalf of the Locality Leads JJC thanked Carolyn Reynolds for all her hard work and support in the development and management of the scheme. Recommendation The Executive Committee were asked to note that there will be no Locality Lead meetings in July due to the Mental Health Workshop and to note the GP Engagement Scheme process for 2013/14. Noted

14 Any Other Business

Tele-health Joint Project with LBS The project links to Falls Prevention. To date take-up has been low and GPs are asked to identify patients at risk of a fall who may benefit from the project. CE asked the Executive to agree that the Project Team contact Practices direct to encourage take-up. Agreed

15 Date of Next Meeting Wednesday 13

th August, Meeting Room 1, Priory Crescent, Sutton

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Sutton Clinical Commissioning Group

Quality Committee

Minutes from the meeting held on

Thursday 15th May 2014

Committee Room, Priory Crescent, North Cheam, Sutton

Present Mary Hopper (MH) Director of Quality (Chair) Les Ross (LR) Secondary Care Consultant Governing Body

Member Simon Elliott (SE) Clinical Lead Medicines Management Karol Selvey (KS) Nurse Practitioner Governing Body Member Megan Milmine (MMi) QIPP Programme Director Christine Harger (CH) Service Re-design Manager Mary McKenna (MM) Secondary Care Nurse Governing Body

Member Hilary Smith (HS) Patient Representative – Health Watch Jonathan Cockbain (JB) GP Governing Body Member In attendance

Alison Robertson (AR) Chief Nurse, SGH (Item Ian Gordon (IG) Acute Contracts Manager, SLCSU Sam Green (SG) Service Re-design Manager Yvonne Hylton (YH) Committee Secretary (SLCSU) Minute Taker

1. Welcome Action The Chair welcomed all in attendance to the meeting.

Apologies were received for: Sally Brearley, Jonathan Bates, Chris Elliott, Geoff Price Declarations of Interest A register of interests is held by the SLCSU and available on request. No further declarations were made in relation to items on the agenda.

2 For approval 2.1 Draft Minutes of the meeting held on 17.4.14

The draft minutes were approved without amendment.

2.2 Action Log and Matters arising not on the agenda The action log was discussed and updated and will be re-circulated to the Committee.

2.3 Primary Care Rebate Schemes Implementation in Sutton CCG The Chair welcomed Sarah Taylor, Acting Chief Pharmacist to the meeting.

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ST introduced the paper advising that Primary care rebate schemes (PCRS) are contractual arrangements offered by pharmaceutical companies, or third party companies, which offer financial rebates on GP prescribing expenditure for particular branded medicine(s). The CCG needs to have a process to ensure that any rebate schemes that are entered into are agreed following robust, transparent and equitable processes which ensure that the CCG maximises the benefits of such schemes, avoids the potential pitfalls and ensures that schemes are only implemented if they are not in breach of UK legislation and that they offered genuine benefits to the NHS and to patients. The process for consideration of a Primary care Rebate Scheme for implementation within NHS Sutton CCG is described below. 1. The details of the Primary Care Rebate Scheme (PCRS) will be

reviewed by the Medicines Optimisation Team and relevant GP clinical leads. This review will be against the CCG Pharmaceutical Industry Policy, Good Practice Principles using the Checklist for Primary Care Rebate Schemes and any relevant guidance issued by the London Procurement Programme.

2. Where the PCRS is supported, the proposal will be reviewed by the Sutton CCG and Merton CCG joint Medicines Management Committee (MMC) and a recommendation made.

3. The proposal and recommendation from MMC will be taken to the Sutton CCG Quality Committee for approval.

4. All PCRS that are entered into will be declared in the CCG Register of Declarations of Interest

5. All savings that are made (ie rebates received) from the PCRS will be documented in the Medicines Optimisation Workstream Savings database and therefore reported via QIPP processes.

Comments ST said that all savings made/rebates received will be non-recurrent. SE asked if savings were non-recurrent how what would happen if prices were increased. ST said that protected from significant price increases. ST ST said that all contracts will have “exit clauses”. In addition it is not envisaged that there will be any “drug switches” more than rebates agreed will be for drugs already in use. Recommendation The Committee is asked to approve the process for ST said that as all savings will be non-recurrent, all rebates agreed will be for drugs already in use, there will be no product switches. Recommendation

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3 Forward Plan Items 3.1 HealthWatch Report on Jubilee Health Centre

The Chair welcomed Pam Howe (PH) from HealthWatch to present this item. In October 2013, following the opening of the Jubilee Health Centre (JHC), Sutton LINk spoke to patients and staff about the service provided. At that time a number of issues were identified and reported on, including poor signage, information boards not working, lack of one door policy thereby isolating mental health services, lack of clarity at reception and poor management of the waiting areas, some of which were cramped. HealthWatch carried out a further enter and view visit in November 2013 to reassess the patient experience and received further feedback on both the same and new issues, these were detailed within the report presented to the Committee and included phlebotomy, poor signage and building temperature. A further report and recommendations was then forwarded to service providers, CCG, NHS Property Services and ESH. No response was received from NHS Property Services and no formal response from the CCG, although the report has been an agenda item on the JHC Programme Board, which is attended by PH. HealthWatch presented the report and findings to the March meeting of the Sutton Overview and Scrutiny Committee (OSC). The Committee endorsed the report but raised concerns that a number of the recommendations had not been progressed. The Committee have since written to the CCG and NHS Property Services asking for a response on each recommendation and an explanation of the key contacts and management oversight of the contract. MH agreed to speak with the Director of Commissioning to ensure the timeframe for responding to the OSC is met. The Chair thanked PH for presenting to the Committee. PH left the meeting.

MH

3.2 GP Quality Alerts The Chair welcomed Catherine Townsend, GP Liaison Officer (CT) and Keith Hilder, Head of GP Engagement (KH) to the meeting. CT opened by saying that she has been in post for 3 years. During the period April 2013 to March 2014 there were 143 Quality Alerts reported for all CCGs, with 75 received from GPs working in Sutton CCG, who are the predominate user of the process.

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In Quarter 4 there were 30 quality alerts reported of which 12 were from GPs in Sutton. A breakdown by directorates and categories was presented and showed that the main areas of concern related to admission and discharge and communication. Other quality alerts received related to consultant to consultant referrals, transport issues and data quality and 2 received were for other providers. Comments Following discussion on the consultant to consultant referral and comments relating to agreed pathway lists, MH agreed to speak to SR with a view to sharing SGH‟s agreed referral pathway to ESH. CH said that the transport issues related to faxes not being received. In the future it is intended that all transport requests are made electronically. The Trust is planning to visit all Practices to deliver training and support the shift from fax to e-mail to alleviate any concerns some Practices may have in regard to the shift. JC expressed his concerns around identification of themes and trends and welcomed the report which provided an overview of QAs reported. CT said that that from next month the CQRG would received the report in the format presented today. In response to comments on minor but persistent issues and how these can be resolved, CT said that the interface between GPs and secondary care consultants needs to improve to share learning and understanding of issues on both sides. SE stated that if some Practices are not using the process the reports are not reflecting a true position. CT recognised this advising that she would be attending Locality meetings to raise awareness and encourage use of the process by all GPs. To support discussion at the Locality Meetings the Committee suggested that examples of success, two way process and learning to be fedback to the Education Lead. In closing discussion the Chair thanked CT and DH for presenting to the Committee. CT/DH and JC left the meeting

MH

3.3 SWL and Surrey Trauma Network The Chair welcomed Leila Razavi (Network Manager) and Kelvin Wright (Clinical Lead for the Major Trauma Network) to the meeting.

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Background The Trauma Network in SWL and Surrey went live in 2010, one year before the rest of the Country. The SWL & Surrey Trauma Centre is made up of the major trauma centre based at SGH, with local hospitals at Kingston, Croydon, St Helier, St Peters, Royal Surrey and Frimley. There is also local community units for example Epsom walk-in centre. KW said that the Network is very keen to involve CCGs as an opportunity to discuss and resolve community issues. Feedback on Performance Review at St Helier The review of St Helier took place on 27th February 2014. Although there was no evidence of unsafe practice the panel did not feel assured that the Trust was operating at its best ability as a Trauma Unit. Therefore the panel will revisit in 8 months time. Prior to this the panel have asked to receive an action plan in three months time to address the key issues and the 2014 dates for key meetings including the Trauma Delivery Group. At the time of the visit only one set of minutes was presented. Comments LR asked if Clinicians at St. Helier were operating as a group. KW responded that primarily Trauma is seen as A&E and there is very no evidence that other clinical areas such as Surgery are engaged. KW said that the focus of trauma is changing with increasing numbers of elderly people seen. The major issues at the moment relate to elderly people and rehabilitation. MH comments on the link between London Quality Standards/SWL collaborative working and the need for trauma units to be included in the discussion. KW agreed saying that trauma was not considered during BSBV and the network very much would wanted to be included in the SWL collaborative discussions, recognising that provide input is key in successful delivery of the whole system approach. KW said that the network welcomed the involvement of CCGs and the opportunity for presenting and discussion. The Chair thanked LRa and KW for attending and presenting a very interesting and informative item. LRa/KW and KS left the meeting

4 Policies for Approval 4.1 Policies

Freedom of Information Policy The Policy was approved by the SQC with a request that in presentation to the Governing Body there is explicit coverage of the

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changes which have been taken directly from guidance issued by the Information Commissioner‟s office and could not be changed. Safeguarding Adults (no changes) Approved Safeguarding Children (no changes) Approved

5 Standing Items 5.1 Quality & Performance Report Month 10

Performance Report Key issues are highlighted below:

52 week waiters o Sutton CCG had 1 patient admitted and a further 3

patients on an incomplete pathway who had waited more than 52 weeks in January. These long waits occurred at four different trusts and each case is outlined in this report.

