NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Bodies Meeting in Common to be held in Public on Thursday, 14 September 2017, 2:15 pm to 4:30 pm at Coventry Rugby Club, The Butts Park Arena, Coventry A G E N D A

Time Item Presenter Enclosure No

1. Standing Items

2.15 1.1. Welcome and Apologies Received AC-P Verbal

1.2. Declarations of Interest: Where possible, any conflict AC-P Enclosure A of interest should be declared to the Chair of the meeting in advance of the meeting. See guide below. 2.20 1.3. Minutes of the last Public Meeting in Common held in AC-P Enclosure B Public held on 13 July 2017 2.25 1.4. Matters Arising/Action Schedule DS Enclosure C 2.30 1.5. Chair’s Report a) Coventry and Rugby CCG AC-P Enclosure D b) Warwickshire North CCG DS Enclosure E 2.40 1.6. Chief Officer’s Report AG Enclosure F 2. Strategy and Planning 2.45 2.1. Director of Public Health Annual Report (Vulnerable JL Enclosure G/ Groups) Presentation 3.00 2.2. Commissioning Intentions 2018/19 JN Presentation 3.10 2.3. Public Health Update a) Coventry and Rugby LG Enclosure H b) Warwickshire JL Enclosure I 3.20 2.4. Communications and Engagement Report: July 2017 JN Enclosure J 3. Quality, Safety and Performance 3.25 3.1. Integrated Safety, Quality and Performance: Enclosure K  Safety and Quality Report GW/JG  Performance Report SJ-D

4. Financial Performance 3.35 4.1. Finance and Contract Report: Month 4 CH a) Coventry and Rugby CCG Enclosure L b) Warwickshire North CCG Enclosure M 3.45 4.2. Procurement Update CH Enclosure N 5. Assurance and Governance 3.50 5.1. Draft CCG Response to the Modern Slavery Act MM Enclosure O 2015 3.55 5.2. WNCCG Annual Report from the Audit Committee to DA Enclosure P Time Item Presenter Enclosure No

the Governing Body

6. Policies for Ratification 4.00 6.1. Corporate Policies: MM Enclosure Q Management of Conflicts of Interest Policy 4.10 6.2. Clinical/Commissioning Policies: a) Diagnosis and Management of Chronic Fatigue SA/CP Enclosure R Syndrome (CFS) and Myalgic Encephalomyelitis (ME) b) Bariatric Surgery Enclosure S

c) Treatments designed to improve aesthetic Enclosure T

appearance d) Rhinoplasty/Septorhinoplasty Enclosure U e) Functional Electrical Stimulation (FES) Enclosure V f) Female Genital Prolapse Enclosure W g) Arthroscopy of knee joint (diagnostic/therapeutic) Enclosure X h) CRCCG Consultant to Consultant SA/CP Enclosure Y

7. Committee Reports for Information 7.1. Coventry and Rugby CCG Committee Enclosure Z a) Clinical Quality and Governance Committee, 24 Chairs May 2017, 28 June 2017 and 26 July 2017 b) Clinical Development Group, 27 June 2017 and 25 July 2017 c) Finance and Performance Committee, 26 June 2017 and 24 July 2017 Warwickshire North CCG

a) Audit Committee: 24 April and 26 May 2017 Committee Enclosure AA b) Commissioning Finance and Performance Chairs Committee: 22 June 2017 and 27 July 2017 c) Clinical Quality, Safety and Governance Committee: 22 June 2017 and 27 July 2017 Other d) Health and Wellbeing Board – Warwickshire, 26 July 2017 e) Health and Wellbeing Board – Coventry, 10 April 2017 f) Health and Wellbeing Board – Coventry, 10 July 2017 4.15 8. Questions from Visitors DS Verbal 4.25 9. Any Other Business DS Verbal

Future Governing Body Meeting in Common held in Public: Date Time Venue Thursday 09 November 17 10.30 am - 12.30 pm Heron House, Nuneaton

Wednesday 10 January 18 2.15 pm – 4.30 pm Coventry, Venue TBC

Thursday 08 March 18 10.30 am - 12.30 pm Heron House, Nuneaton

o

Declarations of Interest

Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. Where possible, any conflict of interest should be declared to the Chair of the meeting as soon as it is identified in advance of the meeting. Where this is not possible, it is essential that at the beginning of the meeting a declaration is made if anyone has any conflict of interest to declare in relation to the business to be transacted at the meeting. An interest relevant to the business of the meeting should be declared whether or not the interest has previously been declared.

Type of Description Interest

Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could include being:

 A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations;  A shareholder (of more than 5% of the issued shares), partner or owner of a private or not for profit company, business or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.  A consultant for a provider;  In secondary employment;  In receipt of a grant from a provider;  In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and  Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional reputation or Interests status or promoting their professional career. This may include situations where the individual is:  An advocate for a particular group of patients;  A GP with special interests e.g., in dermatology, acupuncture etc.  A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);  An advisor for CQC or NICE;  A medical researcher. Non-Financial This is where an individual may benefit personally in ways which are not directly linked to their Personal professional career and do not give rise to a direct financial benefit. This could include, for Interests example, where the individual is:

 A voluntary sector champion for a provider;  A volunteer for a provider;  A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;  A member of a political party;  Suffering from a particular condition requiring individually funded treatment;  A financial advisor. Indirect This is where an individual has a close association with an individual who has a financial Interests interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). This should include:  Spouse / partner;  Close relative e.g., parent, [grandparent], child, [grandchild] or sibling;  Close friend;  Business partner.

Enclosure A: Register of Interests - Governing Body - September 2017

All actions in response to declared conflicts of interests are at the discretion of the Chair

(Note: all members of staff have an interest in both NHS Coventry and Rugby CCG and NHS Warwickshire North CCG)

Current Position(s) held in CCG, ie. Governing Body Declared Interest (Name of the organisation and Title First Name Last Name member, Committee member, Member Practice; CCG Type of interest Date of Interest Action taken to mitigate risk Comment nature of the business) employee or other

From To

Indirect

Personal

Financial

Professional

Non-financial Non-financial

CR CCG Members:

Dr Adrian Canale-Parola Chair Nil Jan-17 to date No actions required.

Chief Officer, Coventry and Rugby CCG and Ms Andrea Green Nil Sep-16 to date No actions required. Warwickshire North CCG

Withdrawal from debate and / or decision on commissioning a Dr Steve Allen Clinical Director Partner, Walsgrave Health Centre, Coventry  Apr-15 to date service that could be delivered by these organisations.

Practice is member of GP Alliance  Nov-16 to date

Chief Finance Officer, Coventry and Rugby Mrs Clare Hollingworth Nil Apr-17 to date No actions required. CCG and Warwickshire North CCG

Chief Nursing Officer, Coventry and Rugby Ms Jo Galloway Nil Sep-17 to date No actions required. CCG and Warwickshire North CCG Current Position(s) held in CCG, ie. Governing Body Declared Interest (Name of the organisation and Title First Name Last Name member, Committee member, Member Practice; CCG Type of interest Date of Interest Action taken to mitigate risk Comment nature of the business) employee or other

From To

Indirect

Personal

Financial

Professional

Non-financial Non-financial

Consultant Anaesthetist, Northampton Withdrawal from debate and / or decision on commissioning a Dr Prashant Kakodkar Secondary Care Consultant  May-15 May-15 General Hospital service that could be delivered by these organisations.

Consultant Anaesthetist, Three Shire Hospital,  May-15 May-15 Northampton

Further declarations to be made on any specific areas identified Special Advisor, Care Quality Commission  Sep-16 Sep-16 which impact on CRCCG.

Further declarations to be made on any specific areas identified Examiner, The Royal College of Anaesthetists  May-15 May-15 which impact on CRCCG.

Local Negotiating Committee Member,  Dec-16 Dec-16 No actions required. Northampton General Hospital

Lay Member, Audit and Governance (Deputy Withdrawal from debate and / or decision on commissioning a Mr Peter Maddock Associate with Capita  May-15 to date Chair) service that could be delivered by this organisation.

Lay Member, Public and Patient Involvement Senior Manager, South Central Ambulance Withdrawal from debate and / or decision on commissioning a Mr Ludlow Johnson  Jun-16 to date and Health Inequalities Service service that could be delivered by this organisation.

Further declarations to be made on any matters that may Specialist Advisor, Care Quality Commission  Jun-16 to date impact on the CCG.

Further declarations to be made on any matters that may Magistrate  Jun-16 to date impact on the CCG.

Expired, archive Lay Member, Public and Patient Involvement Further declarations to be made on any specific areas identified Mrs Pamela Sampson Carer to husband and son  Apr-15 to date end of (left the CCG 30/06/2017) which impact on the CRCCG. December 2017

Expired, archive Further declarations to be made on any specific areas identified Member of Coventry Carers Centre  Apr-15 to date end of which impact on the CRCCG. December 2017

Withdrawal from debate and / or decision on commissioning a Dr Peter O'Brien Locality Lead, InSpires GP Partner at Forrest Medical Centre.  Apr-15 to date service that could be delivered by these organisations.

Practice is ordinary member of GP Alliance  Oct-16 to date Current Position(s) held in CCG, ie. Governing Body Declared Interest (Name of the organisation and Title First Name Last Name member, Committee member, Member Practice; CCG Type of interest Date of Interest Action taken to mitigate risk Comment nature of the business) employee or other

From To

Indirect

Personal

Financial

Professional

Non-financial Non-financial

Withdrawal from debate and / or decision on commissioning a Dr Sarah Raistrick Locality Lead, Godiva GP Partner Willenhall Primary Care Centre 1  Dec-16 to date service that could be delivered by these organisations.

Practice is a member of the GP Alliance  Dec-16 to date

Withdrawal from debate and / or decision on commissioning a Dr Deepika Yadav Locality Lead, Rugby Salaried GP, Forrest Medical Centre  Apr-17 to date service that could be delivered by this organisation.

Further declarations to be made on any specific areas identified Husband is GP, Locum  Apr-17 to date which impact on CRCCG.

CRCCG Co-opted (Non-voting):

Dr John Linnane Director of Public Health Warwickshire Nil Apr-15 to date No actions required.

Ms Liz Gaulton Acting Director of Public Health Coventry Nil May-17 to date No actions required.

