Governing Body Meeting

1. Governing Body Meeting Swindon CCG November 2016

2. Public Question Time • Since the CHC was dissolved by the Government, the cost of managing and commissioning items etc for the NHS has risen to such an extent that it is necessary to reconsider and reduce costs. In planning for 2017/18, what are the best ways to reduce the cost of the CCG e.g. move to smaller less expensive premises, amalgamate jobs? • There is a shortage of GPs in Swindon, why therefore are there three attending this CCG meeting when one would do? • There was a change in the law in July 2016. All visually impaired people should be receiving appointments etc in a font that they can read for themselves. Please would you check to see if this is happening and if it is not, when will VIPs be able to read their own correspondence from the hospital and from their GPs?

3. Patient’s Story

4. Steve’s concerns • Flaws and gaps within the services used by the homeless and the mental health sufferers • Difficult for sufferers to navigate the system and get immediate access to support - desire for a drop in centre for adults and young people in Swindon • If children and young people are not adequately supported through stressful and life changing situations, they will suffer as a result – desire to see 24 hour wrap around care • There are models of support that work in other towns – why can’t we do these in Swindon? • Single point of access should be more than just a website

5. What we have learnt as Commissioners • There is a requirement for better signposting and better information • Organisations not taking the time to listen and learn from what service users are saying • There is more engagement work we can do with vulnerable people to understand the difficulties people are facing in accessing services in Swindon • There is a lack of easy to access crisis support for young people and adults in Swindon

6. Papers A and B Minutes of the previous meeting held on 29 October 2016 • The Governing Body is recommended to approve the minutes. Actions arising as per the Action Log • The Governing Body is recommended to approve the Action Log.

7. Acting Clinical Chair’s Report (Paper C) • The Clinical Chair’s Report is provided to advise the Governing Body of Items which the Clinical Chair wishes to bring to the attention of The Governing Body outside of the normal agenda • The report provides updates on: • Clinical Chair recruitment update • Clinical Leadership Meeting & GP Locality Workshops • STP Clinical Reference Group • Clinical Leadership Meeting decisions • The Governing Body is recommended to review and note the contents of the report.

8. Accountable Officer’s Report (Paper D) This report outlines items of note arising over the last two months which are relevant to NHS Swindon Clinical Commissioning Group and to its health service commissioning activity on behalf of the Swindon and Shrivenham population. National issues • NHS Operational Planning and Contracting Guidance 2017-2019 • CCGs encouraged to support the Government’s Prevent Strategy • NHS England Learning Environment: new case studies added • NHS England report gives an overview of the first year of the national cancer strategy • NHS England announces nearly 300 GP premises upgrades across England • IAPT early implementers announced Local Issues • CCG’s Quarter 2 Assurance meeting • Social Media • Sustainability and Transformation Plan • The Governing Body is recommended to note the contents of the report.

9. 2 year Operating Plan 2017-18 / 2018-19

10. Key Issues faced by the health economy Our view is that the most significant issues facing the local health and care economy are as follows: • Delivery of the Five Year Forward View aspirations • Securing sustainable finances and actively pursuing efficiencies whilst maintaining high quality, safe and effective services for people in Swindon • Closing the health and wellbeing gap by focusing on inequalities within our community, reducing variation and shifting the balance in favour of prevention and self- care. • Delivery of all core access and quality standards for our patients • Facilitating the vertical integration of acute and community services • Stabilising Primary Care, providing an increased range of services and new models of care and operate at scale.

11. More urgently our focus in 2017/18 will be on: • Stabilising primary care capacity • Restoring and stabilising A&E 4 hour performance at Great Western Hospital NHS Foundation Trust • Actively managing emergency activity growth • Delivering aggregate financial balance across our health and care system • Further strengthening integration with health system partners.

12. Delivery of the 9 ‘Must Dos • Delivery of STP plans • Finance (system controls) • Primary Care (workshops to consider future models for working at scale and delivery of increased access/urgent care demand: increase capacity, workforce models: delegated commissioning and development of estates) • Urgent and Emergency Care (111 re-procurement, ED streaming, ambulatory care model, end of life care, ambulance conveyance rates, reduction in DTOCs) • Elective Care and RTT (Clinical Policies, reduction in follow ups, review of pressured specialties including dermatology, pain management and MSK) • Cancer (diagnostics capacity, delivery of national targets, increasing capacity to meet demand) • Mental Health (street triage, Psychiatric liaison and crisis services, meeting dementia requirements, review of placements, CAMHs procurement, ADHD assessments) • People with a Learning Disability (improving primary care annual health check uptake) • Improving Quality (comprehensive quality strategy)

13. Developing Accountable Care • Community Services contract awarded to Great Western Hospitals NHS Foundation Trust in 2016. Complete baseline assessment of current service provision in Q4 • Integration of acute and community services to improve pathways and continuity of care for patients • Outreach of services into community and primary care settings • Flexible workforce • Primary Care model developed • Population budgets developed in shadow • Commissioning functions reviewed and future model agreed (pooled placements budget managed through joint assessment process).