Cancer Waiting Times o The 31 day standard for subsequent treatment was

breached in January by one patient and details are described in this report. 98.9% of patients have been treated within this standard for the year to date (threshold is 94%).

o The 62 day standard for first treatment following GP referral was breached in January and the year to date compliance is just below the 85% threshold at 84.7%. Further details of breaches are within this report.

A&E Waiting Times o Epsom & St Helier Trust‟s A&E performance improved in

January and they met the 4 hour target for All Types and Type 1 activity for both Quarter 4 and for 2013/14 overall.

2013/14 full year 4 hour achievement was:

All A&E types 95.6%

Type 1 only 95.3%

o St George's achieved the 95% target in January but their performance has subsequently deteriorated and they did not achieve the target in February. In February the issues that St George‟s struggled with in December resurfaced, in particular bed capacity issues. The Trust regularly admitted more patients than they discharged and LOS has increased compared to last year. An escalation meeting has been held with the TDA, NHSE, CCGs, CSU and St George‟s and the Urgent Care Working Group has been tasked with reviewing the current trajectory and revising it based on the current issues and performance.

Improving Access to Psychological Therapies (IAPT) o South West London & St George‟s Mental Health NHS

Trust have supplied an Action Plan for improving both

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access and recovery rates for 2014/15 which is attached to this report

Quality Report The Month 10 Quality Report was presented including feedback back CQRGs, CQC and NTDA. Comments MMi referred to IAPT service procurement and asked for clarification of the increase in staff detailed on Page 7 of the Performance Report. MH agreed to contact Adrian Davey to feedback to MM. LM confirmed that all issues highlighted within the report will be captured on the risk register. MMi commented Pressure Ulcers. ESH has now breached this target with 20 reported grade 3s against a target of 16. MH advised that the Action plan is reviewed and discussed at the CQRG. All PUs are declared as serious incidents. SGH Quality Summit Report to be published. . Recommendation The Committee were asked to discuss and note the Month 10 report. Noted

MH

5.2 Medicines Management Committee Approved Minutes of 14.2.14 The Minutes were presented to the Committee for review and note. Comments SE commented on non-medical prescribing advising that there is an issue with retaining and retention of staff raising concerns of a potential impact on the whole system changes as services move into the community. SE said that full investigation is required to understand the extent of the problem and it was agreed that MH would ask CL to feedback to the CQRG.

MH/CL

5.3 Commissioner Walk-rounds Feedback following walk-rounds at Cardiology at SGH and Queen Mary‟s Hospital were presented for information. The Committee noted the reports.

5.4 Quality Risk Register SCCG quality risk register has been updated based on conversations with risk owners during March 2014. Since its last iteration a number of additional controls have been put in place. LM advised that changes discussed during the meeting would be added to the register including (i) Engagement of all GPs in Quality Alerts process (ii) Access to rehabilitation strategy The Committee noted the updated quality risk register.

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6 For information only 6.1 CQRG Approved Minutes/Feedback

The Committee approved the minutes and feedback received from:-

- Epsom & St Helier NHS Trust approved minutes - Sutton and Merton Community Services approved minutes - South West London & St. George‟s MHT feedback summary - South West London & St. George‟s MHT approved actions

The Committee noted the papers as presented.

6.2 Internal Audit – Clinical Governance Report The report was noted by the Committee.

6.3 Commissioning for Quality Workshop Details of the workshop were noted by the Committee

6.4 SCCG Quality Committee Work Plan The Director of Nursing, Alison Robertson at SGH is attending the meeting in May to present and discuss the Trust‟s Quality Strategy. An invitation has been extended to Sutton and Merton Community Services to attend a meeting of the Committee.

7 Any Other Business 7.1 Date of Next meeting


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Quality Committee


Thursday 19th June 2014


Present Sally Brearley (SB) Patient & Public Engagement Lead,

Governing Body Member (Chair) Chris Elliott (CE) Chief Officer Jonathan Bates (JB) Chief Operating Officer Mary Hopper (MH) Director of Quality Les Ross (LR) Secondary Care Consultant Governing Body

Member Christine Harger (CH) Service Re-design Manager Hilary Smith (HS) Patient Representative – Health Watch Jonathan Cockbain (JB) GP Governing Body Member

In attendance

Adrian Davy (AD) Commissioning Manager - Mental Health Yvonne Hylton (YH) Business Manager (for minutes) – SLCSU Observer Deborah Rozansky (DR) OPM Apologies

Simon Elliott (SE) Clinical Lead Medicines Management Karol Selvey (KS) Nurse Practitioner Governing Body Member Geoff Price (GP) Chief Finance Officer Caroline Jones (CJ) Designated Nurse Safeguarding Children

and Vulnerable Adults Mary McKenna (MM) Secondary Care Nurse Governing Body

Member Louise Morgan (LM) Corporate Affairs Manager, SLCSU

1. Welcome Action The Chair opened the meeting and welcomed Deborah Rozansky,

OPM who was attending to observe the meeting. Part 1 of the meeting would focus on quality committee business. Part 2 would be the second development workshop facilitated by Deborah. 3 Declarations of Interest The SLCSU hold a register of interests which is available on requested.

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No additional interests were declared in relation to the item on the agenda.


The draft minutes were approved.

2.2 Action Log and Matters arising not on the agenda The action log was noted. There were no further matters arising not on the agenda.

3 For discussion 3.1 SCCG Quality Risk Register

MH introduced this item to the Committee for review and comment and to note the two new risks added; Risk 917 and 913 as described in the paper. The Committee were asked to confirm the risks represent the main risks to quality for the CCG; mitigating controls are adequate to increase the probability that the CCG will deliver its quality strategy and to highlight any gaps in the actions and/or mitigating controls which would provide more assurance to the Quality Committee. Comments JC referred to a risk in terms of monitoring primary care against the London Quality Standards. CE said that this is part of the co-commissioning discussions and the CCG are not at this point at the moment. However, it was agreed that primary care monitoring and monitoring of specialist commissioners should be retained as a future risk to quality. JB asked that the key risks around the commissioning support provided by the CSU be added, and questioned that although the risk register looks correct in terms of the quality risks captured there are no risks which are rated as „high‟. HS referred to two risks. Risk 667 Patient Participation Groups and asked that Patient Reference Group be added as a mitigating control. HS then referred to Risk 669 where the mitigating control “Director of Commissioning is aware and addressing” and requested that this is expanded to fully describe the controls in place. JB referred to NHSE‟s assurance meetings and how quality risks are reflected in reporting to the Committee. Following brief discussion it was agreed that a summary of the discussion and areas of assurance sought are included in the Quality Report presented to the Committee. It was agreed that this would be useful, as although recognising that NHSE have a London-wide view of performance as opposed to Sutton specific it would be useful to cross reference and highlight any risks

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which may not have been considered by the CCG before. HS asked if the Committee would be alerted of increased „ratings‟. MH said yes, that in the event that developments had resulted in an increased rating this would be alerted to the Quality Committee. SB asked if the risk numbers could be in sequence to make it easier to navigate the risk register. Next Steps MH to feedback the comments received to Louise Morgan, SLCSU. Recommendation The Committee were asked to receive and note the risk register presented. Noted

MH/LM

3.2 SCCG Quality Report – June 2014 MH advised that due to the Governing Body meeting schedule in June, it had been agreed to report the Quality Report to the June meeting with a view to re-commencing reporting of the Performance and Quality Report from September 2014. The Quality Report contains data for all the CCG‟s main providers, ESH, SGH, SWLStG and SMCS and provides information on Safeguarding Adults and Children, Continuing Care Homes and PALS and Complaints. MH presented the highlights for note by the Committee and the following points were noted:- ESH: 31 and 62 day cancer waits. The CCG failed the cancer 62 standard with 10 breaches out of 30 pathways. Actions are in place including monthly meetings chaired by the Clinical Lead for Cancer, and additional resource is now in place. At the June meeting of the CQRG, a presentation from Clinical Lead for Cancer was received with some improvement reported. The CQRG will continue to monitor. ESH: The Trust did not achieve the 98% target within 24 hours of patient discharge summaries to Primary Care in March with performance at 83%.