WNCCG Members (Voting):

1. Partner at Dordon and Polesworth Group  2005 Current Practice

2. Dordon and Polesworth Group Practice is a  Current member of Primary Care Warwickshire Federation Withdrawal from debate on commissioning a service that could Dr Deryth Stevens CCG Chair/GP  be delivered by these organisations. 3. A business partner at Dordon and 2016 Current Polesworth Group Practice has a financial interest in Linden Nursing Home Group

4. Practice provides services to nursing home  in CCG Current

Chief Officer, Coventry and Rugby CCG and Ms Andrea Green Nil Sep-16 to date No actions required. Warwickshire North CCG

Chief Finance Officer, Coventry and Rugby Mrs Clare Hollingworth Nil Apr-17 to date No actions required. CCG and Warwickshire North CCG Current Position(s) held in CCG, ie. Governing Body Declared Interest (Name of the organisation and Title First Name Last Name member, Committee member, Member Practice; CCG Type of interest Date of Interest Action taken to mitigate risk Comment nature of the business) employee or other

From To

Indirect

Personal

Financial

Professional

Non-financial Non-financial

Lay Member for Audit and Governance Mr David Allcock (previously Lay Member for Public and Patient Nil Engagement)

1. GP at Camphill GP led Health Centre  Withdrawal from debate on commissioning a service that could Dr Godwin Igodo Clinical Lead to date be delivered by these organisations. 2. Director at Ripples Healthcare 

1. GP at Station Street Surgery   Withdrawal from debate on commissioning a service that could Dr Arshad Khan Clinical Lead 2. GP Torcross Medical Centre, Coventry   to date be delivered by these organisations. 3. Locum at Recovery Partnership  

1. 50% Shareholder of Graham Nuttall Further declaration to be made on any specific projects 14/09/2015 Current Associates Ltd identified which will impact on the CCG. Mr Graham Nuttall Lay Member - Primary Care  2. Trustee and Board Member at Bulkington Withdrawal from any debate in which Bulkington Village Centre 14/09/2015 Current Village Centre is being considered. ü

1. Consultant (Locum Consultant Physician) Withdrawal from debate on commissioning a service that could Dr Chris Pycock Secondary Care Consultant for South Worcestershire Health and Care Dec-14 Current  be delivered by this organisation. (Community) NHS Trust

Advanced Nurse Practitioner at Bulkington Withdrawal from debate on commissioning a service that could Sue Turner Clinical Lead  Jul-05 Current Surgery be delivered by the Practice.

Withdrawal from debate on commissioning a service that could Current 1. GP at Woodlands Surgery  be delivered by the Practice.

2. Practice participates in the One Thing Withdrawal from debate on payments relating to One Thing  Current Campaign to undertake Health Checks Campaign Health Checks Dr Inayat Ullah Clinical Lead 3. Partner at Longford Primary Care Centre, Withdrawal from debate on commissioning a service that could  Current Coventry be delivered by the Practice.

4. Urgent Care George Elliot Hospital Withdrawal from debate on commissioning a service that could  Current be delivered by the service.

Chief Nursing Officer, Coventry and Rugby Ms Jo Galloway Nil Sep-17 to date No actions required. CCG and Warwickshire North CCG

WNCCG Co-opted (Non-voting):

Joint role with Warwickshire North CCG and Ms Rachel Robinson Consultant in Public Health ü Current No action required Warwickshire County Council Current Position(s) held in CCG, ie. Governing Body Declared Interest (Name of the organisation and Title First Name Last Name member, Committee member, Member Practice; CCG Type of interest Date of Interest Action taken to mitigate risk Comment nature of the business) employee or other

From To

Indirect

Personal

Financial

Professional

Non-financial Non-financial

Attendees: Chief Operating Officer, Coventry and Rugby Further declarations to be made on any specific project Mrs Debbie Pook Director - DP Management  Nov-16 to date CCG and Warwickshire North CCG identified which will impact on the CCG. School Governor  Nov-16 01-Apr-17 No actions required. COO has advised that sister has put arrangements in place Sister Care Quality Commission (CQC)  Nov-16 to date with CQC to avoid inspections that may have implications for Inspector the CCG. Chief Strategy and Primary Care Development Ms Jenni Northcote Officer, Coventry and Rugby CCG and Nil Apr-17 to date No actions required. Warwickshire North CCG

Deputy Director of Corporate Affairs, Coventry Mrs Maria Maltby Nil Sep-17 to date No actions required. and Rugby CCG and Warwickshire North CCG

Mr Steve Jarman-Davies Director of Acute Contracting and Performance Nil to date No actions required. Enclosure B

Unconfirmed Minutes of the Governing Body Meeting in Common Held in Public on Thursday 13 July 2017

Venue: Heron House, Newdegate Street, Nuneaton, CV11 4EL, 9:00am - 10:30am.

Present: Governing Body Members

Dr Deryth Stevens Chair - WNCCG DS Dr Adrian Canale-Parola Chair - CRCCG AC-P

Andrea Green Chief Officer – WNCCG and CRCCG AG

Dr Steven Allen Clinical Director - CRCCG SA (From item 2017/09)

Sue Turner Practice Network Lead: North Warwickshire - WNCCG ST Dr Inayat Ullah Practice Network Lead: Nuneaton and Bedworth - WNCCG IU

Dr Chris Pycock Secondary Care Doctor - WNCCG CP

Dr Arshad Khan Clinical Lead - WNCCG AK

Dr Godwin Igodo Clinical Lead - WNCCG GI

Dr Deepika Yadav Rugby Locality Lead - CRCCG DY

Graham Nuttall Lay Member - Primary Care - WNCCG GN

Ludlow Johnson Lay Member for Patient and Public Involvement and Equality - CRCCG LJ

Rebecca Bartholomew Director of Nursing - WNCCG RB

Glynis Washington Director of Nursing - CRCCG GW Clare Hollingworth Chief Finance Officer – WNCCG and CRCCG CH

Also in attendance:

Jenni Northcote Chief Strategy and Primary Care Officer - WNCCG and CRCCG JN

Debbie Pook Chief Operating Officer - WNCCG and CRCCG DP

Maria Maltby Head of Corporate Affairs - WNCCG MAM

Jenny Horrabin Deputy Director of Corporate Affairs - CRCCG JH

John Linnane Director of Public Health, Warwickshire JL

Rachel Robinson Consultant in Public Health Medicine - WNCCG RR

Jane Fowles (on behalf of Consultant in Public Health Medicine - CRCCG JF Liz Gaulton)

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Nadia Inglis Consultant in Public Health Medicine – Warwickshire County Council NI

Julie Seaborne Governance and Corporate Officer - CRCCG JS

HC Heather Kelly Senior Commissioning Manager (Targeted Care) Apologies:

David Allcock Lay Member for Audit and Governance - WNCCG DA

Peter O’Brien Clinical Locality Lead, Inspires - CRCCG POB

Sarah Raistrick Clinical Locality Lead (Godiva) - CRCCG SR

Peter Maddock Lay Member for Governance - CRCCG PM Liz Gaulton Director of Public Health, Coventry - CRCCG LG

Prashant Kokodkar Secondary Care Specialist Consultant - CRCCG PK

Item Action No: 1. Standing Items

1.1 Welcome and Apologies

Dr Stevens welcomed Members of both Governing Bodies and public attendees to the first meeting in common. She explained that the venue for future meetings would alternate between Thursdays at Heron House and Wednesdays at a venue in Coventry, however, the next meeting was planned for Thursday 14 September due to the Annual General Meeting (AGM) for Coventry and Rugby CCG (CRCCG) taking place on Wednesday 13 September. She added that individual decisions to be made by each CCG would be led by the respective CCG Chair.

Apologies were noted as indicated above.

1.2 Declarations of Interest:

Members were reminded of the need to declare their interest in any items requiring a decision and to remove themselves from such decision making.

No declarations relating to the agenda were made.

1.3 Minutes of the Last Meetings Held In Public:

(A) Coventry and Rugby CCCG – Wednesday, 10 May 2017 Dr Canale-Parola presented the minutes of the last Governing Body minutes for NHS Coventry and Rugby CCG held on 10 May 2017 and these were agreed as a true and accurate record.

(B) Warwickshire North CCG – Thursday, 11 May 2017 Dr Stevens presented the minutes of the last Governing Body minutes for NHS Warwickshire North CCG held on 11 May 2017 and these were agreed as a true and accurate record.

1.4 Matters Arising And Action Schedule:

(A) Coventry And Rugby CCG

Matters Arising There were no Matters Arising from the minutes of the NHS Coventry and Rugby Governing Body held on 10 May 2017.

Action Schedule 15.5.17 (913) - Ms Northcote to ensure that the CRCCG website is up to date in terms of the links to Governing Body papers and Patient Voice events. It was confirmed that this had been actioned. 2

Item Action No: .Warwickshire North CCG

Matters Arising There were no Matters Arising from the minutes of the NHS Warwickshire North CCG Governing Body held on 11 May 2017.

Action tracker 3 – Updated GEH Discharge Policy: policy awaiting ratification and formal sign off. Copy to be provided to Patient Group Forum and Members Engagement Meeting when available. It was confirmed that this had been actioned.

29 - Public Health session for GPs to be organised. This was ongoing and a date yet to be confirmed.

31 – 62 days urgent GP referral to first definitive treatment to cancer target: Dr Stevens and Ms Bartholomew to meet to discuss the actions to be taken to address the non-achievement of the target. This issue had been discussed at the CCG’s Governing Body Development Session. A deep dive was in process which would be reviewed and it was noted that more recent data had shown that this situation had improved.

32 – Community Audiology Provision: Ms Northcote to discuss the issues raised at the Patient Group Forum with Mr Orton. Ms Northcote had raised this issue with the commissioner and received assurance from them that progress was being made.

1.5 Chair’s Report:

(A) Coventry and Rugby CCG: Dr Canale-Parola presented his Chair’s Report for NHS Coventry and Rugby CCG and drew attention to the following items within this report:

Rugby Joint Health and Wellbeing Partnership Group Dr Canale-Parola confirmed that July 2017 had seen the re-launch of the Rugby Joint Health and Wellbeing Partnership Group (formerly the Rugby Locality Partnership Group). The group had been established when the CCG came into being, in order to provide a multidisciplinary forum for exchange of ideas and information re local issues, and to suggest local innovations and operational solutions to meet the overall CCG strategy. Due to staffing and other issues, Coventry and Rugby CCG were no longer able to support the group into this financial year, but the members had been keen for the forum to continue, and Public Health Warwickshire, through Rachel Robinson, agreed to take over the support role. The membership drew from local stakeholders such as County and Borough Council members, CCG, Social Services, Warwickshire CAVA, Community Services including Mental Health, Public Health, local Primary Care, Healthwatch, Chaplaincy (representing all faith groups), and Warwickshire Racial Equalities Partnership, and the Group would continue to aim to achieve its purpose by aligning the strategic direction of the various bodies, prioritising actions and presenting clear plans of what would be done locally to address needs, improve health and reduce health inequalities.

