AGENDA Lead Notes Action 1. Welcome, introductions A Reed Apologies Adrian Marr, Margaret Berry, Anoop Dhesi

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1 East Anglia Area Team & North Norfolk CCG Q1 Quarterly Checkpoint. 26 July Nigel Grimsey Room, Aylsham Care Trusts Centre. AGENDA Lead Notes Action 1. Welcome, introductions A Reed Apologies Adrian Marr, Margaret Berry, Anoop Dhesi and apologies 2. Purpose of Quarterly Checkpoint meetings 3. Reflections on Q1 from CCG and Area Team A Reed AR/ LH AR The purpose of the meeting is in line with the Interim Assurance Framework. The principal purpose is to get assurance on how the CCG is performing. The AT views these meetings as very different from the previous SHA / PCT format and the starting point is that of CCG earned autonomy. The meeting will focus on the jointly agreed agenda on an exception basis. The meeting is also an opportunity for CCG to comment on direct commissioning by the AT as this is a two-way process. AR would welcome feedback on the format of this first meeting and will contact MT and LH for feedback. LH explained that the CCG is developing well and the management team are now fully established. The CCG has good engagement with practices, supported by individual practice visits. These visits allow the whole GP team to hear the CCG plans and strategies of the CCG and commissioning relationships with key providers. The CCG is also garnering stronger relationships with provider clinicians, outside the normal contracting routes. Key issues for discussion are patient safety and patient feedback. Overall good progress has been made but there is much more to do. Relationships with Norfolk County Council (NCC) and local councils are also developing well. Action 1: AR to contact for a feedback meeting on the Q1 process Quality of care for local people C N&N BH AR The Area Team is part of NHS England and does not have its own governance structure. The NHS England role to support and develop CCGs will be is very different from previous performance regimes. The AT has suffered some early problems with car parking, phones, IT and payroll. Some functions are new and there have been a few glitches. The AT have had to intervene in a range of performance issues, including, 111 and urgent care. A&E has been variable across the patch and is usually a wider marker of poor quality services throughout the system?. Other issues are baselines for specialist commissioning, spending review (15/16), development of a primary care strategy, use of S256 funding transfer and the call to action paper. The Director team is now complete with the appointment of Katie Norton. AR thanked Peter Wightman and Carole Theobald for their excellent interim support. AT believes HCAIs are improving at the NNUH. The CCG are assured by the work the NNUH are doing, there still remains issues about allocation of infections. The NNUH has had 13 infections so far this year. The CCG plan is to manage infections on a whole system basis. The NNUH have improved isolation in the hospital, including specialty specific isolation plans.

2 NNUH have good clinical relationships with the AT and community trust (NCH&C). Key to deliver remains good practice and communication at ward level. NHS Constitution Standards 18 week RTT by specialty Q1 recovery Waiting times at NSFT 62 day cancer Ambulance handover and response times IAPT Access 18 weeks - The CCG are assured the NNUH are improving 18week delivery in particular focussing on reducing the number of long waits (>18 weeks). Individual specialty plans are on track, but T&O is an area where the NNUH have failed before. The CCG are locally promoting choice which appears to have improved local access to the NNUH. Patients rights should be made clear. AT will review websites to gain assurance. 62 day Cancer The CCG is not wholly assured on cancer patient tracking and want to see the next round of information. The CCG is also supporting secondary cancers improvements. Waiting times at NSFT The majority of services go through a single referral route, with 3 main waiting list KPI pathways. The CCG have just received information which highlighted some variation to contract agreements and the CCG have issued 3 contract query notices and the trust has responded well. The CCG has been working with the Trust to improve data, which will support a review of their implementation of their reconfiguration strategy. The AT would have expected Monitor to be more involved with the redesign, through a formal business case submission. The CCG has a meeting with the NSFT Chair and Acting CEO of the Trust next week to discuss some of the changes and areas of concern raised by practices. The Trust are conducting a review of SIs. Action 2: to check information regarding patient s rights on CCG website. Action 3: CCG to review cancer tracking Action 4: CCG to resolve data quality issues. Improving Health Outcomes Emergency plans BH IAPT Access The CCG had 3 breaches of the 28 day standard last month. Recruitment targets have not been met, so a contract query notice has been issued. CAMHS wait times are improving following the issue of a contract query notice. Ambulance: This is a major issue for NN CCG. EEAST have a recovery plan, but concern about the focus on delivery targets in aggregate. Local delivery is poor and the CCG views this as a significant patient risk. The CCG has formally expressed concern 6 weeks ago, but no response has been received. The CCG are engaged with the EEAST capacity review, but the review is focusing on average performance, not local performance. Assurance needs to be gained from the EEAST whether they are aiming to deliver national standards for all patients or achieving targets in general. The CCG believes the core issue is a logistical one, based on tethering. The CCG is unsure if their engagement with the consortium will allow for rapid improvement. TD is clear that there are some specific pieces of work required. SS concerned that 2 risk summits (which have now been stepped down) have not delivered change in local delivery. AR suggests this is a key issue to be raised at QSM. EP The central Norfolk plan has been received and the AT will feed back prior the final submission. The plan should explain current performance issues; identify risks to delivery, Action 5: Local NN EEAST delivery to be raised at the next Quality Surveillance Meeting Action 6: AT will provide feedback on Urgent Care Plan.