JC asked if there was a breakdown of specialities to understand the reason and highlight any underlying issues or concerns.

HS advised that HealthWatch have completed their report on discharge summaries. In terms of both timeliness and content there are discrepancies in the data which HealthWatch are working through with the Trust. It was agreed that MH/HS would discuss further outside the meeting with a view to the CCG linking with the HealthWatch work and that the findings from the work be reported back to the Quality Committee.

LR reported that discharge summaries are very important to the Trust,

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and the Medical Director has raised this as high priority for improvement.

SGH: Cancer 62 Days target remains an issue.

Serious Incident Closure reports are discussed at each meeting to identify trends and ensure lessons are learned.

SWLStG: IAPT is very high on the Trust‟s agenda. Work has taken place directly with NHSE and Sutton to look at capacity and demand and influence take up rates.

Elections for the Shadow Council of Governors have been place, and there are 2 service users for Sutton elected.

AD/MH attended a Quality Summit held by the CQC where initial feedback was given on the Chief Inspector of Hospitals visit which had raised 3 concerns.

Overall the Inspection was good, but limited, for example it was focused on Springfield Hospital and there was no in-depth engagement with service users and carers. MH said that for the purpose of Quality reporting the findings of the CQC inspection will be triangulated with local data and intelligence.

AD advised that the Trust have accepted an offer to present the action plan to the Quality Committee. If the Trust do not come back with a data, MH to follow up.

Recommendation The Committee was asked to receive and note the Quality Report. Noted

MH

3.3 Improving Access to Psychological Therapy (IAPT) AD introduced and talked through a presentation describing the background to IAPT, Sutton specifics, capacity and demand and future developments. Background The aim of the IAPT service is primarily to treat patients with mild to moderate anxiety and depression (Cluster 1-4). The service takes a very structured approach to diagnosis and to progress patients to wellness; using national scales, with service users asked to complete a template on entering and leaving the service. Sutton specifics In Sutton from a prevalence of 27,000 there are approximately 9,000 referrals per year, 63% GP referrals and 37% self-referrals. Of these referrals approximately 30% opt out before 1st contact, this is for a variety of reasons including waiting times and sometimes the stigma

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still attached to mental health. Across London the number opting out varies, with Merton and Croydon higher and Kingston lower. In Wandsworth all service users self-refer, and this tends to reduce the numbers opting out. HS said that HealthWatch were concerned that people already suffering a mental health condition are asked to make a phone call to access treatment, which in some cases the service user may not have the capability to do this. In relation to the range of waiting times for both first contact and entering treatment, AD said that the CCG is working with the Trust to improve this. In comparison with other CCGs across London, Sutton is rated „Amber‟. In terms of effectiveness Sutton has the highest level of services entering or retaining employment. Capacity & Demand For 2014/15 targets have been increased to 15% of the prevalence (27,000) to enter treatment with 50% to move to recovery. The CCG are currently working with NHSE to simplify and improve pathways, particularly in relation to „Cluster 5‟ patients. AD explained that these patients suffer severe depression and account for 27% of the caseload, sometimes receiving 20, 40 or 60 sessions and may never benefit from an IAPT service. Work is underway with the Trust to develop new ways of working to avoid these patients falling between an IAPT and secondary care. JC said that the targets do not necessary reflect Quality and that whilst recognising the need to meet targets this should be measured alongside how the service meets the quality needs of patients. In response to a question from HW regarding on-going support following treatment, AD said that IAPT is based on giving service users a toolkit for life and should not be based on reliance. Future Developments Raising awareness with Localities included targeted work with Practices and Community Pharmacists. A proposed Primary Care Mental Health service was discussed at Executive. The model moves away from IAPT and takes a more holistic approach across access to all mental health services and treatments. The Executive has asked for more information before they are able to support the recommended options for either a phased or non-phased approach. The further information is being reported to the Executive Committee on 25th June. More work is needed to target hard to reach groups, traditionally, Men, older people and the BME community.

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SB asked how the Quality Committee can help. In response AD said that in the future quality assurance should be more about patient experience and stories to really understand the quality of care provided, rather than an over reliance on the target data. It is proposed that patients be asked to complete an evaluation form of the service following treatment. CE said that it must be remembered that IAPT has been very successful. However, there are some patients who will not benefit from this type of service. It is important that for these patients, new ways of working and pathways are developed to bridge the gap between IAPT and secondary care. MH proposed that following procurement to a Primary Care Mental Health Model quality indicators, including patient stories, are reported to the Quality Committee to provide assurance to support the data already received. HS commented that the brochures linking IAPT to a long term condition, for example diabetes were very good. The Chair thanked AD for a comprehensive overview of the IAPT service and proposed future developments and work underway to improve the quality of care provided to Sutton.

4 For Note 4.1 CQRG Approved Minutes

The approved minutes from the CCG‟s main providers were received and noted. There were no comments.

5 AOB 5.1 Date of next meeting: Thursday 17th July 2014

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Quality Committee


Thursday 17th July 2014


Present Chris Elliott (CE) Chief Officer Jonathan Bates (JB) Chief Operating Officer Mary Hopper (MH) Director of Quality Les Ross (LR) Secondary Care Consultant Governing Body Member Jonathan Cockbain (JB) GP Governing Body Member Carol Lambe (CL) Community & Childrens Commissioning Lead (Item

3.2) In attendance

Louise Morgan (LM) Corporate Affairs Manager, SLCSU Doris Richards (DR) Chair – HealthWatch Sutton (Item 3.1) Pete Flavell (PF) HealthWatch Sutton (Item 3.1) Maggie Gairdner (MC) Divisional Director, Sutton & Merton Community

Services (Item 3.2) Yvonne Hylton (YH) SLCSU – Minutes

Observer Clare Gummett (CG) Merton Clinical Commissioning Group Governing Body

Lay Member and PPI Lead Apologies

Simon Elliott (SE) Clinical Lead Medicines Management Karol Selvey (KS) Nurse Practitioner Governing Body Member Geoff Price Chief Finance Officer Hilary Smith (HS) Patient Representative – Health Watch Mary McKenna (MM) Secondary Care Nurse Governing Body Member

1. Welcome Action The Chair welcomed CG who was observing the meeting from Merton

CCG as part of an informal arrangement between SWL DoQ to share learning and best practice across emerging CCG Quality Committees. Declarations of Interest The SLCSU hold a register of interests for the Quality Committee. The Committee were asked to declare any interests in addition to those held in relation to items on the agenda. No additional interest were declared.


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The minutes were approved as an accurate record of the meeting.

2.2 Action Log and Matters arising not on the agenda The action log was noted. There were no further matters arising not on the agenda.

2.3 SCCG Quality Risk Register Following last month‟s Quality Committee, the quality risk register has been aligned to the CCG‟s strategic objectives and strategic risks. This will better enable the committee to focus on ensuring the key quality risks are identified, managed and/or mitigated as appropriate and prioritise their scrutiny and assurance roles accordingly. The Committee noted:-

- 3 new risks have been identified and controls are currently being developed

- 2 risks have reduced – 658 and 888 due to improvements in service delivery

- 7 risks have been closed as described within the paper. Comments LR welcomed the new reporting format. LM advised that the Objectives were derived from the CCG‟ Priorities as detailed on the „Plan on a Page‟. It was agreed to expand risk 909 to reflect the increase focus on the 62 day target. CE asked that NHSE‟s 8 key focus areas are cross checked with the CCG BAF to ensure they are reflected, recognising that the CCG will be required to provide assurance to NHSE. MH/LM to action. Recommendation The Quality Committee is asked to agree:-

1. The risks described represent the main quality risks currently

facing the CCG and its patient population 2. The mitigating controls adequately increase the probability of the

CCG delivering its quality strategy 3. Any gaps to mitigating controls or actions that would provide

improved assurance of delivery of the quality strategy to the committee

The Committee agreed the recommendation with the expansion of risk 909 to reflect the risk relating to 62 days.

