NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups Governing Body Meeting In-Common

Transcription

1 NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups Governing Body Meeting In-Common Minutes of the meeting held on Tuesday 6 th February 2018 at 1.30pm, at Clevedon Hall, Elton Road, Clevedon, BS21 7RH Present Julia Ross Chief Executive, BNSSG CCGs JR Sarah Truelove Chief Finance Officer & Deputy Chief Executive, BNSSG CCGs ST Peter Brindle Medical Director, BNSSG CCGs PB Lisa Manson Director of Commissioning, BNSSG CCGs LM Deborah El-Sayed Director of Transformation, BNSSG CCGs DES Anne Morris Director of Quality & Nursing, BNSSG CCGs AMo David Jarrett Area Director, BNSSG CCGs DJ Colin Bradbury Area Director, BNSSG CCGs CB Justine Rawlings Area Director, BNSSG CCGs JRa Martin Jones Clinical Chair, Bristol CCG MJ Tara Mistry Lay Member, Bristol CCG TM Danielle Neale Lay Member & Chair of Audit, Bristol CCG DN Lesley Ward South Bristol Representative, Bristol CCG LW Brian Hanratty South Bristol Representative, Bristol CCG BH David Soodeen Inner City & East Bristol Representative, Bristol CCG DS Richard Laver North and West Bristol Representative, Bristol CCG RL Mary Backhouse Clinical Chair, North Somerset CCG MB Jeanette George Chief Operating Officer, North Somerset CCG JG Kathy Headdon Lay Member & Vice Chair, North Somerset CCG KH Ryan Richards Lay Member & Chair of Audit, North Somerset CCG RR Miriam Ainsworth GP Representative, North Somerset CCG MA David John GP Representative, North Somerset CCG DJo Kath Payne Practice Manager Representative, North Somerset CCG KP Jon Hayes Clinical Chair, South Gloucestershire CCG JH John Rushforth Lay Member, South Gloucestershire CCG JRu Martin Gregg Lay Member, South Gloucestershire CCG MG Nick Kennedy Secondary Care Consultant, South Gloucestershire CCG NK Andrew Appleton GP Governing Body Member, South Gloucestershire CCG AA Janet Biard Practice Manager Representative, South Gloucestershire CCG JB Apologies Kirsty Alexander North & West Bristol Representative, Bristol CCG KA Pippa Stables Inner City & East Bristol Representative, Bristol CCG PS Sally Hogg Consultant in Public Health, Bristol City Council SH Kate Mansfield GP Governing Body Member, South Gloucestershire CCG KM Mark Pietroni Director of Public Health, South Gloucestershire Council MP Sara Blackmore Director of Public Health, South Gloucestershire Council SB In attendance Alison Moon Transition Lead, BNSSG CCGs AM Sarah Carr Corporate Secretary, Bristol CCG SC Marie Davies Head of Commissioning for Quality, BNSSG CCGs MD Louise Rickitt Head of Strategic Planning & Service Redesign, South LR Gloucestershire CCG Robyn Smith Personal Assistant, North Somerset CCG (note taker) RS

2 1 Apologies Jon Hayes (JH) opened the meeting and apologies were noted as above. Julia Ross (JR) welcomed and introduced Sarah Truelove (ST) (Chief Finance Officer, BNSSG CCGs) as a new member of the Governing Body. 2 Declarations of Interest There were no new declarations of interest. JH declared an interest in item 8.3 as three partners in his practice are part owners of Edgemont View Nursing Home (South Gloucestershire). It was agreed that this was not a material interest. 3 Minutes of the Previous Meeting and Matters Arising The minutes were agreed by the Bristol CCG, North Somerset CCG and South Gloucestershire CCG Governing Bodies as an correct record with the following amendments. Page 9 item 8.2, it was noted that there was an action required for the element about suicides, where Governing Bodies asked to know more about why suicide rates were growing in Bristol. A refreshed plan to be reported back to Governing Bodies in March. Page 19 item 13, in reference to the questions from Protect our NHS, it should read JR asked MC to share the gentleman s contact details so the CCG can get in touch with him. It was noted that these details have not been received. 4 s from the Previous Meeting 5 Dec 17 item 9 ref 01, presentation on the Ambulance Response Programme (ARP) deferred until March Governing Body In-Common meeting. The action remained open. 5 Dec 17 item 12.2 ref 01, paper regarding STP digital programme deferred until March Governing Body In-Common meeting. The action remained open. 9 Jan 18 item 7.2 ref 01, perinatal mental health metrics report for Governing Body In-Common is in train. The action remained open. 9 Jan 18 item 8.2 ref 01, revised draft Bristol LA Strategy to be shared with Governing Bodies in March. The action remained open. 9 Jan 18 item 8.2 ref 02, BNSSG wide suicide prevention report to be presented to Governing Bodies in March. The action remained open. All other actions were closed. 5.1 Update from the BNSSG Clinical Chairs Bristol CCG Martin Jones (MJ) reported that: The current locality commissioning leads met as three localities to discuss what they have learnt in working in localities to date, and how to work in the future as BNSSG CCG. Locality provider groups have all met as part of phase 1 of the transformation 2