14. Swindon CCG2017/18-18/19 Financial Plan

15. Proposed Financial Plan • Financial Plan for 17/18 and 18/19 is based on the following assumptions: • Baseline allocation of £257m for 17/18 and £262m for 18/19 which includes £7m of additional funding in each year to move the CCG closer to its fair shares target • Use of the growth funding in line with national planning assumptions • Investments of £0.3m in both years for GP practice transformational support • GP Access Fund of £1.3m which will be used to cover new SUCCESS centre model offering extended primary care hours • Funding providers with sufficient growth to meet activity demands as described in the national IHAMs (Indicative Hospital Activity Model) based on previous years level of activity and local demographic growth • Set aside 1% planned to be spent non-recurrently, but only half of this has to be uncommitted at the start of the year, with the other half being available for immediate investment • Local contingency of £0.5m to cover off any in year ad-hoc risks and financial pressures • QIPP at £8.6m for 17/18 and £9.5m for 18/19 • Outturn reduced from £2.5m surplus to break even • Assuming risks of £2m materialise in 16/17 which would need to be made up in 17/18. • Cumulative 1% to be achieved across two years, have assumed 18/19 to be a breakeven year

16. Overview of 2017/18 and 2018/19 Financial Position Financial Plans for 2017/18 and 2018/19 have been derived from the national planning assumptions and funding growth at historic levels and to take account of local demographic needs. 2017/18 and 2018/19 will again be particularly challenging years financially as demonstrated by the magnitude of the QIPP target at £8.6m and £9.5m. Historically the CCG has delivered a QIPP equating to 2% of the CCG’s overall allocation or circa £5m with the exception of 2016/17, when the CCG set a stretching target of £8.4m and at month 06 is forecasting 85% achievement. Note: 16/17 outturn assumes risks of £2m will materialise

17. Planning Assumptions • Planning assumptions include: • Allocation growth based on estimated revised allocations which equate to uplifts of: • 1718- 2.67% • 1819- 2.57% • Net tariff uplift of 2.1% less efficiency of -2.0% • Prescribing uplift at 7% in line with national • Need to set aside 1.0% as a national reserve of which 0.5% remains uncommitted • Contingency of 0.5% to cover ad hoc risks in year • Growth reflects historic activity levels plus increase in funding allocation to reflect local demographic changes

18. Activity Assumptions

19. Investments The CCG has assumed a number of investments in its 1718 and 1819 plans. Further work is underway to establish current and potential future commitments: Street Triage service, Community Navigator, review of Children’s Services, CAMHS, Eating Disorders and Psychiatric Liaison.

20. QIPP 17/18 and 18/19 QIPP schemes currently being worked up. For 171/18 the CCG has identified potential schemes of £13m vs target of £8.6m

21. Risks

22. NHSE Capital Capital ETTF Bids

23. Swindon CCG Constitution Updates(Paper F) At its last meeting, the Governing Body considered a report outlining indicative changes to the CCG Constitution. Whilst there have been minor amendments to the Constitution since the CCG’s authorisation, a fundamental refresh is regarded as necessary in order to ensure that the Constitution remained up to date and fit for purpose. This paper provides an update as to the progress made in relation to the review of the CCG’s Constitution that is currently being undertaken. Once the final re-drafting has taken place, the Constitution will be circulated to the membership for consultation and endorsement mid-November. It is envisaged that at this point a vote around delegated commissioning or co- commissioning would be taken which would be built into the Constitution. The Constitution will then be presented to the Governing Body in December for final ratification prior to submission to NHS England for approval. • Governing Body is recommended to note the report

24. Winter Planning(Paper G) During winter 2015/16 the urgent care system experienced another tough winter with high levels of demand and acuity. This put considerable pressure on services trying to cope and deliver good quality and safe services for patients. During 2016/17 we have continued to see high demand on our non-elective services, with our acute trust declaring black escalation status during those months we would have traditionally not expected to see this status being declared. The CCG are required to write a plan clearly outlining and providing assurance that the whole system is prepared to meet expected demand during the winter months, have the additional capacity in place to care for all patients both when admitted to hospital but also when they are able to be discharged and ultimately is able to be resilient throughout the winter period. This document, written in collaboration with providers, incorporates their expected demand profiles, outlines lessons learnt from quarter three and four from 2015/16. It details the operationally implemented changes and resilience measures to support the highest possible care delivery within financial constraints. • Governing Body is recommended to note the plan