Coventry Health and Wellbeing Board update Dr Canale-Parola reported that issues of interest from the recent meeting of Coventry Health and Wellbeing Board (HWBB) were:  Dr Canale-Parola’s re-appointment as Vice Chair for a further 12 months  Continuation of Coventry as a Marmot City, working in partnership with the Marmot Programme to reduce health inequalities across the city. Improvements in health and society were already apparent as a result of this work, including a reduction in the gap in male life expectancy between the most and the least deprived, improvements in educational attainment, employment, life satisfaction, and reductions in crime in priority locations.  Continuing commitment to support the STP, and to understand the need for system working and thus work more closely with Warwickshire HWBB, in order to promote the best outcomes for our resident population  New monies to support the BCF (now termed the Improved Better Care Fund – iBCF), specifically to be used to meet adult social care need, to provide support to the NHS (especially through application of the 8 High Impact Changes), and to sustain the social care provider market 3

Item Action No: Constitutional changes Dr Canale-Parola stated that Coventry and Rugby CCG were progressing with proposed changes to its constitution, to reflect joint working with WNCCG and to include changes to the voting system. Member practices had been fully consulted, and the CCG was currently awaiting the final membership vote in order to allow us to effect the changes.

NHS Coventry and Rugby CCG Governing Body members NOTED the Chair’s Report.

(B) Warwickshire North CCG Dr Stevens presented her Chair’s report for NHS Warwickshire CCG and drew attention to the item in respect of an update for the Warwickshire Health and Wellbeing Board. The June 2017 development sessions of Warwickshire HWBB had focused on how to achieve the best strategic alignment and engagement. How to best design services that meet the population needs as indicated by the placed based local profiles being developed by Public Health. How as a board it could commit to embrace the Partnership Principles working with colleagues in both Health and Social care and more widely to drive change.

NHS Warwickshire North CCG Governing Body members NOTED the Chair’s Report.

1.6 Chief Officer’s Report

Ms Green presented the Chief Officer’s Report to advise both Governing Bodies of activity since the July 2017 meeting:

CCG duties in respect of Emergency Preparedness Resilience Response (EPRR) Ms Green reported that the CCGs had a duty as a Category 2 responder within the Civil Contingencies Act 2004, to have plans in place in respect of emergency preparedness, resilience and planning, and in the case of an incident to ensure cooperation and information sharing between all emergency resilience partners across Coventry and Warwickshire.

During June 2017 the CCGs had reviewed the actions taken over the last 12 months to enable them to meet statutory obligations, this included sharing the 24/7 on-call arrangements in place, staff training in emergency preparedness and planning; desk top exercises to test CCG plans and resilience and information and learning from the recent terror and cyber major incidents. The CCG sub-committee responsible for Governance in each CCG had received a full report to provide assurance of the activities and compliance with statutory duties.

The CCGs would be required to complete an annual self-assessment against the Core Standards for EPRR and to submit the assessment to NHS England (NHSE) by 15 September 2017. Given the timing of submission, Ms Green requested that both Governing Bodies approve to delegation of authority to the Chief Operating Officer to sign the self assessment off for submission. The respective self-assessments would then be presented to the appropriate sub- DP committees.

Better Health, Better Care, Better Value (Sustainability and Transformation Plan) update Ms Green reported that during May and June 2017, along with other local NHS, she had been reviewing and progressing how to start to gain broader understanding and involvement in the priority areas that needed to transform if they were to be able to meet the changing needs of the population.

One of the key actions to address was to build confidence, understanding and participation in what the 5 year planning was aiming to achieve. Ms Green had led local Councillor events in both Warwickshire County Council and Coventry City Council to raise awareness of how the NHS worked, the challenges faced in both health and social care such as the changing nature of demands and workforce gaps, and why the service offer needed to be transformed, as well as being really clear that if this was to be achieved as quickly as the population need, their help was needed.

Ms Green confirmed that proposals for improving stroke care were nearing finalisation, and in mid-July 2017 had started another phase of engagement with the public and key stakeholders on the revised proposals which now included proposals for primary prevention of strokes and equitable provision of specialist stroke rehabilitation care.

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Item Action No: Ms Green reported that there had been some misleading media reporting which was being addressed. Ms Green said that this was regrettable but had raised awareness of the engagement programme. As part of the activities over the next 2 weeks, there were 4 public events planned in each of the core population areas. The Clinical and Operational leads in each stroke service who had worked on the Stroke Stakeholder Board had been engaging with their staff on the proposals in an effort to ensure that they can also have their say at this time. The aim was to get a really rich picture of local views about the proposals to take into account in determining what was next for achieving the improvements to save more lives and reduce disability after a stroke.

Ms Green said that improvements were being finalised in out of hospital care, this was the culmination of all the work completed over the last few years where the public, patients and staff had continually helped to shape how to get better outcomes by integrating services in the community, wrapping around general practices.

Assurance for NHS Coventry and Rugby CCG - review by the Good Governance Institute Ms Green reported that as a form of external assurance for the Governing Body, within her report she had attached the independent review commissioned from the Good Governance Institute in respect of the CCGs achievement of actions to improve capacity and capability.

Appointment of Chief Nurse Ms Green announced that the CCGs had successfully recruited Jo Galloway as Chief Nurse who would be taking up her post in September 2017. Ms Galloway was currently working in Worcestershire in a similar role and had worked in Coventry and Warwickshire previously.

End of Life Care improvements in Warwickshire North Ms Green informed members that Warwickshire North CCG had been leading a programme to improve end of life care offer for local people. Some of the needs for improvement had come from the CCG’s Vision for Quality, some from the Health and Wellbeing Strategy, some from local Councillor views and some from the teams providing services.

The CCG was at the stage of bringing this together into a business case to be presented to the NHS Warwickshire North Commissioning Finance and Performance Committee shortly. The proposals would be presented at the meeting today, but Ms Green sought agreement for the decision on the business case to be delegated to the Commissioning, Finance and Performance Committee so that the CCG could start to make progress on any improvements agreed.

Ms Northcote and Ms Kelly gave a presentation to members on the End of Life business case.

The Coventry and Rugby CCG and Warwickshire North CCG Governing Bodies:

 NOTED the Chief Officer’s Report.  APPROVED the delegation to the Chief Operating Officer to sign the EPRR submission off for submission to NHS England.

Warwickshire North CCG Governing Body:  APPROVED the delegation of the decision on the End of Life Care business case to the Commissioning, Finance and Performance Committee.

Dr Allen arrived at 11.02 am

2.1 Five Year Forward View And Delivery Plan:

Ms Green presented this report summarising the key delivery requirements in respect of the Five Year Forward View Next Steps document, including Executive Lead for each action. Ms Green confirmed that the Next Steps document had been published in March 2017 and set a challenging two year delivery plan for CCGs and other partners in the health system.

The Coventry and Rugby CCG and Warwickshire North CCG Governing Bodies NOTED the Five Year Forward View and Delivery Plan.

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Item Action No: 2.2 Communications and Engagement Report: May and June 2017

(A) Coventry And Rugby CCG Ms Northcote presented this report to provide an overview of communications and engagement activity undertaken during May and June 2017. She confirmed that at the start of each financial year an additional section would be added to the report. This would identify areas for improvement regarding the performance of communication and engagement channels. It would be informed by ongoing evaluation of techniques and activities and would suggest areas of focus for the next 12 months.

The Coventry and Rugby CCG Governing Body NOTED the Communications and Engagement Report.

(B) Warwickshire North CCG Ms Northcote presented this report to provide an overview of communications and engagement activity undertaken during May and June 2017. Ms Northcote confirmed that the CCG had continued to undertake a full range of communications and engagement activity during March and April 2017. The highlights for this period were detailed in the written report and included:

 Patient Group Forum  Social media developments  Annual report  Media releases and updates  Stakeholder / partner communications  Dordon Big Day Out public engagement

The Warwickshire North CCG Governing Body NOTED the Communications and Engagement Report.

2.3 Out Of Hospital Contract Award

Mrs Hollingworth presented this report to obtain Governing Body approval to progress the Out of Hospital Programme by appointing a Lead Provider via a Direct Award Process.

Mrs Hollingworth advised that the Out of Hospital (OoH) Programme represented a significant component of the Health strategies for Warwickshire North CCG and Coventry and Rugby CCG and for the Coventry and Warwickshire Better Care, Better Health, Better Value Partnership Plan. It was underpinned by extensive public, patient and stakeholder engagement and sought to address the structural, cultural and professional barriers to delivering person centred care.

Mrs Hollingworth confirmed that the clinical model and outcomes commissioned would be consistent across Coventry and Warwickshire but the underpinning contracts would be based on geographies that people identify with as ‘places’. The rationale of this approach was that the lead providers would be able to tailor the operational delivery of the clinical model to the place and allow them to redistribute their resource (human and financial) in a way that reflected the different health needs of each population; different service provision and different historical levels of resourcing. Contracts at place level would provide the CCGs and their populations with a higher degree of transparency than a single contract when reviewing how the lead provider was redistributing resource, and how effective it was in delivering the outcomes.

Mrs Hollingworth advised that the OoH Programme Board was seeking approval to progress the Coventry component of the OoH Programme by developing a lead provider contract with Coventry and Warwickshire Partnership Trust (CWPT) via a Direct Award and also approval to progress the Warwickshire North and Rugby components of the OoH Programme by developing a lead provider contract with South Warwickshire Foundation trust (SWFT) Coventry and Warwickshire Partnership Trust (CWPT) via a Direct Award.

Dr Allen stated that he felt this was a positive approach in terms of direction of travel as long as the CCGs’ providers were willing to work with the same aim. Ms Green agreed that primary care, along with the patient, was at the heart of the model and this would be addressed at the mobilisation phase.

6

Item Action No: Dr Linnane commented that from a prevention point of view this work would link to the STP and although there was a lot of work to do in terms of cultural change he agreed that this was a very good start.