3 Local priorities MH redesign particularly over winter and how these risks will be addressed. Actions should identify the impact on performance and the escalation processes when delivery is not maintained. The CCG confirmed the plan is assumed on no new money, but schemes that require funding have also been developed if funding does come through. Commissioning within financial allocations Current position finance Current position activity QIPP progress 2% transformation fund S256 Risk Share Local Priorities The CCG confirmed that work has commenced on dementia and supporting carers, living well with dementia. The priority to support people to maintain their independence is also progressing well, with good feedback from practices following data sharing. Knee PROMs have also commenced. The CCG explained that the month 3 report is based on early information, significant risk remains on baselines issues, such as the specialist commissioning adjustment. The AT is reassured that the CCG has not assumed any financial funding from the specialist funding outcome. The CCG has inherited a significant QIPP gap of 10m including 3m of CHC legacy. The initial plan was developed by an interim Chief Finance Officer and has some gaps, but the CCG are examining other areas for savings which may compensate. The CCG will not commit any of the 2% (apart from 200k) due to uncertainty over CHC. The CCG is assured that the CHC Turnaround Planis starting to deliver savings, but this is offset by over performance at the NNUH. The CCG have seen a 12% increase in activity and an increase in the average cost per case. The CCG has sent a query to the NNUH. QIPP The CCG is holding a QIPP meeting on 6 Aug, to address 3.9m gap. The CCG is confident on delivery of prescribing savings, but expect to use 2 % transformation fund as part of the solution to closing the QIPP gap. Action 7: to confirm funding transfer re CAMHS IST. CAMHS IST. CCG will decommission if funding is not transferred to CCG. Risk Share The CCG has come to an agreement to share CHC, blood products, critical care and LD/MH/CHC/individual packages over 100k. Action 8: CCG to send draft S256 proposals to prior to the H&WBB. S256 The AT is informed by Harold Bodmer that joint discussions about the use of S256 are taking place. The AT requires sight of the proposals prior to sending to the H&WB. Conditions of authorisation and beyond DMIC This has caused huge problems for the CCG. The CCG has made payments on account, but reconciliation is still an issue. The AT congratulated the CCG for being fully authorised. MT thanked the AT for their support through this process.

4 Planning 14/15 AH/ The AT highlighted the need to review financial scenarios for next year as soon as possible. The CCG has developed a long term model which provides an idea of where potential risk may occur. The CCG are pleased they may receive more funding from the baseline review. Direct Commissioning Appraisal and revalidation GPIT funding MMR LES/DES Cromer MMR The AT is holding a procurement exercise for prison health, with a desire to communicate and engage GPs in the process. The primary care team are now established and are making communications with CCGs, particularly to discuss quality issues and improvement in primary care, with an aim to develop a memorandum of agreement. A National Primary Care framework is being developed, with national work streams which should inform a local Primary Care strategy with LMCs and CCGs. Initial work suggests primary care at scale may be the way forward, but AT keen to work closely with the CCG. The CCG feels local practices are not aware of the AT, therefore welcome the improved communication, particularly in regard to patient safety and quality issues. Action 9: Area Team to meet with the CCG to discuss primary care strategy AH/ D Cockman J Black Primary Care premises (Cromer). AT is reviewing schemes that require growth funding and re-evaluating the strategic fit. The AT is also reviewing APMS contracting. The AT is also keen to involve the CCG in GMS and PMS rebalancing. GP Revalidation is in progress with generally high standards. There were some issues with access to data from GP software systems, although this is now resolved. GP IT CCG was promised funding for GP IT, but as this has not happened, the CCG has stopped paying the Anglia CSU. MMR The CCG has given notice on LES, with a move to DES. WIC - The CCG would like confirmation of the contract re-procurement, and where savings would go. FHS The NHS has a 40% improvement target for back office functions, the AT preferred approach is to work with SERCO to deliver the savings. The CCG suggested that it would be helpful to involve practice managers in his process. SS The CCG has issue with CAMHS Tier 4 issue at Attleborough. Action 10: Area Team to provide decisions on premises by mid September Action 11: GPIT funding. Darrel Cockman/Ann Hogarth in AT to check position and send out to CCG. Action 12: Area Team to confirm WIC issues Action 13: Area Team to consider involvement of practice managers in FHS savings Action 14: Jane Black to contact Sarah in and Carole Theobold s team