LM MH/LM

3 Key Focus

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3.1 HealthWatch Report – Discharge Summaries The Chair welcomed Doris Richards (DR) and Pete Flavell (PF) from Sutton HealthWatch to the meeting. In 2013, hospital discharge was identified as a priority for Healthwatch Sutton following substantial feedback received from local people who had experienced problems at local hospitals. Hospital discharge was therefore added to the work plan for 2013/14. The report presents the key findings, provider recommendations and next steps. 6 wards at St Helier hospital and 1 ward at Springfield hospital agreed to take part. A questionnaire of 22 questions developed. In total 58 people agreed to take part and 33 interviews were carried out. Unfortunately it was not possible to make contact with any people who stayed at Springfield hospital and all feedback presented originates from patients from St Helier. In responding to a question on why St Helier rather than ESH was chosen, PF said that it was felt that St Helier was more relevant for Sutton however if a further project was undertaken consideration would be given to ESH. Key themes arising from the project related to communication and delays which was not unexpected. Recommendations were agreed for Providers to improve discharge for patients and include earlier discussion with patients, improved communication with external carers for example community services, social care and an improvement in the quality of information given in discharge summaries to GPs. Next steps involve the continued monitoring of progress against the agreed actions. In addition a separate work piece of work with Springfield hospital. PF said improving the patient experience which was the focus of a recent meeting Chaired by ESH Chief Executive. Comments MH said that the CCG is working closely with ESH to improve discharge and suggested that the HealthWatch work feeds into the wider piece of work underway. Discrepancies in Quality Account reporting and HealthWatch report were noted and are being worked through. The link between poor discharge and re-admissions is well known. As part of the CCG‟s aim to reduce unplanned admissions all Sutton Practices have signed up to the Unplanned Admission Initiative, which involves Practices identifying vulnerable patients and being alerted if they are re-admitted.

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In closing, CE thanked PF and DR for presenting to the Committee. PF and DR left the meeting.

3.2 Sutton and Merton Community Services The Chair welcomed Maggie Gairdner (MG), Divisional Director from Sutton and Merton Community Services (SMCS) to the meeting. MC tabled a presentation describing the Quality Strategy and Initiatives for 2014/15. Quality Strategy Quality is reported to the Trust Board monthly via the Quality Assurance and Risk Committee and covers Risk Management, Board Assurance Framework and Complaints made against the Trust. In addition the Quality Scorecard is reviewed by the SMCS CQRG each month and reports on areas such as never events, pressure ulcers and serious incidents. All Complaints are read by Executives and the Chief Executive and there is a Complaints team in place to monitor and ensure that all actions are achieved. Complainants are invited to meet with the Trust either at the Trust or in their own homes at an early stage of the process which provides valuable learning. The CQRG meeting takes place monthly. Issues from the CQRG are actioned and monitored by the weekly Divisional Management Strategy Meeting and the monthly Divisional Team Meetings for SMCS Chaired by MG. Community Services have taken part in two Audits, one which looked at governance process and the second into lone working procedures to safeguard staff. This recognises that primarily DNs work alone. Quality Initiatives MG said that the Quality Initiatives link back to the Outcome Framework which in turn links to the CCG‟s Initiatives. In 2013/14 the Trust achieved 94% of the agreed CQUIN goals which were around pressure ulcer management and reporting, preventing admissions, reducing emergency admissions for under 18 (which exceeded the target) and Diabetic Eye Screening. CQUINs have been agreed for 2014/15 and include acting as a pilot site to test pressure ulcer reporting and management; the phased expansion of Friends and Family to the Community and Reducing Admissions to A&E from Nursing and Residential homes. A NHSE CQUIN is still to be agreed. MG outlined some of the challenges faced by Community Services and the actions agreed which include:-

- Embedding quality where primarily staff are working on their

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own, in people‟s homes. To address „quality Wednesdays‟ have been introduced to validate the quality of care provided;

- There are high numbers of temporary staff – at this time out of 250 staff there are 42 nursing vacancies. Work is underway to address this national problem including recruitment of more senior nurses to provide leadership and support to Junior Nurses and those new to community services;

- Commissioner Walkabouts and how these can be reflected in the Community

Complaints and Quality Alerts It was agreed to circulate a breakdown of Complaints and Quality Alerts to the Committee after the meeting. Comments MH referred to the workforce issues and asked how these are being resolved. MG said that all team meetings provide an opportunity for staff to put forward suggestions and be involved in planning and share learning. JB asked what the 3 top quality concerns are for SMCS at this time. MG responded:-

1. Pressure Ulcers 2. Workforce – high number of vacancies 3. Improving performance for the service in a way that is better

for patients In response to incidents report on the SMCS dashboard, MG said that there is a robust monitoring process in place at the Trust to ensure that all incidents are reported and investigated. SMCS CQRG receives the dashboard and supporting data which is reviewed monthly at the meetings. JC referred to the DNs relationship with GPs, which is poor and non-attendance at MDT meetings. MC responded that she will take this back, the quality restructure and appointment of senior nurses was to ensure that nurses could attend meetings. In regarding to the working relationship it is envisaged that as services are integrated and DNs work within localities this will improve. In regard to a concern regarding inconsistent wound formularies between the CCG and SMCS, MG said that work had taken place with both CCGs to mitigate this issue. To provide an overview the Committee were informed that in Sutton and Merton there are 700 home visits made each day by the team. The Chair thanked MG for presenting to the Committee.

MG

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MG left the meeting.

4 For Note 4.1 Serious Incidents/Never Events

There is a new serious case review following a child death earlier this year. The SCR has been agreed and the timeline has been set, the case will be known as Child E. The other SCR for Child D still continues.

4.2 CQRG Approved Minutes The approved minutes from the CCG‟s main providers were received and noted. There were no comments.

4.3 Quality Committee Work Plan The work plan was noted by the Committee.

5 AOB 5.1 Date of next meeting: Thursday 21st August 2014

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SUTTON CLINICAL COMMISSIONING GROUP MINUTES OF A MEETING OF THE FINANCE COMMITTEE Wednesday 16 April 2014 Present : Dr Brendan Hudson ( chair ) Paul Sarfaty ( lay member, governance and audit )

Les Ross ( lay member, secondary care doctor ) In attendance: Geoff Price, CFO; 1. Apologies and minutes of the meeting of 19 March 2014

Apologies – Jonathan Bates. The minutes of the meeting of 19 March were approved.

2. Financial position

M12 Financial Report Mr Price reported that the CCG is able to forecast with a high degree of confidence that it will meet its planned control total of £2.1m. However, this is after using all available reserves including the uncommitted balance on the 2% reserve, and having secured funding of £2.483m from the SWLondon risk pool ( a net £1438k borrowing ). The risk pool funding is repayable over 3 years and is included in the CCG’s 5 year financial plan.

The issue with NHS Property services has been resolved to the CCG’s satisfaction with NHPS recognising the effective ‘ double charging ‘ and agreeing to issue credit notes to the value of £1.158 million..

The drivers for the financial position are the acute contract overspend of £5m and the prescribing overspend of £0.9m. QIPP savings are reported as 91% year to date with 89% achievement forecast full year. It should be noted that £900k full year savings are

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reported from the budget savings exercise which was not part of the original planned QIPP savings. The main areas of under delivery are

Urgent care centre savings

Older peoples pathway

1st OP attendances The Chair commented that it was disappointing to report that LB Sutton had refused to reimburse the CCG for funding passed in error to LBS ( by the former PCT ) despite repeated attempts by the CCG to recover these funds. The committee discussed the QIPP dashboard report. It asked for a narrative report at the next meeting on the QIPP areas that underperformed including reasons why and action being taken to resolve where appropriate. Mr Price commented that given agreements had been reached with the main acute providers on a full year position, and the issue with NHSP resolved, there remained low risk to the final position. Draft annual accounts are due to be submitted on 23/04 and final audited accounts on 06/06. The Audit Committee of 29 may will review the accounts and make recommendation to the Governing Body which meets on 04 June. The current bottom line showed a surplus of £2.122 m , a £32k favourable variance on the plan of £2.090 m.

Also included in the papers are the the proposed head of internal audit opinion, which based on the work undertaken in 2013/14, is that significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives. The Committee were pleased to receive this opinion. With regard to the action from the last meeting for a comprehensive report into the ESH contract overspend, the CSU are proposing that this is carried out by Sara Cottingham , a commissioning Director from SE London. The CCG are happy with this proposal.

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3. Charitable Funds Mr Sarfaty the Committee.

There only grants made in 1314 were to Sutton and Merton CCG staff for the Christmas dinner. The Committee work now centered on

Consideration of how best to make known the funds available more widely

Revising bid documentation

Contact with voluntary services umbrella organisations ( rather than individual organisations )

A review of the investments and their make up.

4. Financial Plan 1415 to 1819

Mr Price reported that the final 2 year plan was submitted to NHSE on 04 April and the final 5 year plan was due early June. Mr Price updated the Committee on salient matters ;

Contracts had now been agreed with all the CCGs main providers.

The ESH contract had been agreed at £89.25 million. This coincidentally is equal to 1314 outturn. StGeorges is agreed at £12.2 million compared to £10.5m outturn. The reasons are set out below.

The CCG receives around £4m ‘pace of change’ funding in 1415. However this is largely utilised in moving the CCG from an underlying deficit of £1.5m to a surplus of £2 m.