Dr Allen also talked about the organisations’ approach to information sharing which was the best way forward for patients. Dr Ullah drew attention to information sharing in his locality and suggested that the learning could be replicated across other areas.

NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Bodies:

 APPROVED the recommendation to progress the Out of Hospital Programme in Coventry by appointing CWPT as a lead provider via a Direct Award;  APPROVED the recommendation to progress the Out of Hospital Programme in Warwickshire North and Rugby by appointing SWFT as a lead provider via a Direct Award;  SUPPORTED the overall approach to commissioning Out of Hospital Services for Coventry and Warwickshire.

2.4 Coventry And Rugby CCG 2017/18 Coventry Better Care Fund:

Mrs Hollingworth presented this report to seek CCG approval for the programme plan that would underpin the Coventry Better Care Fund for 2017 to 2019.

Mrs Hollingworth advised that the Better Care Fund was a programme spanning both the NHS and local government which sought to join-up health and care services so that people could manage their own health and wellbeing, and live independently in their communities for as long as possible.

Mrs Hollingworth added that in March 2017, a new policy framework for the Better Care Fund covering the period 2017 to 2019 had been issued. At the same time, significant additional funding had been made available to Local Authorities to help protect adult social care. This funding arose from the 2015 spending review and the 2017 spring budget; together these sums comprised the Improved Better Care Fund (iBCF).

Mrs Hollingworth stated that the iBCF funding was intended for three purposes i) to meet adult social care needs ii) to provide support to the NHS and iii) to sustain the social care provider market. Mrs Hollingworth added that Coventry City Council would receive non-recurrent iBCF resources of £8.1m in 2017/18 and £11.1m in 2018/19. The proposed investment plan for these resources was set out in section 5.1 of the report. Mrs Hollingworth further added that it was proposed that the CCG contribution to the pooled budget be increased from the 2016/17 value of £35.9m to £36.2m in 2017/18; the increase being an inflationary uplift to the Protecting Social Care sum that the CCG was required make available. An updated Section 75 Partnership Agreement would need to be developed between the City Council and the CCG once the detailed plans were complete. These plans would again be subject to a joint NHSE/LGA assurance process.

Ms Green said that at a recent Coventry Health and Wellbeing meeting there had been a question from Coventry Healthwatch about how public and patients were engaged. She noted that the engagement that had been undertaken in relation to the Out of Hospital programme was reflected in the BCF proposals.

Mrs Hollingworth advised that the Warwickshire Better Care Fund work was progressing at a slower pace and outline resource plans had been developed with further engagement work taking place with partners over the next few weeks. It would be taken through the Warwickshire City Council Cabinet in early September 2017. Given that there would be no Governing Body meeting prior to this, Mrs Hollingworth requested that the Governing Bodies delegate authority to approve the Warwickshire Better Care Fund Programme to their respective CCG’s Finance and Performance Committees.

The Coventry and Rugby CCG Governing Body Members:  APPROVED the programme plan for the resources made available through the iBCF against the areas identified for 2017/19.  APPROVED the CCG entering into a new Section 75 Partnership Agreement with Coventry

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Item Action No: City Council for the delivery of the BCF plan once completed.  APPROVED the City Council continuing as the pooled budget holder.  DELEGATED approval of the Warwickshire Better Care Fund Programme to the CCG’s Finance and Performance Committee.

The Warwickshire North Governing Body Members:  DELEGATED approval of the Warwickshire Better Care Fund Programme to the CCG’s Commissioning, Finance and Performance Committee.

3.1 Integrated Safety, Quality and Performance Report:

(A) Coventry and Rugby CCG

Quality Mrs Washington advised that University Hospitals Coventry and Warwickshire Trust (UHCW) had made improvements against the target for sending clinic letters and there had been no reports of patient safety concerns related to these delays. The CCG was assured that there were processes in place to enable a clinical review of patients on the waiting list for clinic appointments including a process for the regular review of patients awaiting follow up in ophthalmology when this may be delayed.

Mrs Washington drew attention the following issues in relation to Coventry and Warwickshire Partnership Trust (CWPT) quality:  Assurance was being sought regarding the impact on patients of delays in accessing appointments in IPU’s 3-8 and 18-21. The Trust had completed a demand and capacity review and were developing an improvement plan for review by the CCG.  The CCG was assured regarding the processes in place to prioritise, monitor and escalate children waiting for follow up CAMHS appointments.

Mrs Washington confirmed that in respect of CQC inspections reports published within the past few months they identified 2 practices as inadequate, 3 as requiring improvement and 1 practice as outstanding. The CCG was working with NHSE and the practices to ensure that there were robust improvement plans in place.

(B) Warwickshire North CCG

Quality Ms Bartholomew drew attention the following key points in respect of quality for George Eliot Hospital:  Mortality: GEH Trust had the lowest HSMR in comparison to its West Midlands peers. Recent SHMI data has also shown a fall in numbers. Although a SHMI outlier, the trust was within range when adjusted for palliative care. Ms Bartholomew said work was continuing with the Health Economy Mortality Oversight Group and progress had been positive and that she was expecting an update on progress today  Safety Thermometer Falls with harm data indicated that improvements were continuing.  Statutory training compliance: GEH Trust was now above the compliance level.

For Care Homes:  Quality Assurance Visits: there were 4 Assurance visits during Q4. One home had been put into a placement stop.

Primary Care:  No Primary Care concerns had been escalated to Providers Performance Information Gathering Group (PPIG).

Ms Green said that she was pleased to hear that progress on the mortality issue had been positive however this would be kept under close scrutiny.

Performance

Mr Jarman-Davies noted the following key points:

8

Item Action No: Referral to Treatment Times Both UHCW and GEH were not currently meeting the 92% standard. Performance notices had been issued to both providers. A draft Remedial Action Plan was expected from UHCW this week however the current recovery trajectory did not meet the 92% during 2017/18. For GEH, the issues generally related to implementation of the Lorenzo IT system.

A&E 4 hour waits Both UHCW and GEH had not met the 95% target in April. The CCGs were continuing to work with the providers to ensure Remedial Action Plans were being delivered. The A&E Local Delivery Board was meeting weekly. Cancer waiting times In April there had been 62 day wait breaches at both UHCW and GEH. Both providers were compliant with all other Cancer targets.

Dementia Diagnosis. Neither CCG was achieving the 67% target however actions plans were in place.

Delayed Transfers of Care (DTOC) UHCW performance had deteriorated against the DTOC target of 3.5% of occupied beds. After falling to 5% in April 2017, delayed transfers of care have been averaging 7% of occupied beds during May 2017.

Improving Access to Psychological Therapies (IAPT) Both CCGs were on target to achieve the annualised access rate for Psychological Therapies target of 15%.

The Coventry and Rugby CCG Governing Body Members and Warwickshire North CCG Governing Body members NOTED the contents of the Integrated Safety, Quality and Performance Reports.

4.1 Finance Report Month 2:

(A) Coventry and Rugby CCG Mrs Hollingworth advised that the CCG was reporting an overall balanced position at Month 2 compared with the agreed financial plan. The key points highlighted were:

 At Month 2 the CCG was forecasting a surplus of £1.1m against its in-year notified allocation and an overall underspend of £4.4m against its’ confirmed allocation which included a brought forward surplus of £3.3m. This was in line with the CCG’s agreed planned position with NHS England.  Initial activity data from University Hospitals Coventry & Warwickshire (UHCW) the CCG’s main provider, indicated performance at month 1 is slightly below plan. Most providers were addressing issues as a result of HRG4+.  Running costs expenditure was predicted to be on plan with a slight underspend year to date due to slippage in posts.  QIPP delivery was currently forecast to be achieved in line with plan. Further work to identify previously unidentified QIPP had been completed. Monitoring was now in place to provide further assurance of delivery in line with planned profiles.

(B) Warwickshire North CCG Mrs Hollingworth advised that the CCG was an overall balanced position at Month 2 compared with the agreed financial plan. The key points highlighted were:  At Month 2 the CCG was forecasting an overspend of £4.3m against its in-year notified allocation and an overall overspend of £18.6m against its’ confirmed allocation which included a brought forward deficit of £14.3m. This is in line with the CCG’s agreed planned position with NHS England.  Initial activity data from George Eliot Hospital NHS Trust (GEH), the CCG’s main provider, indicated performance is on plan.  Running costs expenditure was predicted to be on plan with slight underspend year to date due to slippage.  QIPP delivery was currently forecast to be achieved in line with plan. Further work to

9

Item Action No: identify previously unidentified QIPP had been completed. Monitoring was now in place to provide further assurance of delivery in line with planned profiles.

Mrs Hollingworth concluded by advising that both CCGs could deliver their agreed control totals but this would require ongoing management focus and the support of partners, including primary care.

The NHS Coventry and Rugby CCG Governing Body Members and Warwickshire North CCG Governing Body members:

 NOTED the overall balanced position for Month 2  NOTED potential risks associated with QIPP delivery

4.2 Procurement Update:

(A) Coventry and Rugby CCG

Mrs Hollingworth advised that much of the report was for information but highlighted the following:

 The CCG Out of Hospital programme of work was at award stage and had been considered earlier as a separate agenda item.  The new Warwickshire CAMHS contract, awarded to Coventry & Warwickshire Partnership NHS Trust was expected to go live on 1 August 2017.  Warwickshire Care Homes – Warwickshire County Council were about to complete a further opportunity for eligible providers to be added to their framework, which is open to both CCGs

Mrs Hollingworth went on to advise that she was asking the Coventry and Rugby Governing Body members to approve two contract extensions. These were detailed in the paper and the recommendations had been forward by the CCG’s Finance & Performance Committee.

(B) Warwickshire North CCG Mrs Hollingworth advised that the CCG currently had 2 in the pre-procurement planning stage; 1 live procurement; 1 in contract award; and 1 in contract mobilisation.

Coventry and Rugby CCG Governing Body Members:  NOTED the report and progress of the current procurements.  APPROVED a six month extension to the Rugby Out of Hours contract (to 31 March 2018)  APPROVED a twenty four month extension to the two current Non Obstetric Ultrasound contracts (to 30 June 2019).

Warwickshire North CCG Governing Body members NOTED the report and and progress of the current procurements.

5.1 Public Health Updates:

(A) Public Health – Health Protection Strategy 2017-2021

Dr Inglis presented the Health Protection Strategy for Coventry and Warwickshire. It was noted that the strategy outlined seven key priority areas for all partners to adopt and support within their own organisations and with other partners across the Coventry and Warwickshire area; Air Quality, Tuberculosis, Screening and Immunisations, Hepatitis B and Hepatitis C, Infection Control, Emergency Planning and Excess Winter Deaths/Fuel Poverty.