3 scheme, ready to move to phase 2. Refresh of the Bristol Health and Wellbeing Board meeting in February, leading a piece of work to refresh the Board by inviting wider providers from acute trusts and mental health. Looking to try and position the Board much more in a leadership role. There has been a discussion with the Board about how this fits with the Sustainability and Transformation Plan (STP). 5.2 Update from the BNSSG Clinical Chairs North Somerset CCG Mary Backhouse (MB) reported that: The ongoing work on Healthy Weston has moved towards the end of an active phase of working with the public. There have been a series of engagement dialogues out in the community. Continued to do visits, such as the alzheimer s society and addaction. The conversations highlighted that they were not concerned about the temporary closure of A&E overnight; they were concerned about primary care access and continuity of care. As an organisation conversations out in the community will continue. First of the major codesign events on care homes has taken place. Positive event building on next piece of work, The People and Communities Board had an appreciative inquiry on complex individuals; and the police commissioner led this appreciative inquiry. Looked at how organisations together and working in the area can make sure that these people do have the opportunities to recovery and create more healthy lives. 5.3 Update from the BNSSG Clinical Chairs South Gloucestershire CCG Jon Hayes (JH) reported that: South Gloucestershire continues to deliver the commitment for the timescales for the 3Rs (rehabilitation, reablement and recovery services). There has been a constructive meeting between the Local Authority (LA) and North Bristol Trust (NBT). Locality development is going well in terms of both commissioning and provider perspective. Providers have met for the first time in their full capacity, and have achieved the first sign off point for developing locality. JH and David Jarrett (CJ) have visited just over 50% of practices since Christmas in terms of engagement. There is a commitment to be system players in terms of driving commissioning forward. 6.0 Chief Executive Report JR welcomed ST to the Governing Body in common, and expressed thanks to Glyn Howells who has done a tremendous job as Chief Finance Officer in the interim. Glyn will be staying with the organisation to support a range of different projects; however will not attend Governing Body meetings going forward. Moving towards April, the CCGs are continuing the process of restructuring. Executive Directors have been undertaking interviews for the senior management teams and appointments are almost complete. JR confirmed the appointment process for the BNSSG CCG clinical leaders for clinical leadership roles have concluded. Appointments will be published later this week, and it will be clear who are clinical leaders for pathways and for commissioning localities; 3

4 including the individuals that will be members of BNSSG CCG Governing Body from April. The process for the appointment of BNSSG CCG Governing Body independent members has concluded; JR expressed thanks to those who expressed an interest in the roles; and confirmed the following appointments. Vice Chair of Governing Body and Chair of Audit John Rushforth Independent Secondary Care Doctor Nick Kennedy Independent Registered Nurse Alison Moon JR provided an update on the executive lead role for the STP. JR and Robert Wooley had gone forward as a job share for the role, and colleagues have agreed this approach. The third part of the process is to attend a formal interview with NHS England (NHSE) and NHS Improvement (NHSI) on 21 st February. Last week JR and the Area Directors met for the first time with the new GP provider locality leads. JR commented that the meeting was very positive, there were lots of questions and challenges, and a real sense of energy and engagement. Monthly meetings were agreed going forward. Two things as next steps were agreed, one is to look in detail at improved access at the next meeting, and the second is to step firmly into facilitating and enabling the dialogue between GP localities, practice localities and the rest of the providers in the community system. JR explained that University Hospitals Bristol (UHB) and Weston Area Health Trust (WAHT) have announced their intention to closer working formally. This will support the development of the Healthy Weston approach, not only how to achieve more integrated engagement in the Weston element, but also in terms of acute trusts networking more broadly, including with NBT. JR announced that the planning guidance has been released and agreed to send the NHS confederation briefing to Governing Bodies. It is very clear in the guidance that STPs are expected to continue and grow and to become increasingly the leaders of the system. There is a real drive for integrated system working. : JR to circulate the NHS Confederation briefing to Governing Body members. 7.1 Healthy Weston Programme Update Colin Bradbury (CB) gave an update on the progress the Healthy Weston programme is making on the codesign and public dialogues phase, which runs until 2 nd March. There has been a great response from public, patients and wider stakeholders who want to get involved. It was noted that the online survey is still live, and there has been a great response so far with 676 online survey responses to date. As well as the larger public events, the programme has also involved established local groups; and Protect our NHS is engaged in the programme, as are the Health Overview and Scrutiny Panel (HOSP) of the LA. Over the course of January to March the programme is also running a series of codesign meetings. Specific targeted workshops on particular themes of special 4