The CCG has made a number of investments and met certain cost pressures

o ESH contract reflects funding of DMO drugs ( £650k ) and counting and coding changes

o The StG contract reflects the raising of the NETA threshold to 1213 levels such that far less activity attracts the 30% tariff. This has ‘ cost ‘ the CCG ( or it has lost the benefit ) of some £1.7million NETA adjustment.

o Around £1 m has been invested in community services including growth to recognise non demographic change,

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staff required for the older peoples pathway, and specialist school nursing.

The QIPP saving requirement is £5 m and £7m of schemes are in place to deliver this.

The CCG retains a low level of reserve with around £1 million general reserve, £1 million in the 0.5% contingency and £1 m in the SWL risk pool ( though it could bid for more ).

The CCG has described how it has accounted for the £5 per head investment in older people’s services.

Overall it will be a challenging year financially for the CCG. The aim is to meet the 1% surplus run rate without support and thus put the CCG on a firm financial footing going forward to face the challenges set out in ‘ Everyone Counts ‘. The LTFM will set out a 5 year financial plan describing how the CCG will meet the challenge of ‘Everyone Counts ‘whilst maintaining financial sustainability.

5. Any Other Business

There was no other business. The next meeting is on 28 May 2014.

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SUTTON CLINICAL COMMISSIONING GROUP MINUTES OF A MEETING OF THE FINANCE COMMITTEE Wednesday, 28 May 2014 Present: Dr Brendan Hudson (chair) Paul Sarfaty (lay member, governance and audit)

In attendance: Geoff Price, CFO; 6. Apologies and minutes of the meeting of 19 March 2014

Apologies – Les Ross, Jonathan Bates. The minutes of the meeting of 16 April were approved.

7. Financial position

M12 Financial Report Mr Price presented the final management accounts (subject to external audit ) for the financial year 201314. Mr Price noted that these are in accordance with the annual report and accounts which are being considered by the Audit Committee on 29 May before submission to NHSE on 06 June. The CCG faced significant financial challenges in financial year 2013/14 as it inherited an underlying deficit and is below target resource allocation. However, the CCG ended the year meeting its financial target of a £2.1 million surplus or 1% of resource limit but this was after securing additional resource of £1.5m from the South West London CCG’s risk pool and utilising reserves. The main driver for this position was the 2013/14 acute contract overspending of some £5 million, although there was also a prescribing

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overspend of around £900k. A significant additional contributory factor is the fact that the CCG is around 10% below its target resource limit in 2013/14, a position that is being largely remedied by the 'pace of change (POC)’ policy re CCG allocations over the next 5 years The summary management accounts are set out in Appendix 1. The Committee noted the final 2013/14 financial position. The papers included the CCG draft annual report and accounts. Mr Price highlighted salient areas, including the Remuneration report and these were noted by the Committee. Mr Price noted that the CCG has an underlying recurrent deficit of around £1.6m at the end of 2013/14. Going forward the CCG has a 5 year long term financial plan for the period 2014/15 to 2018/19. This includes known allocations for the first two years and estimates for the following three years. These include the welcome increase in allocations under the POC policy that address historic underfunding. Financial year 2014/15 will be challenging as the CCG addresses the underlying deficit and funds acute services pressures and invests in community services. However, the CCG intends to establish a firm financial footing in 2014/15 so that moving forward it can meet the challenges of ‘ Everyone Counts’ and commission high quality services for its population whilst maintaining financial sustainability. Matters arising The Committee considered the full year QIPP report prepared by the QIPP project director. This highlighted areas of QIPP over and underperformance. Underperforming areas include urgent care at ESH, urgent care at home, the older peoples pathway and all planned care schemes. Each had a detailed narrative as to why and action being taken. The Committee was satisfied that appropriate action was being taken including planned peer review of outlier Practices. The Committee also considered the prescribing report. There had been a £900k prescribing overspend in 1314; the reasons were set out and action being taken, including planned peer review of outlier Practices.

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MR price commented that net budget ( after QIPP ) had been set at a 1.8% increase on 1314 outturn. With regard to the action from the last meeting for a comprehensive report into the ESH contract overspend, this will be included for the next meeting.

8. Charitable Funds Mr Sarfaty, as Chair of the Charitable Funds Committee, presented this item to the Committee.

He stated that the Charity Committee was meeting tomorrow (29/05) and had around £1m in bids to consider. He felt that many were outside the remit for charitable Funds funding. He also noted that the Charitable Funds 2013/14 accounts were not being consolidated with the CCG accounts on grounds of materiality but would be produced and audited earlier this year than in previous years.

9. Update on Financial Plan 141/5 to 18/19

Mr Price reported that the final 2 year plan was submitted to NHSE on 04 April and the final 5 year plan was due 20 June. A draft 5 year strategy had been prepared by SWL Collaborative Commissioning. This would be considered by the Board in early June.

10. Waiver of Tender / quotation

The Committee considered two waivers. The first was re the ‘Kinesis ‘ tool that allowed GPs to consult with hospital consultants before making a referral. This was for £46k with a request to waiver the need for quotation. The second was a tender waiver for the Institute of Public Care re support to the new Olders Peoples pathway in the sum of £67k.

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The templates set out the reasons for waiver and these were agreed by the Committee.


There was no other business. Subject to availability, the next meeting is on Wednesday 18 June.

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Minutes of the Meeting of the Sutton Clinical Commissioning Group Audit Committee

Thursday 6th February 2014

9.00am – 11.00am

Priory Crescent, Sutton, Surrey, SM3 8LR

Chair: Mr Paul Sarfaty Present:

CE Dr Chris Elliott Clinical Chief Officer MM Mary McKenna Independent Nurse Member PS Paul Sarfaty Lay Member: Chair of Audit Committee/Vice Chair

In Attendance:

DM David May Audit Manager – Baker Tilly

GM Gary McLeod Manager, Public Sector Audit and Assurance - KPMG

SE Sue Exton Engagement Lead - Grant Thornton

KJ Kam Johal Assistant Counter Fraud Manager – London Audit Consortium

LM Louise Morgan Corporate Affairs Manager – SLCSU

GP Geoff Price Chief Finance Officer – SCCG

Supporting Officer

TF Tony Foote Board Secretary – SLCSU

ACTION

1.

Welcome and Apologies for Absence

Paul Sarfaty (PS) welcomed all to the meeting. Apologies were received from Dr Dino Pardhanani and Sarah Ironmonger (Engagement Manager, Grant Thornton).

2. Declarations of Interest

The Sutton Clinical Commissioning Group Audit Committee is required to maintain a register of members‟ interests which can be made available on request. At meetings of the Audit Committee, members are expected to declare interests in respect of items on the agenda if appropriate. No further interests were declared.

3. Minutes of Previous Meetings

3.1 To approve the minutes of the Sutton Clinical Commissioning Group Audit Committee meeting held on 7th November 2013.

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The following amendment was requested.

Item 8 – Close of meeting The time of the meeting‟s close to be stated as 10.20am. With incorporation of the above amendment, the minutes were approved as a correct record of the meeting.

TF

4. Matters Arising

4.1 Action Log 06.02.14 – For note

The Committee noted the actions taken and the verbal updates as follows: 5.2 Board Assurance Framework (BAF) and Risk Register Louise Morgan (LM) informed the Committee that the BAF would be reviewed in light of the CCG‟s two and five year plans with a revised version to come to the Committee‟s May meeting. PS noted that the main agenda item at the May meeting would be the CCG financial accounts and annual report and decided that the meeting should be extended to three hours. 6.2 Counter Fraud Update Kam Johal (KJ) stated that the Anti-Bribery Risk Assessment Tool would be presented at the May meeting PS enquired about the current status of the Whistle Blowing Policy. KJ replied that this was still under review and would also be ready for the May meeting PS expressed concern at the delay in this and it was agreed that it would be circulated electronically to Audit Committee members for comment. The policy would then go to the Governing Body for approval.

LM

KJ

KJ

5. For Review

5.1 Arrangements concerning the review and approval of the CCG‟s annual report and financial statements - Update

PS provided a verbal update on this item and that, as already stated, the CCG‟s financial statements and annual report would be considered at the meeting on the 29th May 2014. PS added that he would be attending a meeting of Audit Committee Chairs on the 19th February and would be able to compare progress with other CCGs.

5.2 Charitable Funds – Update Report on the first meeting of the Sutton and Merton CCGs‟ Charitable Funds Committee

GP (Geoff Price) presented this item and informed the Committee that the Charitable

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Funds Committee had now met twice and agreed the 2012/13 fund accounts. These had then been approved by the Governing Body at its January meeting. The fund currently totalled £1.9m. Mary McKenna (MM) noted that at the Charity Committee‟s meeting in December 2013 a bid for paediatric equipment had not been approved. PS responded that the Committee‟s decision was that it considered the equipment should have been funded by the CCG and to approve the bid may have set an inappropriate precedent. PS added that at the Charity Committee‟s February meeting there had been a discussion about how to use the fund for the most benefit whilst respecting the wishes of those who had bequeathed the funds. PS informed the Committee that work was ongoing to consolidate some of the various fund “pots” along with consideration of whether some bequeathed specifically for community services could be paid out now. The Patient and Public Engagement Leads for Sutton and Merton CCGs – both members of the Charity Committee – would also be seeking discussions with voluntary organisations for other views on how funds could best be used.