The Coventry and Warwickshire Health Protection Committee had been established in 2013 with the transition of health protection functions to a range of organisations. It was a partnership Committee chaired currently by the Director of Public Health (Warwickshire County Council) on behalf of the two sub-regional Directors of Public Health. Members of the Committee included Public Health England, NHSE, CCGs, and Heads of Environmental Services. The Committee reported to Health and Wellbeing Boards in Coventry and Warwickshire.

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Item Action No: The Coventry and Rugby CCG Governing Body and the Warwickshire North CCG Governing Body NOTED and ENDORSED the Coventry and Warwickshire Health Protection Strategy 2017 – 2021.

(B) Warwickshire Public Health Update Ms Robinson presented the Warwickshire Public Health Report which outlined the Public Health Core Offer work programme with Warwickshire North CCG and Rugby locality.

The report included updates on the following areas:  Ask Warwickshire Consultations  Warwickshire North Health and Wellbeing Partnership  Atherstone Place Based Needs Assessment  Cancer Screening Workshops  Dementia Friends

Warwickshire North Governing Body members NOTED the Warwickshire Public Health Report.

6.1 PRIMARY CARE COMMISSIONING REPORT Quarter 1:

(A) Coventry and Rugby CCG

Ms Northcote provided an overview of key items considered by the newly established Primary Care Committee (PCC) which held its first public meeting in June 2017. It was noted that there had been one formal meeting of both the Public and Closed Primary Care Committee and one development session during the period. The key themes/ items considered at the Committee were:

 PCC reporting, Terms of Reference and schedule of business  Personal Medical Services (PMS) Reinvestment proposals  Primary Care Quality report  Contract matters including performance and contract variations  International Recruitment of GP’s:  General Practice Forward View Clerical Correspondence Training proposal  Primary Care delegated budgets and finance  Estates Dispersal – STP process

Coventry and Rugby CCG Governing Body Members NOTED the report.

(B) Warwickshire North CCG

Ms Northcote provided an overview of key items considered by the Joint Commissioning Committee (JCC) between January 2017 and June 2017. It was noted that there had been three formal meetings of both the Public and Closed Joint Commissioning Committee during this reporting period. The key themes/items considered at the Committee were:

 General Practice Five Year Forward View CCG Submission to NHSE  Primary Care Transformation Funding  Primary Care Quality Dash Board  Enter and View Update  CCG Primary Care Report: International Recruitment of GP’s  Conflicts of Interest Policy  General Medical Services Contract update

NHS Warwickshire North CCG Governing Body Members NOTED the report.

7.1 CCG Committee Minutes and Reports:

Coventry and Rugby CCG Governing Body Members NOTED the following Committee minutes:

 Audit Committee minutes held on the 14 March 2017 and 30 May 2017.  Clinical Quality and Governance Committee held on 25 January 2017, 22 February 2017, 11

Item Action No: 22 March 2017, 26 April 2017 and 24 May 2017.  Clinical Development Group minutes held on 28 February 2017, 25 April 2017 and 23 May 2017.  Finance and Performance Committee held on 24 April 2017 and 22 May 2017.

Warwickshire North CCG Governing Body Members NOTED the following Committee reports:

 Commissioning Finance and Performance Committee meetings held on 27 April 2017 and 25 May 2017.  Clinical Quality, Safety and Governance Committee held on 27 April 2017.

Coventry and Rugby CCG Governing Body Members and Warwickshire North CCG Governing Body Members NOTED the following minutes:

 Warwickshire Health and Wellbeing Board meeting held on 22 March 2017.

8. Questions From Visitors:

Mr Orton (Chair WNCCG Patient Group Forum) stated that concerns had been raised at the Patient Group Forum regarding the lack of information coming from the Sustainability and Transformation Plan work. Concern had also been raised about arthritis and Neurological services being under review. Ms Green advised that she would provide an update at a future AG Patient Group Forum.

Mr Orton advised that concerns had been raised from patients about UHCW only undertaking blood tests by appointment Dr Stevens advised that clarification would be sought and an update DS/AG provided for a future Patient Group Forum.

Questions asked/comments made by Ms Kondakor were:

What exactly were the proposals for the GEH Health and Wellbeing campus? Ms Green advised that there were no fixed proposals at this point. GEH were consulting with partners to develop a health and wellbeing approach to address local health inequalities.

The Stroke consultation had not been widely publicised. Ms Green expressed her disappointment that this was the view as a significant amount of planning had been undertaken to ensure wide coverage. Ms Green advised that the deadline would be extended to ensure all opportunities to gain feedback were maximised.

Concerns had been raised relating to letters about information sharing being sent to households over the county border. Dr Allen said every resident in the county either had or would be sent letter in respect of the sharing of patient information and he gave assurance that no information was shared with other organisations unless patient consent and been gained. With regards to households over the county border receiving letters, Dr Allen advised that this had occurred as the CCG could not distinguish CCG patients from a postcode and some patients residing close to the county border could register with a Coventry or Warwickshire GP.

What progress is there on increasing GP provision in Warwickshire? Ms Green said that was work taking place to increase GP provision and she would bring an AG/JN update to a future Governing Body on this work. Dr Canale-Parola said that there was also work taking place looking at the access issue to primary care in its entirety and consideration about the way primary care is provided in terms of initial help and advice from a whole range of providers.

9. Any Other Business:

There were no additional items business.

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Item Action No: Date of the Next Meeting Held in Public: Date: Thursday 14th September 2017. Venue: Coventry Rugby Club, The Butts Park Arena, Coventry Time: 2.15pm to 4.30 pm.

Signature: (Chair CRCCG) Date:

Signature: (Chair WNCCG) Date:

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ENC C: ACTION SCHEDULE - WNCCG AND CRCCG GOVERNING BODY - MEETING IN COMMON TO BE HELD IN PUBLIC

WN / CR ACTION MEETING AGENDA ACTION RESPONSIBLE COMPLETION CURRENT UPDATE REF DATE ITEM OFFICER DATE STATUS

Mental Health Commission - Action Plan and Concordat Request (Chief Officer's Report): Once the CCG has understood the impact of the findings on the WN 17 12-Jan-17 6 Jenni Northcote When available Update 04/07/17 - Not yet available. CCG’s plans and finances a report to be presented to a future Governing Body meeting.

Director of Public Health Annual Report (Vulnerable Groups): Information to Update 04/09/17 - Presentation on WN 24 09-Mar-17 7.1 Rachel Robinson 14-Sep-17 Complete be provided to a future Governing Body meeting. agenda for September 2017 meeting.

Update 31/08/17 - RR confirmed that WN 29 11-May-17 6 Public Health session for GPs to be organised. Rachel Robinson TBC In Progress the planning process was ongoing.

Update 13/07/17 - This issue had been discussed at the CCG’s Governing Body Development Session. A deep dive was in process which would be reviewed and it was 62 days urgent GP referral to first definitive treatment for cancer target: Dr Rebecca Bartholomew noted that more recent data had WN 31 11-May-17 8.1 Stevens and Ms Bartholomew to meet and discuss the actions to be taken to 28-Sep-17 In Progress Deryth Stevens shown that this situation had address the non-achievement of the target. improved. Update 25/08/17 - The Learning from 62 Day Cancer Breach report was due to be presented at the September CQSG and CF&P Committees.

Update/14/09/17 - Submission due on EPRR: Present the signed off EPRR Self Assessments to the Clincial Quality and CR/WN 33 13-Jul-17 1.6 Debbie Pook 30-Sep-17 In Progress 15 September. Expect to present to Governance Committees of both CCGs following submission in September. Committees in September/October.

Patient Group Forum: Provide an update on STP and MSK work to a future WN 34 13-Jul-17 8 Andrea Green 30-Oct-17 Not yet due Patient Group Forum WN / CR ACTION MEETING AGENDA ACTION RESPONSIBLE COMPLETION CURRENT UPDATE REF DATE ITEM OFFICER DATE STATUS

Blood Tests at UHCW: DS to clarify the position in relation to UHCW only WN 35 13-Jul-17 8 undertaking blood tests by appointment and provide update to a future Patient Deryth Stevens 30-Oct-17 In Progress Group Forum

GP Provision in Warwickshire: Provide update to future Governing Body Andrea Green/ Jenni CR/WN 36 13-Jul-17 8 When available Not yet due meeting on the work being undertaken to increase GP provision in Warwickshire Northcote NHS Coventry and Rugby Clinical Commissioning Group Enc D

Report To: Governing Body in Common

Report Title: Chair’s Report

Report From: Adrian Canale-Parola - Chair of NHS Coventry and Rugby North CCG

Date: 14 September 2017

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Body of activity since the July 2017 meeting of the Governing Body.

Key Points: • Coventry and Warwickshire STP Design Authority (26th July 2017) • Rugby Joint Health and Wellbeing Partnership Group (2nd August 2017) • Proposed Coventry and Rugby CCG Constitutional changes

Recommendation: The Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this Leadership report: Conflicts of Interest: None Non-Recurrent Expenditure: None Recurrent Expenditure: None Financial: Is this expenditure included within the CCG’s Financial Yes No N/A Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable

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NHS Coventry and Rugby Clinical Commissioning Group Enc D

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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Enclosure D Coventry and Rugby CCG Chair’s Report - September 2017

I am most encouraged by our continuation along the path of greater integration of all stakeholders in Coventry and Warwickshire. It is increasingly clear that we all basically share common values, and using these as our bedrock, we are starting to move towards an alignment of cultures, necessary if we are to make progress in the post-transactional world we are now entering, and relevant to our local population as we focus on providing the best possible outcomes in health and social care. Examples of how this integration agenda is now manifesting among the various local stakeholders are listed below.

Warwickshire Health and Wellbeing Board (26th July 2017)

The draft Health and Wellbeing Board Annual Review 2016/17 and Delivery Plan 2017/18 were discussed, with the final version to be considered at the HWBB meeting on Wed 6th Sept. Emphasized was the relevance of the HWBBs in Coventry & Warwickshire moving forward together as leaders of change in the commissioning and provision of services, towards one of increased collaboration, and of greater focus on the prevention of ill-being. Included as an example was the proposal for rationalising stroke care in Coventry & Warwickshire to provide an equitable pan-system pathway with a focus on best outcomes.