5 interest to local people are set up. The four workshops will focus on these specific topics which are care homes, maternity, potential services on the Weston site and urgent and emergency care. All feedback, issues and ideas are being captured through these events and are being written up in real time and being reported back to the clinical and workstream design group. CB explained the next steps of the programme. The Commissioning Context document, which was published in October 2017, commits the CCG to a checkpoint at the end of March. Planning is underway for this checkpoint, and a large public meeting is being arranged to review what has been heard so far, to summarise the codesign process, and to take discussions on next steps and likely future direction of travel. The commitment for this is the end of March; however given where Easter falls this year, it is proposed that the event itself be held in early April. JR agreed with the proposal to hold the event in early April, and suggested that the date be published as soon as possible. CB advised suitable venues are currently being looked at and the date will be confirmed and advertised very soon. Martin Gregg (MG) asked if CB could comment further on the evaluation exercise, particularly if this approach is how the CCG is going to model work in other localities, it would be useful to see how an evaluation exercise could inform other parts in the NHS in terms of what works well and what doesn t. CB explained there is several elements, one being that the University of the West of England (UWE) will be doing an independent evaluation of the process, that is to capture the learning as to how to devise a methodology that could be replicated through BNSSG as required; and Peter Brindle (PB) is also supporting in that in terms of being a learning organisation. The programme also has a contracted and independent third party organisation called National Evidence Centre to do an evaluation of the codesign; they are already in the process of developing that independent report which will also inform part of the checkpoint update in April. Governing Bodies noted and discussed the following update. 7.2 Healthy Weston Partnership Strategic Outline Case Verbal update given under item 6.0, Chief Executive Report. 7.3 Update on 3Rs Lisa Manson (LM) explained the purpose of the paper is to update on next steps following the decision to abandon the procurement of the 3Rs. Following the decision to abandon the procurement route the CCGs have commissioned an external management consultancy agency (Attain) to provide capacity to undertake an independent option appraisal on the next steps for Frenchay and Thornbury. The scope of the work by Attain is outlined in the paper, and it provides a recommendation for a procurement route; and building on the substantial work which has been undertaken to date. It also supports optimal implementation of the model of care; and considers any opportunities and issues arising from the changed commissioning context of BNSSG. A weekly steering group has been established to maintain focus and momentum. 5

6 Governing Bodies are asked to recommend that the Strategic Finance Committee (SFC) undertake further review of the assumptions of an independent assessment because the intention is to take back the full report to the first BNSSG CCG Governing Body meeting in April. DJ reiterated that the CCGs have made the commitment to make recommendations to the Governing Bodies to take a revised procurement route. It was also made clear that the steering group has been established to monitor the work; which includes representation from Public Health. AMo asked if it would be necessary for a member of the quality team to sit on the steering group. LM suggested a member of the quality team will be asked to attend as and when appropriate. Governing Bodies: Noted the update on the 3Rs programme. Recommended that the Strategic Finance Committee in March tests the assumptions of an Independent Assessment. 7.4 Working with an industry partner to optimise continence prescribing through training delivery deferred until March Update on the development of locality commissioning groups and locality provider groups within BNSSG CCGs Justine Rawlings (JRa) presented the update on the development of locality groups. Locality commissioning groups were already established in Bristol CCG; however these groups have now been established in North Somerset and South Gloucestershire areas. Member practices have established six commissioning groups: three in the Bristol area, two in the North Somerset area and one in the South Gloucestershire area. JRa explained that the Bristol locality leadership group have met to consider next steps and how they might work differently within a new BNSSG CCG. JRa commented that Area Directors will shape the relevant Terms of Reference (ToR) for locality groups and these will be brought to governing body for agreement. Area directors are also speaking to practice managers about how to do better at keeping the line of communications open; Kath Payne (KP) had offered some helpful thoughts on how to do this better across BNSSG going forward. David John (DJo) referred to section 3 of the paper, financial/resource implications, and queried the population figures for Weston and Woodspring, and expressed a concern that his practice may not be included in the correct locality. JRa undertook to share the underpinning information to ensure that it was correct. : JRa to check that the locality and population information for the locality transformation scheme payment 1 st phase is absolutely accurate; and share the information with DJo. Martin Gregg (MG) referred to section 8 of the paper, consultation and communication, 6