5.3 Board Assurance Framework (BAF) and Risk Register

LM presented this item and informed the Committee that work continued on developing the BAF and Risk Register. CCG senior managers have reviewed their strategic and operational risks and implemented a number of the recommendations made by the CCG‟s Internal Auditors in December 2013. Plans are in place to align the risk management processes with the development of the CCG‟s two year operational plan and five year strategic plan. An analysis of the key risks to the delivery of these plans will be presented to the Audit Committee in April 2014. Since the last meeting of the Audit Committee, the following new risks have been added to the BAF:

803: Alignment of Call to Action, Better Care Funds and Out of Hospital Strategy programmes

805: Achievement of all constitutional pledges by providers commissioned by Sutton CCG e.g. Cancer waiting times, Referral To Treatment waiting times, Health Care Acquired Infection rates

The following risks have reduced in likelihood:

529: That QIPP programmes will not achieve all planned objectives, leading to the CCG being unable to realise its cost savings and financial balance

677: That Sutton urgent care services being unable to provide sufficient capacity to meet patient demand may result in providers failing to meet key quality and performance commissioning expectations

The following risk has a reduced impact score:

531: That costs for commissioned services may exceed the resources available to the CCG, resulting in non-delivery of financial balance

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With regard to the Risk Register, the following risks have been closed and removed:

563: Failure of the CCG and member practices to establish a sound reputation with partner organisations, resulting in lack of confidence and credibility.

675: Primary Care - Change in commissioning arrangements leaves the CCG with limited scope for achieving drugs expenditure savings.

The following risk has reduced in likelihood:

672: IFR Panel: Lay Member membership might make quorate rules difficult to fulfil

PS asked whether the risks could be listed in order of the highest rating downwards. LM said that it was possible, via an Excel spreadsheet, and she would do so for the Committee. GP thanked LM for her work on the BAF and noted that risks were currently shown under relevant objective. David May (DM) suggested that a “dartboard” approach – where the highest rated risks were shown nearest the centre - may be helpful for the Committee and would share an example of this with LM. GP informed the Committee that a “deep dive” would also be undertaken with regard to two risks. A query was then raised about the consistency in ratings and DM suggested that further training for risk owners could be provided. The Committee considered certain specific risks. Risk 529 – That the QIPP programmes would not achieve all planned objectives Dr Chris Elliott (CE) noted that, with the Audit Committee only seeing a quarterly picture of risks it was important for the Committee to appreciate that in some areas, such as the QIPP, the current situation may be different to that stated. Risk 530 – That the CCG fails to commission adequate commission support CE noted that the CCG was currently in the process of re-procuring its commissioning support for 2015/16 and so the rating may need to be amended. Risk 531 – That costs of commissioned services may exceed CCG resources GP informed the Committee that the rating on this risk had now been reduced. CE then asked a general question about what happens to a risk once closed. LM explained that it remains (as “closed”) on the 4-Risk system: for example, the risk relating to Better Services Better Value was now closed but the underlying issues remained. Accordingly, thought would need to be given to formulating a new risk to address this. GP informed the Committee of current manpower problems (due to staff sickness and general capacity) being experienced by the CCG‟s QIPP team. He suggested

LM

DM

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that this was an issue the Committee should be monitoring. PS thanked LM for her contribution and looked forward to further developments.

5.4 Gifts and Hospitality Register – Update

GP presented this item and explained that the CCG held a Gifts and Hospitality Register but that no declarations had yet been made. KJ commented that this was not untypical of CCGs but may be a result of a lack of awareness amongst staff. MM noted the efforts at raising staff awareness and enquired whether the need to declare any gifts and hospitality received was included in staff inductions. KJ said that, at present, this was not a specific part of the information provided but she would add it to the programme. KJ added that the Counter Fraud Service does carry out an annual awareness survey amongst staff and she would include Gifts and Hospitality on future surveys. CE expressed concern that this area may be a difficult one for clinicians working on behalf of the CCG and asked whether written information – including examples of what would need to be declared – could be provided for them. KJ agreed to look into this. PS requested that the Gifts and Hospitality Register be considered again as a “matter arising” at the next Committee Meeting.

KJ

KJ

KJ

1. Auditor Reports

6.1 Internal Audit Update (David May – Baker Tilly)

Internal Audit Progress Report David May (DM) introduced this item and began by thanking the CCG for its re-appointment of Baker Tilly as its internal auditors. DM then explained that since the last meeting of the Committee reports of three completed audit reports had been published: Assurance Framework/Risk Management; QIPP; Remuneration of Members.

Assurance Framework/Risk Management DM noted that the changes recommended by the audit had now been implemented by GP and LM.

QIPP The audit had shown not all programmes to have had a Equality Impact Assessment carried out. There was also some concern expressed at over-ambitious targets

Remuneration of Members Good practice had been identified by the audit and the report proposed no recommendations.

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In general, DM informed the Committee that the planning process for 2014/15 had begun and he hoped to attend the Chief Finance Officers‟ meeting to ensure a consistency of approach. NHS Update – January 2014; The BHS update was noted by the Committee. KPMG CSU Internal Audit report Gary McLeod (GM), of KPMG, provided the Committee with an update on progress. The design of the CSU‟s key financial controls had been reviewed with “walkthrough” testing of theses. Based on this initial work, the findings are that overall the design of the key financial systems are adequate, although with a small number of areas for improvement identified. A fuller review will be undertaken and, once complete, a report will be issued in early April 2014. Furthermore, KPMG has followed up the CSU legacy recommendations and can confirm that all have now been implemented. The remaining planned audit reviews for 2013/14 are:

Service auditor reporting

Performance reporting & data management ICT for primary care

Support for adult continuing care

Purchasing (non-clinical)

CCG governance / quality management

Management of outsourced financial provider. GM stated that, overall, KPMG‟s opinion would be a positive one. There followed comments and questions from the Committee. GP stated that he was pleased with the positive opinion and noted the importance of this as the CSU provided many key services for the CCG. He then asked whether KPMG looked at CSU systems as a whole or if they worked with each CCG. GM confirmed that a general sample (average size: forty) was used but this would include all CCGs. GP said that he felt there was a lack of clarity concerning the auditing of services provided by the CSU: a recent audit of governance procedures, including interviewing CSU staff, had been undertaken by the CCG‟s internal auditors. Should this not have been carried out by KPMG? GM replied that both KPMG and the CCG‟s internal auditors had a role to play and that KPMG would avoid reviewing areas already covered. Accordingly, GM confirmed, KPMG would not be auditing all CSU services commissioned by the CCG. CE stated that the South London CCGs had commissioned KPMG to look at the benchmarking of services as part of the procurement process. PS thanked GM for his contribution.

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6.2 Counter Fraud Update (Kam Johal – London Audit Consortium )

Counter Fraud Progress Report Kam Johal (KJ) emphasised the importance of CCG staff and Governing Body members being aware of anti-fraud, bribery and corruption issues and processes. The Counter Fraud Team would be presenting to the Governing Body at its March meeting. The Counter Fraud Team has a counter fraud newsletter which will be issued and shared electronically with Sutton CCG employees this month. This will include case studies of potential areas of weakness and fraud “trends” which may have been highlighted through investigations across the client base of the London Audit Consortium. In addition to this, the Counter Fraud Team will be issuing the Annual Fraud Awareness Staff survey to evidence the level of fraud awareness across the CCG. The results of the staff survey and other feedback will be used to address any concerns raised by staff and plan further training for the CCG. Results will also be shared at a future Audit Committee meeting. Fraud Risk Assessment KJ or LC presented the Fraud Risk Assessment methodology developed by Baker Tilly and, as part of collaborative working arrangements, this has been conducted for all CCG‟s in South London. She explained that this report contains the findings of a review carried out by the Counter Fraud Team to assist the CCG in identifying areas of risk and, with support of the accompanying workplan, addressing these. The Counter Fraud Team identified a number of key areas which it believes to require greater management control or a revision of the current policies and practices.

The Bribery Act Strategy and implementation of supporting policies

Policy and procedures governing Gifts and Hospitality , Conflicts of Interest and Declarations of Interest, Financial policies and high risk Human Resources policies and the Standard Contract of Employment

Fraud and Bribery awareness sessions There followed comments and questions from the Committee. CE enquired whether there was any feedback from the meeting (referred to in the workplan- appendix A) with the Human Resources Team on the 27th January 2014. KJ replied that the meeting had been delayed and feedback was expected the following day. She would – via TF – circulate this to members. PS asked whether any investigations were currently ongoing that related to Sutton CCG. KJ replied that there were not but, in other areas, such matters as staff invoicing for un-worked hours, prescription fraud by a community pharmacist and stolen prescriptions were currently under investigation.