Coventry &Warwickshire STP Design Authority (26th July 2017)

Feedback from an Away Day (7th July 2017) was discussed, including agreed principles of operation working beyond organisational boundaries and interests, and making recommendations based on the criteria of quality and safety. A report on Primary Care Development workstream was also presented, with emphasis on promoting new ways of working to support new types of consultation, in order to improve productivity, and to enable interdisciplinary care co-ordination.

Rugby Joint Health and Wellbeing Partnership Group (2nd August 2017)

One of the main item discussed was the drive, following on from 5YFV and GPFV, towards integration of Primary Care provision into hubs centred on a 30k – 50k population base, each with its own Integrated Neighbourhood Team, in order to provide improved access and community care, with the continuing aim of providing the right care in the right place, at the right time.

Finally, CRCCG’s proposed constitutional changes have been agreed by the GP membership, and are now awaiting ratification by NHSE. These changes should bring us into much closer alignment with WNCCG, and further support the move to a common culture.

NHS Warwickshire North Clinical Commissioning Group Enc E

Report To: Governing Body in Common

Report Title: Chair’s Report – September 2017

Report From: Deryth Stevens - Chair of NHS Warwickshire North CCG

Date: 14 September 2017

Previously Considered by: N/A

Action Required

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Body of activity since the July 2017 meeting of the Governing Body.

Key Points: The Chairs Report covers the following:  Members Council Meeting  Annual General Meeting (AGM)  Members’ Meetings  Health and Wellbeing Board Meeting in July  Clinical Design Authority Update

Recommendation: The Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this IAF Leadership Domain report: Conflicts of Interest: None Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory Equality and Diversity: on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful.

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NHS Warwickshire North Clinical Commissioning Group Enc E

Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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NHS Warwickshire North Clinical Commissioning Group Enc E

Chair’s Report - September 2017

1. Members Council Meeting

In July Warwickshire North CCG (WNCCG) and Coventry and Rugby CCG (CRCCG) held the first Governing Body meeting in common.

I felt that this meeting in common overall went well. Feedback to date from the WNCCG Governing Body was consistent with my opinion and a few suggestions regarding means of improving content and flow have been discussed. There are some issues regarding the best way to present integrated reports and ensuring that there is attention and focus on not diluting the current ‘place based’ approach each CCG has for its population and health economy.

2. Annual General Meeting (AGM)

WNCCG AGM took place at Bulkington Village Hall on 20th July and was well attended. We presented our Annual Report. Highlights included a presentation from the physiotherapy department at George Eliot Hospital regarding the recently set up Musculoskeletal pathway.

Discussions following the formal event were then held which highlighted how our Vision for Quality has translated into improving care and services with plans related to local maternity provision and discussion regarding the recently published Better Births document for Maternity Services in England. We also looked at Stroke Pathways and improving resilience in Primary Care.

3. Members’ Meetings

The July meeting focussed on two ongoing Public Health England Consultations:  Drugs and Alcohol Services and  Healthy Lifestyles

The results of these will be made available when we have them.

The Members’ Meeting in August addressed whether WNCCG practices would like to consider delegation of primary care to WNCCG. The next opportunity to do this will be in April 2018.

We also discussed the proposed Constitution changes as previously discussed at the Members’ Council meeting earlier in the year and fed back comments the CCG had received regarding this issue.

4. Health and Wellbeing Board Meeting in July

The Draft Health and Wellbeing Annual Review and Delivery Plan was presented. This sets out the achievements and reviews the activity programme for 2017-18.

An update to the place-based joint strategic needs assessment (JSNA) for Warwickshire was discussed.

There was also a presentation from Warwickshire Cares: Better together programme and HEART (Home Environment Response Team) which is a service to improve the home environment for vulnerable individuals and cut delivery times for major adaptations to homes.

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NHS Warwickshire North Clinical Commissioning Group Enc E

5. Clinical Design Authority Update

This group is now meeting regularly and have agreed the Terms of Reference. We are now assessing how best to ensure a robust and clear process for assessing any change in clinical pathways and ensuring that the process for changes follows a standardised format.

There is an agreement that a clear clinical template be designed and agreed among the group. This would then have to be completed for any transformational work stream and be submitted to the Clinical Design Authority for sign off before a recommendation could be made to the STP (Sustainability and Transformation Plan) board.

Deryth Stevens Chair, Warwickshire North CCG

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

Report To: Governing Body meeting in Common

Report Title: Chief Officer’s Report

Report From: Andrea Green, Chief Officer

Date: 14 September 2017

Previously Considered Not applicable by:

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this report is to provide members of the Governing Bodies with information on key issues and activities undertaken by the Chief Officer since the last Governing Body meeting in common in July 2017.

Key Points:

The Chief Officer’s Report covers the following:

1. Development of place based engagement forums in both Rugby and Warwickshire North

2. Emergency Planning Resilience and Response - Self-Assessment Core Standards

3. Coventry and Rugby CCG Constitution Changes

4. Warwickshire North CCG Constitution Changes

5. Better Care; Better Health; Better Value Update

5.1 Q1 Stocktake letter and progress update

5.2 Stroke Programme update

5.3 Out of Hospital Programme including Better Care Fund and update on End of Life investment

5.4 Update on strategic commissioning for Better Births

Recommendation: The Governing Body is requested to NOTE the report.

Implications

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

Objective(s) / Plans supported by this Better Health: Better Care; Better Value report: Conflicts of Interest: None identified. Non-Recurrent Expenditure: Not applicable. Recurrent Expenditure: Not applicable. Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified. Quality and Safety: None identified. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could Equality and Diversity: be deemed unlawful. Has an equality impact assessment been Yes No N/A  undertaken? (Delete as (attached) appropriate) The People’s Commissions in Rugby and Warwickshire North are proposed as an additional systematic method of “place based” engagement. Patient and public engagement in the Improvement in Stroke services was Patient and Public undertaken 15 June to 28 July, a report on the engagement will be presented at a Engagement: future meeting, potentially November. The plan for engagement on Better Births is in development, with Healthwatch Coventry and Warwickshire being approached to help and inform the specification. Clinical Engagement: None identified. Assurance of compliance with EPRR Category 2 responsibilities Amendment to NHS WNCCG Constitution will be implemented as agreed by Risk and Assurance: NHSE

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

1. Development of place based engagement forums for Warwickshire North and Rugby 1.1. We invited community leaders from Rugby, North Warwickshire and Nuneaton and Bedworth to meet us to discuss forming a People’s Commission, one in Rugby and one in Warwickshire North. The principle of the forums was agreed with our Health and Wellbeing Partnerships, and the main ambition was to create a place based forum, with community leaders that represent all sectors of the population, with the aim of improving and systemising engagement, networking and communications on health topics and health planning. There was broad support from those who attended each event and we are currently collating terms of reference from the discussions at each meeting. 1.2. We suggested that the forums could help to debate, test, inform and shape our responses to some of the challenges the NHS faces in planning clinically and financially sustainable services, as well as helping us to articulate some of the difficult conversations we may face in a way that will be understandable by local people. 1.3. A common theme in both meetings has been to confirm that this is not a decision making body, it is one element of the generative governance process for engaging, networking and communicating with local people in a more meaningful way. We acknowledged that we may not be able to secure the engagement of some groups using this approach and other methods would be required for this. 1.4. Both groups are keen to understand more about the Better Care; Better Health; Better Value planning, and one of the standing items for each fora will be discussion and information sharing on the workstreams, people were keen to understand the timelines for each of the workstreams, and this will be part of the next meetings agendas. 1.5. We are about to extend an invitation to Community Leaders in Coventry to see if they are supportive of establishing a similar forum in Coventry.

2. Emergency Planning Resilience and Response (EPRR) - Self-Assessment Core Standards 2.1. As a Category 2 responder within the Civil Contingencies Act 2004, NHS England requires CCGs to complete an annual self-assessment against the Core Standards for EPRR. The purpose of this process is to enable NHS England to assess the preparedness of the NHS, both commissioners and providers, against common NHS EPRR Core Standards. The self-assessments for both CCGs have now been completed and both are assessing as fully compliant in the core standards, the Governing Bodies, at the meeting in common in July 2017, approved delegation of authority to the Chief Operating Officer to sign off the CCGs’ annual self-assessments for submission. . 2.2. To support continual improvement of CCG EPRR processes, NHS England undertake an annual deep dive review and the topic this year is EPRR organisational governance. This deep dive includes assurance of areas such as EPRR accountability; reporting to Governing Body meetings and committees; and having a realistic work program with solid training and exercise programme. 2.3. Of the 6 areas tested, both CCGs have assessed: 4 Green, 1 Amber (relating to publication of EPRR compliance in the Annual Report) and 1 Red (the need to have a named Non-Executive Director assigned to EPRR). A rectification plan will be implemented with immediate effect to enable full compliance to be recorded for the 2018 assessment. 2.4. To ensure Committees are fully sighted on the assessment and rectification plans the respective self- assessments will be presented to the Clinical Quality and Governance Committees.

3. Coventry and Rugby CCG Constitution Changes 3.1. In July 2017, Coventry and Rugby CCG Members approved the proposed changes to the CCG’s Constitution. These were submitted to NHS England. Approval was expected during August however NHS England have recently submitted a number of queries prior to approval which are being worked through prior to a re-submission during September.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

4. Warwickshire North CCG Constitution Changes 4.1. Warwickshire North CCG Members supported the proposed changes to the CCG’s constitution at its meeting on 17 August. Proposed changes were minor, the main themes relating to • Facilitation of Joint/Collaborative commissioning arrangements; • Management of Conflicts of Interest; • Amendments to Committee Terms of Reference following routine annual review. 4.2. The proposed amendments will be submitted to NHS England during September.