7 which refers to the development of the locality models of care ensuring appropriate and proportionate involvement and engagement; however he did not see this coming out of the report. JR commented that the localities are just getting set up, and there are three ways to do this in the future. Patient and Public Groups (PPGs) should be involved, patients and the public should be involved in the design of pathways and models; thirdly, going forward, there will be patient and public involvement (PPI) work done at an area level. Nick Kennedy (NK) asked what the money is going to be spent on, and who oversees what is being spent. JRa responded to say the money is to support transformation, in the first instance set up of the provider locality groups and, in the next phase, to support the work; including some of the meetings they will want to have with other locality providers such as community providers. In support of the first phase, each of the GP locality provider groups has provided documentation to explain the arrangements for working together, and the leadership for their locality and how they will be selected on that basis the money was then released. Governing Bodies: Noted the progress made to date in developing locality commissioning groups and locality provider arrangements. Noted and agreed the next steps outlines within the development of the locality transformation scheme supporting the development of the locality provider structures. 7.6 BNSSG CCG Website Development Deborah El-Sayed (DES) provided an update on the website re-development project and future thinking for developing digital first relationships with the BNSSG population. There is a project underway to update Governing Body colleagues on the progress of the re-development, which is one part of the paper. The second part is to get support and views on the direction of travel to more strategic approach to the new BNSSG CCG website. The first piece of work is about merging the three CCGs websites, we currently have existing CCG websites and a really important thing to do is bring those together, which is more complex, as each website has various links to other websites. Omni Digital is the current host, supplier and developer of the existing CCG websites, and they have been commissioned to support the website re-development. This project has been brought together and needs to be delivered by the end of March, for launch on 1 st April in line with the new organisation. PPI colleagues are currently being engaged to make sure there are representatives, and to ensure the way the language is presented makes sense for people and things are being communicated in a positive way. DES explained there is an opportunity for something much bigger in terms of strategic ambition. There have been significant changes in how more mature people interact; and changes to how the population interact. There are a wide range of health websites, NHS Choices being one of the more prominent websites available. DES proposed that the CCG need to start thinking differently and to think about how to connect to national services, and to direct patients and the public back to local services they need. The proposal is to explore with colleagues and lay members, and to engage with local communities to create a new way of interacting with the 7

8 population. DES referred to section 7 of the paper, implications for equalities, which notes the CCG will seek to improve user experience where English is not a first language; and commented that there is a keenness to look at whether there is a possibility or opportunity to align with third sector organisations to help make the language used easier to understand and for people to connect. Tara Mistry (TM) asked if, in the interim, the CCGs will be meeting the accessible standard compliance. DES commented that, in terms of the statutory responsibilities, the CCGs will absolutely be compliant. Peter Brindle (PB) requested a little more detail in terms of the advantages for patient and organisation perspectives. DES suggested that patients will not need to go through as many routes to find the information they want or need, there will be links to take patients through to existing data on the web. There is a need to really think about what reason people come to the CCG website. MG referred to the footfall, and said that he encourages people to look at the website regularly; and asked what the strategy is going to be for encouraging people to use the website more, and if there will be a link with social media such as Facebook. DES commented that this is about behavioural change, and the first question to ask is why an individual would go to the website and the need to understand people s drivers and how to connect to that. In terms of the whole communications strategy, conversations have started about how the social media strategy and digital strategy have to combine and become seamless. John Rushforth (JRu) supported the website re-development, and commented a key focus should be the audience in getting the right messages, but also in terms of getting the tone of voice and language right. Also ensuring there is a strong measurement system in place to see what works; measuring what the population want is critical. Governing Bodies: Considered and endorsed the approach to phase 1 of the project (merge of three existing sites into a single site). Discussed and shared views. 7.7 BNSSG CCG Visual Identity DES provided a brief update, and explained that the CCGs have got a visual identity and it will be as of 1 st April. The new BNSSG CCG website will be in the new visual identity delivery. Governing Bodies noted the report. 8.1 Quality Assurance Report Marie Davies (MD) attended for this item. AMo introduced the quality assurance report that notes key issues of quality work discussed at the BNSSG Quality Committee in 8