KJ

6.3 External Audit Update (Sue Exton – Grant Thornton)

Sue Exton (SE) provided the Committee with an update on progress as of January 2014.

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An independent examination of the 2012-13 charitable funds had been undertaken and the accounts approved by the CCG‟s Governing Body in January 2014.

The 2013-14 Accounts Audit Plan was still in progress and not quite yet ready for sharing with the Committee. However, SE hoped it would be possible to circulate it – via TF – to members when ready.

A new timetable for submitting the final 2013-14 accounts:

- 23/04/14 – Noon: CCG submission of full draft annual report and accounts - 06//06/14 - 5pm: auditors submit signed annual report and accounts - 06/06/14 – 5pm: CCG load onto website full annual report and accounts

PS noted the requirement of the CCG to submit its Annual Report and enquired as to whose responsibility this would be. GP felt that this would be Jonathan Bates responsibility and he would discuss this with JB.

GP


7.1 Waiver of Tender

The CCGs scheme of delegation states that where there is a waiver of tender, the Chief Finance Officer must ensure the Finance Committee approves instances and these are also reported to the Audit Committee. GP reported that the Finance Committee, at its meeting on 22 January 2014, had approved a waiver of tender in relation to project management work at the Jubilee Health Centre, under section 6(f) of the CCGs scheme of Delegation. The relevant minute from that Finance Committee meeting follows:

“Any Other Business

Mr Price reported that the CCGs scheme of delegation states that where there is a waiver of tender, the Chief Finance Officer must ensure the Finance Committee approves instances and these are also reported to the Audit Committee. Mr Price noted that there was one waiver of tender to be approved. Members of the Committee will be aware that earlier in the financial year there were a number of issues ( inherited from the former PCT ) to address at the Jubilee Health Centre that required immediate and urgent attention including the project management of the transfer of a number of services from ESH. The objective was to complete this ‘Phase 1’ of the JHC by December 13 latest. The CCG scoped the market and identified a suitable individual with relevant experience to carry out this work. The estimated cost was £95,000 (net of VAT). The work was completed in December 2013 at this cost. Mr Price apologised that this had come late to the Committee. The Committee noted the reasons for the tender waiver and formally approved the waiver.”

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This was formally noted by the Audit Committee.

8. Close of Meeting

The Chair closed the meeting at 10.40am

8. Date of Next Meeting

29th May 2014 (9.00am – Noon)

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Minutes of the Meeting of the Sutton Clinical Commissioning Group Audit Committee


9.00am – 12.00 noon

Priory Crescent, Sutton, Surrey, SM3 8LR

Chair: Mr Paul Sarfaty Present:

CE Dr Chris Elliott Clinical Chief Officer (until 10.45am)

MM Mary McKenna Independent Nurse Member (until 11.00am)

PS Paul Sarfaty Lay Member: Chair of Audit Committee/Vice Chair

DP Dr Dino Pardhanani Clinician/GP

In Attendance:

DM David May Audit Manager – Baker Tilly SI Sarah Ironmonger Engagement Manager – Grant Thornton SE Sue Exton Engagement Lead - Grant Thornton KJ Kam Johal Assistant Counter Fraud Manager – London Audit Consortium LM Louise Morgan Corporate Affairs Manager – SLCSU GP Geoff Price Chief Finance Officer – SCCG MD Mark Dowell Head of Finance - SLCSU MCS Martin Campbell Smith Financial Controller - SLCSU OM Orla Mooney Senior Financial Accountant – SLCSU

Supporting Officer

YH Yvonne Hylton Committee Secretary – SLCSU

ACTION

1. Welcome and Apologies for Absence

Paul Sarfaty (PS) welcomed all to the meeting, advising that the main purpose of the meeting was to review the draft annual report and accounts 2013/14 with a view to recommending approval to the Governing Body on 4th June 2014. No apologies were received.

2. Declarations of Interest

The Sutton Clinical Commissioning Group Audit Committee is required to maintain a register of members‟ interests which can be made available on request. At meetings of the Audit Committee, members are expected to declare interests in respect of items on the agenda if appropriate. No further interests were declared.

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3. Minutes of Previous Meetings

3.1 To approve the minutes of the Sutton Clinical Commissioning Group Audit Committee meeting held on 6th February 2014.

The Committee requested the following changes to the minutes:- Page 2, Item 4 Under 5.2 “version to be come” remove ”be” Page 8, Item 7 Reference to December 2014 to be amended to December 2013 With the above changes incorporated the Committee approved the minutes as an accurate recording of the meeting.

4. Matters Arising

4.1 Action Log 29.5.14 – For note

The Committee noted the actions taken and the verbal updates as follows: 5.3 Board Assurance Framework (BAF) and Risk Register Louise Morgan (LM) informed the Committee that the BAF is being revised in light of the CCG‟s two and five year plans and will come to the Committee meeting on 7th August. 6.3 External Audit Update The 2013/14 account audit plan was circulated to the Committee following the last meeting.

LM

5. For Approval

5.1 Sutton CCG Annual Accounts and Annual Report for the financial year 2013/14

GP introduced this item and presented the following papers for consideration by the Committee with a view to recommending Governing Body approval:-

the Sutton CCG 2013/14 draft annual accounts

the Sutton CCG 2013/14 draft annual report

the Auditor‟s ( Grant Thornton ) „ Audit Findings „ report in relation to the accounts

the draft Letter of Representation The next meeting of the Governing Body is 4th June 2014. Salient points for note:-

The annual accounts are consistent with the CCG‟s „Financial Statements „which themselves are directly derived from the CCG‟s financial ledger. The CCG is required to sign a formal consistency statement to that effect. The Financial Statements are used by the NHSE to prepare the consolidated NHS accounts.

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The annual accounts are consistent with full year management accounts reporting.

In terms of financial performance

The CCG has met its financial target of a £2.1m surplus or 1% The CCG has operated within its running costs allocation of

£4.5million

Against the Better Payment Practice Code target to pay 95% of invoices on time, the CCG achieved 87% for non NHS suppliers. The CCG plans to meet the target in 2014/15.

The annual report is consistent with the annual accounts A draft set of accounts was submitted to NHSE on 23 April. The accounts now presented have only changed from these in terms of some descriptive narrative; removal of notes that are not applicable; and changes to some agreement of balances that have no net effect. Any further changes to these accounts now presented can only be made when the financial ledger reopens for a short period in early June. The changes known at this time are:-

amend staff and continuing care costs to correct mis-posting

amend staff whole time equivalent figure following further review

amend operating lease disclosure note re NHS Properties The accounting policy on revenue is likely to be expanded to reflect how the CCG treats recharges. These are presentational changes with no effect on reported financial performance. There may be other adjustments as audit work is finalised up to accounts submission. In order to handle this it is requested that delegated authority is given to the CFO to make final, minor, non material changes to the accounts and annual report as may be necessary (and will be subject to audit) in presenting the accounts and annual report to the GB and subsequent submission to NHSE. Should there be any material changes, these would need to be reviewed by the Audit Committee. Due to the tight timeframe a Chair‟s Action process would take place, subject to approval by the Audit Committee.

Draft Annual Accounts GP invited the Mark Dowell, Head of Finance to present the draft annual accounts. MD started by tabling a short presentation describing the CCG accounts process, which differs to that used by the PCTs.

- CCG accounts are derived directly from the Ledger, with the exception of QIPP reporting;

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- A national coding structure has been introduced, with no local flexibility. This helps NHSE collate and produce consolidated accounts quickly. It also automatically calculates the split between running and programme costs.

- All deviations to the ledger must be reported to NHSE via a consistency statement.

- In addition, as CCGs have no assets, following the transfer to NHS Property Services, CCG accounts are less complex than PCT accounts.

CCG accounts are made up of four primary Financial Statements, each supported by an explanatory note.

- Statement of Comprehensive Net Expenditure - Statement of Financial Position - Statements of changes in taxpayers equity - Statement of Cash Flows

MD then talked through in detail the Financial Statements and associated explanatory notes. Comments

- PS requested clarification of split between Running and Programme costs. MD said that for 2013/14 Running costs for all CCGs was £25 per head or a total of £4.5 million and these costs related to the operational/administrative work of the CCG (HQ costs). Programme costs were those which related to the clinical services commissioned by the CCG.

- In response to a question from PS, MD confirmed that the “capital

receipts surrendered” under Statement of Cash flows would be removed.

- CE referred to Note 16 “Payments to Individuals” listed. MD said that the payments are made to the named individuals GP Practice for clinical services commissioned by the CCG and not to individuals themselves.