5. Better Health: Better Care; Better Value Update 5.1. Q1 Stocktake and general update The Sustainability and Transformation Partners attended a Q1 stocktake meeting led by NHS Improvement at the end of May to discuss progress, a copy of the letter is attached for information. The Partnership have been finalising the governance and leadership of the programme, and it has been agreed that we will establish a Reference Group with Health & Wellbeing Portfolio Holders and Non Executive Directors /Lay Members. The Partnership have established a delivery group, to ensure the work programmes are being progressed in a timely manner and that there is adequate system wide reporting of progress. New requirements have been set out for the Partnership in respect of being a forum for collective oversight of the local system performance, and now all bids for national funding, need to be signed off at the STP Partnership level before they can be submitted to NHS England or NHS Improvement. 5.2. Stroke Programme Update The engagement programme on Stroke services ran for 6 weeks from the 15th June to 28th July 2017. The programme was delivered as planned but was extended by an extra week to accommodate an extra public meeting in Coventry in response to feedback during the Coventry Healthwatch AGM on 11 July, that the public meeting venue in Coventry, was not accessible for some people. A full report on the outcome of the engagement and actions to address the points raised is being developed. In the meantime, the date for the final assurance meeting with NHS England has been put back as we have some outstanding issues to address that are taking longer to resolve than originally planned. It is expected that a full report will be bought back to the Governing Body in November, however should we need to make decisions before this, we may need to call an extraordinary Governing Body meeting. 5.3. Out of Hospital Programme Update It has been decided that the Better Care Fund should going forward, be considered as part of the Out of Hospital Programme. By way of background, the Better Care Fund (BCF) policy framework was finalised and issued at the beginning of July and outlined the Better Care Fund requirements for local areas for the next two years of the programme 2017/19. The policy framework outlines the four national conditions: • A jointly agreed plan • The NHS contribution to social care is maintained in line with inflation • Agreement to invest in NHS commissioned out-of-hospital services • Implementation of the High Impact Change Model for Managing Transfers of Care The planning process for 2017/19 requires Local Authorities and their CCG partners to submit their jointly agreed plans by the 11 September 2017. In light of this timescale, at the last Governing Body meeting in common the Governing Bodies agreed to delegate authority to their respective Finance and Performance Committees to sign-off the Warwickshire BCF plan (CRCCG having approved the Coventry BCF plan in July). WNCCG Commissioning, Finance and Performance Committee signed of the plan at the August meeting. Due to timing, the CRCCG Finance and Performance Committee delegated approval to the

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

CCG Chair, Committee Chair and the Chief Officer. Both CCGs have now approved the draft Warwickshire Plan for submission. The Plan is based around five key workstreams: • Community Capacity / Resilience • Care at Home • Accommodation with Support • Integrated Care • Housing For 2017/18, the Pooled Budget that supports the Warwickshire BCF ‘Better Together’ programme will increase to £117.6m of which CRCCG will contribute £9.54m and WNCCG will contribute £16.89m. The full report on the draft plan was agreed by the Warwickshire Health and Wellbeing Board and can be seen on the Warwickshire Health and Wellbeing Board website. 5.4. Strategic Commissioning Better Births The three Coventry and Warwickshire CCGs have started work on developing the improved outcomes we will commission in response to the National Maternity Review - Better Births. The first actions underway are working with Public Health Consultants in Coventry and Warwickshire to update the maternity needs assessment, and during September we will be working with our five Collaborative Commissioning colleagues to agree the strategic commissioning approach. During September we aim to work with Healthwatch in Coventry and Warwickshire, to develop a specification for engagement and co-production of the outcomes with patients and the public. A more detailed plan will be bought back to the Governing Bodies at the end of the year.

End of report

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Appendix 1

Quarter 1 Stocktake letter

09 Better Health, Better Care, Better Value

09 Better Health, Better Care, Better Value 8

09 Better Health, Better Care, Better Value 9

09 Better Health, Better Care, Better Value 10 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

Report To: Governing Body in Common

Report Title: Director of Public Health’s Annual Report

Report From: Dr John Linnane, Director of Public Health, Warwickshire County Council

Date: 14 September 2017

Previously Considered by: Not applicable

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this report is to provide members of the Governing Bodies with the Director of Public Health’s Annual Report.

Key Points: • Directors of Public Health have a statutory requirement to write an annual report on the health of their population. The Director of Public Health Annual Report is a vehicle for informing local people about the health of their community, as well as providing necessary information for decision makers in local health services and authorities on health gaps and priorities that need to be addressed. • This year’s report includes: an overview of the health and wellbeing of the Warwickshire population, and provides a focus on the theme of this year’s report; vulnerability, together with information on progress with the 2016 recommendations. • The report will make a series of recommendations which require a concerted joint effort if they are to be achieved. • The report can be accessed on the Warwickshire Health and Wellbeing Board website. Hard copies will be provided to Governing Body Members at the meeting. Key Headlines are:

Health and Wellbeing • Rate of teenage conceptions continue to fall from 22.9% in 2014 to 19.5% in 2015. • Physical inactivity in adults has reduced from 1 in 3 down to 1 in 4 • The estimated rate of adults smoking in Warwickshire increased from 12.1% in 2015 to 14.5% in 2016. • Hospital admissions as a result of self-harm in 10-24 year olds in Warwickshire have generally risen since 2011/12 and are above the England average.

Vulnerability • There is no single count or definition of vulnerable people across Warwickshire but a wide range of different population are at risk of potential harm. Examples include 639 homeless people, 795 Children Looked After, 1 in 3 residents aged 50-59 who provide unpaid care. • The health and wellbeing of the Warwickshire population in general has seen significant improvements over recent years, whilst the health and wellbeing of vulnerable groups continues to lag behind. For example nationally almost half of children in care have a diagnosable mental health disorder, young carers are more likely to have lower educational attainment and research shows loneliness can be as harmful for health as smoking 15 cigarettes a day.

Recommendation: The Governing Bodies are requested to NOTE and support the Director of Public Health Annual Report 2017

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

Implications

Objective(s) / Plans supported by this The report supports the objectives of the Warwickshire Health and Wellbeing Board. report: Conflicts of Interest: None identified. Non-Recurrent Expenditure: Not applicable. Recurrent Expenditure: Not applicable. Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified. Quality and Safety: None identified. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public None identified. Engagement: Clinical Engagement: None identified. Risk and Assurance: None identified.

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NHS Coventry and Rugby Clinical Commissioning Group Enc H

Report To: Governing Body in Common

Report Title: Report from the Acting Director of Public Health Coventry – Public Health Commissioning Update

Report From: Acting Director of Public Health Coventry – Liz Gaulton

Date: 14 September 2017

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report:

The purpose of the report is to provide CRCCG Governing Body with an overview of Public Health commissioning activity and new service models expected to be in place during 2018.

Key Points: Since 2014 Public Health Coventry has gone out to the market for a large proportion of our contracted services. 2017 has seen significant re-procurement activity and this paper presents an overview of Public Health commissioning.

This paper outlines: • Current contracts held by Public Health Coventry • Recent and current Public Health procurement activity • Our commissioning function, partnerships and approach to delivering efficiencies and improving quality of Public Health services

Recommendation: Governing Body are asked to: • Note the breadth of commissioning activity being undertaken by Public Health on behalf of Coventry City Council

Implications

Objective(s) / Plans supported by this Supports CRCCG Commissioning Principles report: Conflicts of Interest: None Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: N/A

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NHS Coventry and Rugby Clinical Commissioning Group Enc H

Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public N/A Engagement: Clinical Engagement: N/A Risk and Assurance: N/A

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Enclosure H

Coventry and Rugby Clinical Commissioning Group Governing Body

Report from the Acting Director of Public Health Coventry – Liz Gaulton

Public Health Commissioning Update

1 Background

Since 2014 Public Health Coventry has gone out to the market for a large proportion of our contracted services. 2017 has seen significant re-procurement activity and this paper presents an overview of Public Health commissioning. From 2018/19, once the major re-procurement activity is completed there will be around eleven contracts in place, the majority of which will have a long contract period.

2 Current Contracts

We currently hold 35 contracts covering a range of service areas. Currently 4 contracts cover the majority of our contracted spend:

• Health Visiting • Adults Drugs and Alcohol Misuse • Sexual Health • School Nursing

All of these large contracts, apart from Sexual Health, are currently out for tender or a new contract has recently been awarded.

3 Recent or Current Procurement

3.1 Adults Drug and Alcohol Recovery Service

Following a successful tender process, this service will comprise of three new contracts, which will start on 1st November 2017; an Adults Drug and Alcohol Treatment Service, a Prevention, Advocacy and Family Support Service and a City Centre Late Night Triage Service (funded by Coventry and Rugby Clinical Commissioning Group). Contract length is 3+2+2 years.

3.2 Adult Drugs and Alcohol Rehabilitation

Working in partnership with Leicestershire and Warwickshire County Councils, a Rehabilitation Framework is currently being procured (led by Leicestershire). This framework will replace the spot purchasing contracts currently used with Rehab providers.

3.3 0-19 Family Health and Lifestyles Service

Health Visiting, School Nursing, Family Nurse Partnership and children and families lifestyle services are out to tender within an integrated Family Health and Lifestyles Service. (40% of current contracted spend collectively) alongside a number of small in-house services.

This procurement is a three stage process – Invitation for Expressions of Interest / Dialogue / Final Bid, which is currently in the Dialogue phase. The contract will be for 5 + 2 + 2 years and the new contract is due to start between April and September 2018.

3.4 Integrated Adults Lifestyles Service

A standard Invitation to Tender is currently out for an Integrated Adults Lifestyle Service (bringing together Stop Smoking Services, Health Checks, weight management services and lifestyles advisors). Tenders have now closed and are being evaluated. The new contract will replace 5 current contracts, which account for 5.7% of current contracted spend collectively, along with an in-house service. The contract will be for 5 + 2 + 2 years and the new contract is due to start on 1st April 2018.

3.5 Holistic Early Intervention and Young People’s Substance Misuse Service

This service will be tendered shortly, combining 2 currently separate services - Young People Substance Misuse Service and the Early Intervention service. This will be a standard Invitation to Tender. The new contract will start at the same time as the Families Health and Lifestyles contract, i.e. between April and September 2018.

In addition to these larger procurements, new contracts are currently being put in place for Keeping Coventry Warm 2017/18. An evaluation of the current Blood Borne Viruses (BBV) contracts is underway and will inform the commissioning intentions for 4 of these contracts from August 2018.

4 Public Health Commissioning Function

A recent review of commissioning roles within Public Health has resulted in a new commissioning structure within the team. This restructuring will provide focused commissioning and contract management resources for Public Health whilst aligning the function with both Adult’s and Children’s commissioning teams within Coventry City Council People Directorate.

5 Commissioning in Partnership

Where appropriate, Public Health commission services in partnership. For example:

• Adult Drugs & Alcohol Rehabilitation services with Leicestershire and Warwickshire County Councils. • Warwickshire and Coventry Councils have worked in partnership previously commissioning Sexual Health and Drug and Alcohol services.