25. Clinical Priorities – STP alignment(Paper H) Aim : Alignment of commissioning policies and process across the STP by 1/4/17 Proposal we are taking to Governing Body: • Alignment of the first 7 policies across BaNES, Swindon and Wiltshire for Abdominoplasty and Apronectomy, use of Botox, Bunions, Cataracts, Ganglia, Ear Micro-Suction and Tonsillectomy • Clinical input to agree these policies has included the Clinical Effectiveness team and GP representation across all 3 CCGs • CLG approved the revisions to the above 7 policies with further work to be carried out to align the Varicose Vein policy and Breast policies • CLG noted additional preparation work to support new policies for: Cataracts - additional education to take place with the Optometrists Ear micro-suction - confirmation of the provision of Ear Syringing within Primary Care • CLG approved commencement of engagement with Health Watch in relation to alignment of IVF policy

26. Benefits / impact of this approach • Single view of application of best practice guidance locally • Patients can easily access policies which will be consistent across county borders • Policies accompanied by forms to guide patient referrals to right service first time • Simplicity in application of policies for acute hospitals • Improved economies of scale and resilience of Referral Management Resources across the STP • Improved value for money for commissioning spend

27. Next Stages • Phased discussions for alignment of policies due to volume of policies and necessary clinical time to discuss; further reviews and recommendations over latter part of 2016/17 • Engagement with Health Watch and PPI Forum prior to formalising policy changes • Development of SCCG web-site for easy access to policies and referral forms • Development of our Referral Support Service function to support greater use of e-referrals and manage health community capacity and demand through informed ‘Choice’ discussions

28. Integrated Quality, Performance and Finance Report (Paper I) This report provides an integrated view on the quality, performance and finance of Swindon CCG. There is an overview of the quality of services commissioned including information relating to patent safety and experience, as aligned to the relevant CCG assurance domains. The report identifies examples of best practice, together with any identified key areas of concern or trends in reporting. The CCG assurance framework recognises that assurance is a continuous process that considers the breadth of a CCG’s responsibilities. For the purpose of this report the following components of the CCG assurance domains have been considered: 1. Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; 2. Better Care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas; 3. Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; 4. Leadership: this domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest. • The Governing Body is recommended to note the contents of the report.

29. Assurance Framework • Overall Rating of ‘Requires Improvement’ across the 4 domains: • 1 rated as ‘green/good’: Better Health • 3 rated as ‘amber/requires improvement’: Better Care, Sustainability & Leadership • Better Health: good on appropriate prescribing and managing people with Falls. Need to improve on treatment of people with diabetes • Better Care: good on providing specialist treatment for patients with learning disabilities and autism plus low level of still births. Poor on treating people within 18 weeks and diagnostics within 6 weeks. Deep dive service reviews have identified issues over coding and capacity which are being addressed. Trajectories seeing improvements in these areas over next few months and confidence that targets will be achieved on sustainable front by April 17. A&E more of a concern with target not being met and less confidence given current pressures on achievement. • Sustainability: CCG currently forecasting it can deliver its target surplus at year end but with risks at £3.5m and additional ad hoc pressures in year from SEQOL closedown and FNC, very unlikely that this position is sustainable. Reporting high performance vs QIPP at over 88% YTD • Leadership: much work has been done on Governance including reviewing Constitution and establishing a Risk Management Panel. Further public engagement on the APMS provision and CCG using social media

30. Six Clinical Priorities • Performing well on Learning Disabilities and Mental Health • Need improvement in: • Cancer: 2 week wait target breached in dermatology; recovery plan developed and signed off • Diabetes: working on educating patients and improving practice data recording • Maternity: low score (57%) on choices offered to women in Maternity services. CCG is working to improve as part of SW Maternity Network and are proposing to run a consultation event with local women on maternity choice offered by providers. • Greatest need for improvement: • Dementia: specific project support to work with practices to ensure data is being uploaded. Additional funding to Memory Clinic for x2 staff to sustain work on assessment/diagnoses. Dementia Specialist Team to assist with data gathering.

31. Committee Reports for noting (Paper J) • Clinical Leadership Group: 13 October May 2016 • IGC: 8 September 2016 • Audit Committee: 8 September 2016 • Joint Primary Care Committee: 6 July 2016 • PPI Forum: 25 July 2016 • A & E Delivery Board: 17 August and 21 September 2016 • The Governing Body is recommended to note the contents of the minutes from the meetings.

32. Date of next meeting Date: Thursday 15 December, 2016 Venue: CCG HQ Time: 09:30 – 12:00