9 January as well as any key issues that are not captured in the quality and performance report. There was a focus to the approach to assurance visits in the report, which is also covered in item 8.3 of the agenda in more detail. MD highlighted that the paper focuses on three areas, the first being safety visits to BNSSG Emergency Departments (EDs). This was taken in response to the pressure on EDs in January, and that was undertaken by the quality team. The good practice seen is noted in the report; and this is an updated visit to those that were made in November and December last year. Any comments that were made following the visits last year had been taken in to account and positive changes were seen. From a Serious Incident (SI) update, it was mentioned previously that one single BNSSG SI panel has been established which looks at all the SIs across providers. MD advised that the CCGs are being able to identify learning and trends to a much greater extent. There was one issue in that the review within 28 days, which is an obligation under the SI framework, is not hitting 100% target due to the way papers are received and circulated; therefore the panel has moved to meeting weekly which will resolve this issue. The third area was a scoping exercise that was done as part of the musculoskeletal (MSK) STP project and looking at fractured neck of femur. MD commented that some really interesting data was presented, and there was an active discussion around the outcomes of the scoping project and the plan to develop a universal quality standard and how that will be delivered. AM referred to the pressures around ED and asked whether follow up visits looked at one up, which is when ward areas take additional patients in times of extreme situations, as part of looking at the pressures. AMo confirmed this has been done before, particularly in response to the significant pressures in the system, and is described in the second quality assurance paper in more detail. It was looking at the process for the standard operating process that the Trusts have for setting this up. This was not reviewed at UHB as they did not have one ups in place at the time, but their policy was discussed. JR referred to page 3 of the paper which talks about visits to Acute Medical Units (AMUs) and highlighted the line that says At this visit the CCG were assured that.. and asked if the CCG were assured, or reassured. AMo explained in particular relation to AMUs there were areas of good practice which was witnessed, however there are also challenges in the way the area is laid out. The assurance process is how the Trust manages that and they utilise a number of tools to do that; and the patient safety checklist is instrumental in that assurance process. Issues are addressed at the time of the visit, but there is also the ability to do an audit process at looking at what the Trust does. AMo commented that at that visit the CCG were assured. Governing Bodies noted the area of work undertaken; noted assurances received and actions agreed. 8.2 Never Event Report / Quality Surveillance Report MD attended for this item. AMo introduced the quality surveillance paper, which begins to describe the BNSSG development of quality surveillance approach to patient safety which is led by the CCG quality team. It describes the current situation and how the 9

10 CCG will assist the leaders to develop this approach further. The CCG continues to work with NHSE and NHSI and take part in learning events. The CCGs aim is to provide leadership in its own health care system to improve patient safety. MD advised the paper describes the current never events, and some of the learning events that have taken place that take the CCG forward in terms of what we can learn to prevent never events happening again. The CCG are looking at its role in the health system in terms of developing and improving patient safety. There have also been some discussions with Acute colleagues about developing some patient safety bids that have gone in to Health Education England (HEE). Discussions have also been had about how to learn from experiences and how to involve acute providers particularly in looking at never events, and sharing each other s experiences to learn in the future. JR referred to section 4.1 of the paper which notes that UHB were issued with a Contract Performance Notice (CPN) in November 2017, and asked for an update. MD advised that the CCG are in discussion with UHB and have received a Remedial Plan (RAP), and a contract meeting is scheduled where this plan will be discussed and agreed formally. UHB recently held a learning event which the CCG and NHSI were invited to attend, and they are planning to look at foresight training and that is an approach that used to be used by National Patient Safety Agency. JR commented that the timeframe for sign off of the RAP is quite significant, and the timeframe of November 2017 to February 2018 is quite a long period of time. AMo advised that the issue with the particular action plan was the trajectory for improvement, UHB have been asked for more detail in it. DJ referred to section 4.3 of the paper which notes the never events reported for WAHT since April 2017; two of which were reported on behalf of Somerset Surgical Services (SSS), which is a private organisation that operates out of WAHT theatres; and commented that as a proportion of elected capacity that is a relatively large number of never events for a small provider. DJ also asked if the CCG captures all never events for all AQPs (Any Qualified Providers) as well. MD confirmed that any AQPs are obliged through their contracting to inform the CCG of any SIs. Two never events at SSS is quite significant in a short time, therefore the CCG sought assurance and visited the service. As the service works out of WAHT the CCG were clear that the Trust needed to participate in the investigations, and these are services that are commissioned by NHSE as associate commissioners, so they were also involved. During the visit the incidents were looked at in detail, the Route Cause Analysis (RCA) has been done as a joint investigation between WAHT and SSS, which is subject to full review and sign off by NHSE. AM recalled a discussion at the Governing Body meeting in January about human factors and asked what the CCGs thinking was based on the conversations previously had about the learning from human factors as it is not reflected in the paper. AMo commented that it is how this is managed, and one of the bids which has been submitted is around developing human factors, not necessarily in terms of training, but about how to manage the culture. Governing Bodies: Noted the contents of the report. Agreed the approach being taken to ensure system wide learning and 10