5 Service Issues Stroke CSU in Norfolk Community hospitals Stroke - The CCG agrees that stroke services are not acceptable. The recovery action plan received is not sufficient and the CCG wants to see more pace and focus. The QEH and JPUH appear to be delivering high quality services within tariff. Stroke care is at greater risk because of the ambulance performance. The AT suggests the system insists on a very robust Action 15: CCG to request improved recovery action plan and strengthen 14/15 contract for stroke at the N&N. recovery action plan and strengthens the 14/15 contract. CSU - The CCG welcomes the change of leadership. The BDU have met with the CCG twice and the stakeholder group met last week, presenting an honest diagnostic of current issues. The CCG have requested a recovery action plan (RAP) and is considering some marginal changes. Ernst and Young have been engaged to support the longer term view. The service has been poor and the CCG has been covering CSU responsibilities. The CCG does not feel the split of charges for the CSU is equitable. Community Hospitals - The CCG commissions care from 5 community sites, many in the north of the patch, commissioned from NCH&C. The hospitals have been subject to regular reviews and mainly provide the same type of service. The CCG has reviewed these facilities and initial ideas include a more focused use, including end of life care and admission avoidance. The review will also examine key skills and competencies of staff required to undertake potential new services. Action 16: CCG to advise the AT of community hospital review outcome CCG Organisational Development NHS England Organisational Development 9. Action summary and reflections A Hogarth Pathology AT concerned that not all CCGs are signed up to procurement. The CCG has concerns about transitional costs of 7.8m and this is holding up progress. The CCG cannot show VFM without details of the actual costs incurred. AT suggests the CCG goes back to the strategic team, but AH will check with AM. The CCG has 3 main OD targets. Develop the Governing Body (GB), develop the GPs who are not on GB, and strengthen the CCG management team.external consultants have been used to support the GB through sessions on meeting in public and future strategies. The CCG is considering how it engages with GPs and are recruiting a number of posts to underpin the the senior team structures. There are national workstreams set up to implement the OD model. Consideration is being given to how much OD will be devolved to ATs and on the relationship between Region and AT. The AT is reviewing internal working arrangements and setting a system of departmental and individual objectives. The staff survey has been OK, but there is more to do to clarify roles and responsibilities. AT summarised the meeting. The key areas are 18 week at the NNUH, this is improving but needs continuous focus. There are mental health issues with information, IAPT and CAMHS waits. EEAST are delivering very poor response times and there is a real need for all us to Action 17: AT to advise CCG on course of action to obtain actual costs for pathology

6 keep close focus and raise the issue at QSG. The AT welcome the prudent assumption made for Specialist Services adjustments, but shares the CCG concern over the CHC liability and QIPP plan shortfall and therefore supports the retention of the 2% transformational reserve. There are concerns about the growth in NNUH activity and inability to review because of the DMIC issues, although we welcome the audits taking pace. The AT will respond to the CCG on GPIT funding. The AT supports the move to DES funding for MMR. The stroke service at the NNUH is extremely poor and needs strong contractual approach. The AT looks forward to the outcome of the hospital review. The AT notes the current position of the CSU and supports the CCG in understanding the actual costs of Pathology set up costs. North Norfolk (CCG) Jackie Schneider (JS) Mark Taylor (MT) Dr Linda Hunter (LH) Mark Burgis (MB) Helen Stratton (HS) Area Team (AT) Ann Hogarth (AH) Andrew Reed (AR) Tracy Dowling (TD) Peter Wightman () Birte Harlev-Lam (BH)