- DP asked for a breakdown of “other costs” of £402k reported in the accounts. GP stated that this would be provided ( and DP was subsequently advised that the £402k was made up of £315k for the continuing care provision, £20k for health promotion and £67k for psychiatric assessments )

- CE asked that any amendments from this version be highlighted in presenting to the Governing Body.

There were no further questions relating to the account accounts. PS asked the Committee to agree the recommendation for delegated authority to the CFO for non material changes. In the event of material changes and mindful of the timeframe a Chair Action is proposed, subject to approval by the Audit Committee.

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In response to the above request the Audit Committee agreed the recommendation to provide flexibility in meeting the deadline for Governing Body and final submission to NHSE. GP thanked all staff involved in the production of the first CCG accounts, including the auditors, for their hard work. External Audit Findings Report The Chair invited Sue Exton (SE) to present the Audit Findings Report, prior to presentation to the Governing Body for formal approval. SE stated that subject to Governing Body approval it was planned to issue an Unqualified Opinion in respect to the CCG Financial Statements and Regularity. In addition, as a public sector organisation a value for money condition is required. External Auditors are required to assure themselves that the CCG had put in place proper arrangements to ensure efficient and effective use of resources. In this matter the Auditors plan to issue that there are no matters to report. In terms of the Audit Findings report, under sections „ Accounting policies, Estimates & Judgements‟ and „Unadjusted misstatements„, SE referred to a provision of £315k for continuing care claims received after 31.3.13. The auditors state that this provision is contrary to NHS Accounts Directions. The CCG recognises this but has nonetheless made the provision on the grounds that, in its judgement, this treatment follows the principal of prudence in the preparation of accounts given that, if and when the liability crystallises, it is very likely that NHSE will require the CCG to meet such liability. This statement is specifically included in the Letter of Representation from the CCG to the Auditors. This is reported as a non-adjusted misstatement. It is a condition that all matters above £250k must be reported. Comments CE referred to Page 15 and asked for assurance of the CCGs process to mitigate journal self-certifications. Martin Campbell-Smith (MCS) said that self-certifications are highlighted in reports to the CSU, who in turn inform the CCG to take appropriate action. GP said that all staff responsible for authorisation journal entries had been made aware of the need for separate duties. Draft Annual Report PS asked the Committee to review and comment on the draft CCG Annual Report. The following amendments were requested prior to presentation to Governing Body:-

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- All acronyms to be written in full - All reference to Audit and Governance to be revised to Audit - Page 3 – south west London amend to South West London - Page 7 – 2nd paragraph remove „around’ - Page 11 – under Hospital care „It is It is’ amend to „It is’ - Page 14 – final sentence remove trust - Page 15 – „Areas we will include’ to be re-worded - Page 18 – remove blank bullet point - Page 23 – penultimate paragraph CCGs amend font to black - Page 65 – (as clinical lead) amend to (as clinical lead, see below)

There were no further comments in relation to the draft annual report. The Letter of Representation GP informed the Committee that this is a letter from the CCG to the Auditors stating that the accounts and annual report give a true and fair view of the CCG affairs; are in accordance with statutory requirements and that accurate representations have been made to the Auditors. This must be approved by the Governing Body. Recommendation The Audit Committee were asked to recommend approval of the CCG Draft Annual Report and Accounts and Letter of Representation at its meeting on Wednesday 4th June 2014. Following full review, discussion and examination the Audit Committee agreed the recommendation for approval by the CCG Governing Body.

6. For Review

6.1 Sutton CCG Board Assurance Framework and Corporate Risk Register

Louise Morgan, Corporate Affair Manager, SLCSU introduced the Board Assurance Framework and CCG Risk Register. LM advised that as part of the annual planning process, SCCG has redefined its strategic objectives for 2014-15 to align with the ambitions described in the annual plan. Correspondingly, the CCG Assurance Framework will be re-focussed on identifying risks facing the CCG during 2014-15 and to ensuring that mitigating controls and actions are identify to increase the probability of achieving the annual plan. The Corporate risk register will also be updated following meetings with each of the risk owners. Comments PS asked for an update on changes to the Board Assurance Framework and Risk Register. LM said that a paper describing all changes had been omitted

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in circulating to the Audit Committee and would be re-circulated following the meeting. CE suggested that all target dates for mitigating actions are reviewed and updated where necessary; and where actions have been completed these are moved to a control. To provide the Audit Committee with an in-depth understanding of the risks, actions and progress made it was agreed to introduce a rolling programme to invite Executive Directors to attend Audit Committee on an annual basis with a view to identifying specific areas of focus for the Committee. It was agreed to invite the Director of Commissioning & Planning and Director of Quality to attend the Audit Committee meeting on 7th August.

LM YH

CE left the meeting

6.2 Register of Declarations of Interest

In accordance with the CCG‟s Constitution, members of the Governing Body and others are required to declare interests which are relevant and material to the CCG. Such interests are entered upon a register which, in turn, is available to the public via the CCG‟s website. The Register is updated on a regular basis and members must report, within twenty eight days, any change being required to their declaration. Members of the Governing Body and its Committees are also asked to declare at the start of each meeting any relevant interests in the issues to be discussed. Details of these declarations will be recorded within the minutes of the meeting. A copy of the Register of Interests is available at all meetings of the Governing Body and Sub-Committees and by request from the Board Secretary.

7 Auditor Reports

7.1 Internal Audit Annual Report 2013-14 and Internal Audit Strategy for 2014-15 and 2015-16 (for approval) David May (Baker Tilly)

Internal Audit Annual Report 2013-14 DM referred to Page 1 Internal Audit Opinion which stated that based on the work undertaken in 2013-14 a significant assurance opinion can be given. Appendix A reflected the current issues facing SCCG. Since the last meeting of the Audit Committee, three further audit reports have been completed:-

- Finance and Payroll feeder system; - Clinical Governance - Information Governance

In relation to the Governance, GP advised that action plans have been developed in response to recommendations for:-

- CCG Workplan - Annual reviews of sub-committees

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- Action plan trackers for Finance and Executive Committee A full report and action plan will be presented to Audit Committee in August 2014. Next Step GP advised that the Internal Audit Governance Statement will be updated to reflect the very strong endorsement of significant assurance from Baker Tilly. Internal Audit Strategy 2014-15, 2015-16 DM introduced the Internal Audit Plan 2014-15 for review and approval by the Committee. The report has previously been shared with GP with positive feedback received. DM advised that the plan (described in Appendix B) is based on 65 days with flexibility to meet the needs of the CCG. Comments PS referred to the absence of Safeguarding Adults and Children. GP responded that the plan had been circulated for comments to all Directors and no comments had been received. GP added that a vast amount of work had been undertaken to provide the CCG with assurance of the Safeguarding arrangements in place in Sutton. Recommendation The Audit Committee was asked to approve the Internal Audit Strategy Plan for 2014-15. Following full review and discussion the Audit Committee agreed the recommendation. GP referred to the review of the Commissioning Support Unit carried out by KPMG. The final report is now available and will be shared with the Audit Committee for information. GP to action

NA GP

MM left the meeting

7.2 Counter Fraud Update

KJ introduced this item. The proposed work plan for 2014-15 was presented to the Committee for approval. The plan is based on 35 proactive days. For 2013-14 the CCG purchased 55.5 days for both pro-active and re-active investigations. This was due to the CCG being a newly established organisation where Counter Fraud arrangements had not been established and there was no NHS Counter Fraud Strategy Implemented. Counter Fraud have carried out a risk assessment of each standard and has

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graded each red, amber or green (RAG). Following review the Audit Committee approved the proposed work plan for 2014-15. Counter Fraud progress update KJ stated that there are four investigations under way all within the target date. The following rag rated red actions were noted: Ref 8. Overpayment of salaries, expenses and other. The CCG has requested that responsibility is included within employment contracts. The Committee were advised that the employee and the employer have responsibility to avoid overpayments. GP is taking forward in discussion with Human Resources. Ref 16. Review of GP Governing Board Members Declarations of Interest. KJ advised that this is in hand. The anti-bribery action plan was presented for note. At this time there are two actions rated amber, e-learning package for staff and a letter to be sent to external contractors. All other actions are rated green. In response to a request from PS, KJ provided a brief overview of current investigations advising that there have been no referrals for Sutton CCG. The Counter Fraud annual report for 2013-14 describing will be signed-off by the CFO and submitted by 31 July 2014.

8 Any Other Business There was no further business for discussion. Meeting Closed: 11.20am Date of Next Meeting: Thursday 7th August 2014

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Documents

Report to the Sutton Clinical Commissioning Group Governing Body · 2014. 8. 28. · SCG GB 03.09.14 Att 15 Internal Audit Strategy and Internal Audit Plan 2014/15 GPr emphasised