11 triangulation with other quality assurance approaches in relation to Patient Safety Incidents including Serious Incidents and Never Events. 8.3 Quality Assurance Visits AMo introduced the planned approach for quality assurance visits. The paper describes the BNSSG approach to quality assurance in the form of assurance visits. This is one mechanism that is used to gain assurance form providers and for the CCG to also provide support during the visits. It also describes the series of assurance visits made to Acute providers during December and January when the system was under significant pressure, and NHSE and NHSI were invited to accompany the CCG during the visit which they did. The approach is to continue to secure improvement in the quality of services that are reviewed, and looking at quality schedule requirements. The paper describes the planned approach and how the CCG plan to have a key focus on patient experience and there will be a more detailed plan which is currently in development. It was noted that a list of the visits is included in the paper as an appendix. AMo explained that there is a template for the visits that has been shared with other CCGs which has been commended by NHSE. Whilst there will be a programme of assurance visits, the CCG will also want to be doing other visits alongside the programme. All areas of good practice will be revisited to share that learning. Kathy Headdon (KH) asked if there has been any thought given to building visits of any type in to primary care practice, particularly in light of the CCG taking on primary care commissioning. AMo advised she has met with members of the practice nurse workforce and there is a plan to look at how peer review can be done using practice nurse colleagues who are keen to develop something and to support that work. TM commented that, when the CCGs operated with three separate quality committees, the Bristol CCG committee used to receive reports on care homes which noted the support they needed to be compliant with the Care Quality Commission (CQC), and asked if the quality assurance visits being discussed are in addition to those original visits. AMo confirmed the CCG still do those visits and will be looking at how to structure those visits going forward as BNSSG is such a wide area. There are also groups of providers that have several care homes in several different areas so the CCG will be looking at how to structure those visits carefully. AMo commented that the CCG need to be aware of what it is they are quality assuring and why, and also how to work with LA colleagues who also commission beds and carry out assurance visits in care homes, and it s about how the CCG work in partnership with these large organisations. David Soodeen (DS) asked who is involved in the assurance visits. AMo advised currently the quality team carry out the assurance visits, however as part of the developing strategy, they would like to involve other interested members to join the visits, so need to identify who to involve and why. AM expressed that the approach is really good practice, and commented that the CCG would benefit from targeting specific areas, and there are some good examples included around fracture neck of femur to understand why UHB were not achieving standard. There is a question however about how the CCG prioritise what is done, particularly thinking about some of the issues that were raised last year and playing them in to the programme for 2018/19. For example, based on a previous discussion 11

12 around Avon and Wiltshire Mental Health Partnership (AWP), perhaps safeguarding issues in AWP may be a priority to look at. AMo explained that there is a plan for AWP, looking at going in and working with them on their governance processes particularly around things such as safeguarding; and the CCG can look at particular areas of concern which have been raised in their CQC report. MB asked if the nurses and doctors in training are engaged with in terms of their insights as they often move around different sites; and also how is this information shared within the system in correlating what is seen during visits. AMo suggested as part of this process one of the things that is being looked at is how staff are managing; something that directly came out of a staff report some years ago was around patient experience and what is happening on wards. Therefore a quality ward round template has been developed that can be used when in wards when talking to the junior and senior staff, both doctors and nurses, and also patients, which gives opportunity to talk to people the CCG may not otherwise hear from to give a valuable perspective. AMo confirmed that at the end of the visits findings are shared with providers in writing immediately with the response; this can also be shared with quality surveillance group colleagues. Governing Bodies: Noted the contents of the report. Noted both the visits undertaken and those planned to assure the CCG in relation to the quality of commissioned services. Noted the proposed approach to Quality Visits. 9.1 BNSSG Finance Report as at Month 9 ST presented the BNSSG finance report and explained the position at month 9, the forecast outturn is 29.9m deficit with 5.0m worth of further unmitigated risk, and that remains in line with the forecast agreed with NHSE as month 6. NHSE have agreed that from month 10 onwards the CCG can reflect the unmitigated risk in the forecast outturn, so the outturn position will move at month 10 to 35.0m deficit. The forecast outturn relies on a savings delivery of just over 40.0m which is a slight deterioration from the position that was reported at month 8. The main issues to be resolved to ensure delivery of this position by the end of the year are a few outstanding issues on the two main acute contracts, and some outstanding discussions being had with Bristol City Council about the Better Care Fund (BCF). Danielle Neale (DN) asked if ST is able to provide an update on the financial settlement for next year. ST confirmed the planning guidance was published on Friday 2 nd February, the CCG will get an additional allocation out of the growth that was announced in the autumn budget of about 9.5m, that is because the 1.6b that is being given out to the NHS in the autumn budget has been split, so 600m is being allocated to providers as part of the provider sustainability fund, and 600m to commissioners which is being allocated on fair shares, with the BNSSG share being 9.5m. The other 400m will go to the CCGs who are in deficit as a commissioner sustainability fund. DJo referred to page 8 of the paper, and commented that the forecast versus plan varies considerably amongst the three CCGs and asked if there was a particular reason for that. ST explained there are numerous reasons, some of it is about the last 12

13 financial year and therefore under the way the accounting works for CCGs some of that will be about how that is carried forward in to this year. KH reiterated the point that there is a difference in terms of the financial figures for the three individual CCGs, and asked what the CCGs are learning from the differential circumstances in terms of commissioning and services in the three individual CCGs. ST expressed there are diseconomies of scale in the small acute provider in Weston, but there are also issues because of the way the CCG have supported the PFI contract at NBT which means the CCG are paying additional subsidies in to NBT. LM suggested one thing the CCG can give assurance of is that trough the control centre process in terms of looking at the savings plan through 2017/18 the CCGs have been consistent in terms of looking for opportunities. Governing Bodies: Noted the financial position, the key risks, issues and mitigations. Noted the detailed financial assessment of the financial position including the risks and mitigations undertaken at the Joint Strategic Finance Committee in January. Noted the BNSSG forecast outturn for 2017/18 is a deficit of 29.9m and net risk of 5.0m Noted the requirement of the external auditors to write to the secretary of state for health of the likely breach by each CCG to spend more than its revenue resource limit. Noted the forecast position reported to NHS England BNSSG Quality and Performance Report LM explained the key highlights within the report. A&E remains challenged across the system, still having difficult days with a number of providers in OPEL 4, whilst the system remains in OPEL 3. A number of the actions that have been taken have started to make improvements in some of the metrics that underpin A&E delivery. In regards to 18 weeks performance is at 90.14% against a trajectory of 89.3%, this is on the back of the work done in terms of maintaining flow rates in to the providers. 62 day cancer performance has been delivered across the CCG for the third month in a row; this is starting to give confidence about embedded delivery across the providers. AMo made reference earlier in terms of the visits to EDs in terms of the quality metrics and giving the CCG assurance around how the providers are coping on a daily basis in terms of the significant numbers of patients coming through. What is clear in ED performance there is around a 9% increase of admissions this year above plan and last year s position and the CCG are looking to try and understand why this is. AMo highlighted the SI reporting compliance at AWP which is consistently low and does not meet the timescale. The CCG have worked with AWP on this and have now issued a CPN and have a RAP. As a result AWP have made changes to their processes and to how their team work to meet their trajectory and the CCG will continue to monitor through the Quality Sub Group. MD talked through the constitutional standards. C. difficile performance remains below threshold for BNSSG CCGs this is due to a breach in trajected numbers for this month, and still behind trajectory in totality. There have been some mixed sex 13

14 accommodation (MSA) breaches at UHB therefore the CCG are working with the specialist commissioners to understand that. In terms of other exceptions, it was noted that WAHT is shown to have reduced the standardised hospital-level mortality indicator (SHMI) for the third quarter in a row. Although VTE compliance at national standard has not been met for WAHT as yet there performance (87%) is ahead of the trajectory the CCG set in their CPN. TM referred to page 7 of the report which notes that there has been progress in developing an Eating Disorder hub and spoke model, and asked what the model might improve and what the timescales are for recruiting for this. LM advised there is not a timescale, however the CCG will be getting a clear trajectory once staff are in post because there will be patients who will need to be seen as urgent who have been waiting longer. Once the CCG get the trajectory they will be monitoring performance on a monthly basis. AM referred to page 24 of the report and asked, in terms of the CQC action plan for AWP and the three red areas of escalation following the CQC report, what are the timescales for delivering the action plan. AMo commented that when the action plan was reviewed with AWP at the last Quality Sub Group meeting they did not have a particularly organised way of demonstrating what actions they are taking, so AWP have been given a different template to work to for the next Quality Sub Group meeting. AMo has asked AWP to link some of the good work that they are doing around patient safety, and also safer wards, to their CQC action plan. JR referred to page 4 of the report and highlighted that the consultant led follow ups activity is shown as red, and expressed the assumption that this will form part of the planning for next year. LM commented that there are two elements to note, one being that there was a very ambitious planning assumption that went in to the contracts last year which was not delivered in 2017/18, which the CCG need to follow through in 2018/19 planning assumptions and also consider how to best deliver with providers. Jeanette George (JG) referred to page 20 and the outpatient pending list for WAHT. It was noted that the backlog of patients has been cleared ahead of the agreed trajectory which has been a long standing issue. AMo commented that the Trust worked hard to achieve this, and that the Trust have been asked to write up how they have achieved this. Governing Bodies noted the performance position of the CCG and that of our key providers, including risks, mitigating actions and responsibilities as appropriate BNSSG CCG Draft Constitution Louise Rickitt (LR) attended for this item. JR introduced the draft constitution and explained that it has been through a number of iterations with colleagues, member practices, NHSE and to Governing Bodies prior to this meeting. JR expressed thanks to LR and others who have done a great deal of work to ensure that the CCG have a strong constitution to take into the new BNSSG organisation. LR informed the Governing Bodies that version two of the constitution was approved by all member practices, and some comments were received from NHSE which are reflected in version three of the document, these changes are highlighted in the cover 14

15 paper. LR advised that there is one other potential change which NHSE are revisiting, which is their desire to include committee terms of references (ToRs) in the constitution. This would mean when changes are made to ToRs the CCG would need to consult with member practices and submit a constitution variance to NHSE for approval which may potentially take several months. This has a potential impact on the flexibility of the organisation. It was noted that the hustings event for the Clinical Chair applicants is on 13 th February, and LR suggested that would be a good opportunity for member practices to all sign the constitution. DJo referred to page 45 of the constitution, the membership decision making arrangements; and expressed that he is slightly concerned that decisions will be carried by a simple majority vote. DJo has discussed this with LR previously and requested this be noted in the minutes. Governing Bodies recommended to the BNSSG GP practices that they accept the proposed constitution and join as members the new BNSSG CCG on establishment Update on the proposed CCG merger and supporting organisational arrangements LR attended for this item. It was noted the purpose of the paper is to provide assurance that there is good progress being made across all the workstreams in the merger and transition programme; and also some reassurance that there are no significant issues emerging as the CCGs approach the final stage of preparations for the proposed merger. LR referred to the bottom of page one of the paper which notes a decision is expected to be taken in mid-february by the NHSE Regional Director, Rachel Pearce, and noted it should say Jennifer Howells. It was noted that this decision is likely to be made week commencing 19 th February. LR drew attention to the update on the appointment of a Governing Body for the proposed BNSSG CCG and explained that there are no difficulties anticipated arising from this. In terms of the conditions good progress is being made. In terms of the wider transition to a single commissioning voice, a major piece of ongoing work concerned the restructuring of the organisation which is coming to the end of phase two the appointment of SMT and Executive PAs. The formal consultation for phase 3 was launched last month with staff on the proposed merger and accommodation. LR highlighted other pieces of work taking place which includes work around finance and contracts that is being led by Mike Vaughton to put in place all the systems and structures that are needed, including payroll. This work also included work around contracts and understanding and having a clear position for all contracts, including individual placements for patients, to ensure the transfer of those contracts to the new organisation is properly managed. KH asked if there are any liabilities that may have a financial implication and asked if 15

16 these will be transferred to the new organisation. LM advised that the BNSSG CCG will inherit the liabilities of the CCGs because the organisations are merging as three existing CCGs to form one, so those inherited liabilities from those pre-existing CCGs will transfer. JRu asked if the Officers of the new BNSSG CCG will be authorised to sign off the accounts of the three bodies after they cease to exist. JR confirmed that the Officers are able to sign off the accounts of the predecessing organisations as they form part of the liabilities coming into the CCG so effectively it is consolidation of a group of accounts. JG commented that the CCG have sought advice from NHSE regarding this and it is documented. JR expressed thanks to the transition team for their work. Governing Bodies noted the report Minutes of the BNSSG Sustainability and Transformation Sponsoring Board (November 2017) Governing Bodies received and noted the minutes Minutes of the BNSSG Strategic Finance Committee (December 2017) Governing Bodies received and noted the minutes Minutes of the BNSSG Quality and Governance Committee In-Common (December 2017) Governing Bodies received and noted the minutes Minutes of the North Somerset CCG Clinical Commissioning Leadership Group (November 2017) Governing Bodies received and noted the minutes Minutes of the South Gloucestershire CCG Clinical Operational Executive (November 2017 and December 2017) Governing Bodies received and noted the minutes. 13 Questions from the Public There were no questions asked. 14 Any Other Business No other business was discussed. 16

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