Public Health also work closely with colleagues from Coventry and Rugby CCG in the development of services with:

• All of the recent and current procurements being presented to the CCG’s Clinical Development Group. • CCG representatives contributing to the review of the specifications for both the Family Health and Lifestyles and Adult Lifestyles services. • The procurement phase of the Family Health and Lifestyles tender being supported by specialist advisors including representatives from Coventry and Rugby CCG.

6 Public Health commissioning and contract management – delivering efficiencies and improving quality

Public Health endeavours to generate efficiencies supporting the Council to deliver savings targets and national cuts to the Public Health Grant allocation. Across our commissioning activity we have a strong focus on quality and best practice whilst ensuring value for money is achieved. We use a range of tools to do this including evidence reviews, needs assessment, benchmarking, co-production of specifications, price/quality scoring and payment by results/incentive schemes.

In August 2017 the Coventry City Council Internal Audit Team undertook a review of Public Health commissioning and contract management assessing the extent to which:

• Robust specifications and contracts are defined to underpin effective delivery of services • Key performance indicators are established to enable the Council to effectively monitor service delivery and ensure value for money • Appropriate contract monitoring arrangements are in place • The structure of the Public Health Team is fit for purpose to effectively support commissioning and contract monitoring arrangements

The report was very positive and we have been given a rating of ‘significant assurance’.

7 Summary

Since 2014 there has been substantial consolidation of contracts with significant savings achieved. Once the tenders which are currently in process are concluded and let, approximately 96% of Public Health external spend will be tied into contracts with a minimum of 7 years to run. Effective contract management is going to be the single most critical factor, both in managing performance and potentially taking out additional efficiencies (dependent upon available budgets and austerity measures).

NHS Warwickshire North Clinical Commissioning Group Enc I

Report To: Governing Body in Common

Report Title: Public Health Update

Report From: John Linnane, Director of Public Health, Warwickshire County Council

Date: 14 September 2017

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To update the Governing Body on the Public Health Warwickshire, Core Offer work programme with Warwickshire North CCG and Rugby Borough.

Key Points: The report includes updates on the following areas:

● Social marketing research (Smart Start) ● Ready for School? - Pilot Project ● Fitter futures ● MECC Programme ● Smoking in Pregnancy ● Active Travel ● JSNA ● Rugby Health & Wellbeing Partnership ● Warwickshire North Health 7 Wellbeing Partnership ● Mental Health Employment Support Service ● Fitter Futures

Recommendation: The Governing Body is requested to NOTE this report

Implications

Objective(s) / Plans supported by this Business Plan 2015/16 Refresh and Forward View to 2020 report: Not applicable Conflicts of Interest:

Non-Recurrent Expenditure: Not applicable Financial: Recurrent Expenditure: Not applicable

NHS Warwickshire North Clinical Commissioning Group Enc I

Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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NHS Warwickshire North Clinical Commissioning Group Enc I

Public Health Update September 2017

Smart Start Parent Guides Smart Start research in Warwickshire in 2016 found that parents had wanted more opportunities to learn about becoming a parent, particularly during pregnancy and the early days after birth. In response, Smart Start has funded the launch of three online Solihull Approach courses for parents: ● Understanding your Pregnancy, Labour, Birth and your Baby (9 modules) ● Understanding Your Baby (11 modules) ● Understanding Your Child (11 modules for parents of children aged 6 months to 18 years) The Solihull Approach is a well evaluated intervention, aimed at helping all parents understand and shape positive relationships with their infants. This helps their infants to develop emotional and behavioural self-regulation skills - increasing their long-term resilience and mental health. A soft launch of three online guides for parents took place on Wednesday 12 July targeting front-line workers and relevant professional groups and organisations. The public launch of these three guide was on Wednesday 17 August. Note: further social marketing research- beyond the 17 August launch - will be required to help explore the most effective ways of promoting the ‘Understanding Your Child’ course to parents via early years, primary school and secondary school settings. Ready for School? pilot project This ‘Ready for School?’ pilot project has been designed to test the introduction of an electronic health needs assessment questionnaire targeting children aged 3-3.5 years, with the aim of using this intelligence to prioritise and tailor public health interventions in areas of need in order to ultimately improve school readiness. The pilot process also aims to build greater public health partnership work across early years settings and services. The pilot, which is being delivered by Compass, as one of the Smart Start funded projects, is taking place in Nuneaton, Bedworth and North Warwickshire only. The pilot will be evaluated with support from Coventry University, and results will be shared in early 2018. A multi-agency working group has been established to oversee and drive this project forward. Fitter Futures Fitter Futures Warwickshire provides the following services: young people and adult physical activity/ healthy lifestyle on referral service, young people and adult weight management, family weight management and healthy lifestyle services for families of 0-5s. More information is available at fitterfutureswarwickshire.co.uk.

"Fitter Futures Warwickshire is commissioned by Warwickshire County Council Public Health. Since 2015, it has received over 4000 referrals for Weight Management, Physical Activity and Family Lifestyle Services.

Many case studies are collected. These case studies outline the amazing progress that many patients/clients achieve as a result of these programmes.

From mid October, case studies will be saved on the Fitter Futures website.

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NHS Warwickshire North Clinical Commissioning Group Enc I

Outcomes include:

● Increase in physical activity levels ● Weight loss ● Improved mental well being ● Reduction in feelings of loneliness and isolation ● Reduction in prescribed medication ● Reduction in clinical appointments ● Improved blood pressure ● Improved family relationships ● No longer have Type II diabetes ● Plus many more!

Quarter 1 has seen 1347 referrals - the largest amount of referrals in a quarter since the services started.

There has been an increase in number of maternity referrals and dentistry is now beginning to refer into the Change Makers programme.

A pilot has just been completed at Round Oak School with 7 young people where a Fitter Futures Physical Activity on Referral 9 week pilot programme was delivered in the school. Kingsbury High School are about to embark on a programme too. This pilot is to gain the views, feedback and health improvement outcomes from young people to establish what would make it easier for them and encourage them to access Fitter Futures as referrals from young people are currently low - the findings will be evaluated later in the year. Fitter Futures are also working with the School Health and Wellbeing service and Youth Champions who will be giving their views on the best ways to engage their age group into Fitter Futures services. There have been 17 taster sessions during Q1, at schools in order to encourage children and their families aged 4-12 to attend the Change Makers programme.

The number referred to Slimming World has gone up from 10% during 16/17 to 14% in Q1. This is above the national average of 11% and some targeted promotion work is being done to continue this increase.

MECC - Making Every Contact Count

Public Health Warwickshire has recently redesigned their MECC programme. This is in response to feedback both nationally and locally that staff working outside of the NHS find it difficult to raise the traditional lifestyle messages that are included within the MECC training around smoking, physical activity, diet and weight management. The new training programme (e-learning and face-2-face training) is for staff and volunteers working with vulnerable people or people living in difficulty to deliver broader health and wellbeing messages that are appropriate to the clients and relevant to the client's situation such as healthy lifestyles, fuel poverty, falls prevention, debt management.

The MECC training programme formally launched to external H&WBB members on 31st July 2017. Next steps for this project is to liaise with agencies booking face-2-face training

Smoking in Pregnancy

The Warwickshire Stop Smoking in Pregnancy Service offers non-judgmental support & advice to pregnant smokers to help them take steps towards a healthy, smoke-free pregnancy, including free nicotine replacement therapy (NRT) such as patches, lozenges, and other products. Pregnant smokers can either self refer or be referred by their midwife. Support for partners and family members who want to quit too is also available.

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NHS Warwickshire North Clinical Commissioning Group Enc I

The percentage of women smoking at time of delivery in England has fallen by 0.1% in the last year to 10.5%. For Warwickshire the % of women smoking at time of delivery has fallen in the last year in all 3 CCGs: Coventry and Rugby from 12.2% to 10.9%; South Warwickshire from 7.7% to 7.4%; Warwickshire North from 11.7% to 11.5%

The Smoking in Pregnancy service has reported an average 25% increase in referrals across Warwickshire during 2016/17 as a result of an increase in Carbon Monoxide (CO) testing and identification of more pregnant smokers by midwifery staff. In particular the Risk Perception Midwives in both George Eliot Hospital and South Warwickshire Hospital have been pivotal in supporting this increase and raising the profile of CO testing and referrals across their Trusts. In 2016/17 the Specialist SiP team had a 32% increase of successful 4 week quit attempts compared to last year. They were also awarded runners up award for “Team of the year” in a national stop smoking advisers publication in recognition of their work.

Active Travel - 'Choose How You Move'

Joint 12 month campaign across Coventry and Warwickshire to promote Active Travel with the focus on modal shift and part modal shift. Supported by both Public Health Teams in Coventry and Warwickshire this will include a single web page with information on travel planning, car share schemes, cycle schemes and health benefits of changing travel choices. Promotion on dedicated social media pages on Facebook and Twitter with competitions and challenges to help embed messages and long term behaviour change. Branded as Choose How You Move launched at the end of August.

Warwickshire Joint Strategic Needs Assessment (JSNA)

The JSNA provides the evidence base for understanding the current and future health and wellbeing needs of the local population. It is used to inform the Health & Wellbeing Strategy, along with specific commissioning decisions.

Warwickshire’s Health & Wellbeing Board recently endorsed a new ‘place-based’ approach to the delivery of the Joint Strategic Needs Assessment (JSNA). The current work programme, approved by the Health & Wellbeing Board in 2015, is now complete and focused on a number of priority themes (such as carers, children looked after, CAMHs and smoking). The next programme of work will focus on understanding need on a geographical basis. This is in line with the requirement to inform the Proactive & Preventative element of the Sustainability & Transformation Plan (STP) and the out of hospital programme, which seeks to build integrated services around populations of around 30,000 – 50,000. Transformation programmes relating to both adult and children’s services and community hubs are also based on the need to understand service needs at a more local level. The new JSNA Geographies were approved by the JSNA Strategic Group in June 2017 and can be viewed by accessing the maps below. The JSNA has delivered significant benefit to the county, providing both a broad evidence base and bank of specific needs assessments based upon priority themes. With the previous work programme now complete, a JSNA 2017 update has been produced which shares the most recent outputs and updates on the rationale of the new place-based approach. For more information on the JSNA, please contact [email protected]

The new JSNA Geographies were approved by the JSNA Strategic Group in June 2017 and can be viewed by accessing the maps. Aside from the development of the JSNA Geographies, there has been a considerable volume of work completed through the JSNA in recent months and a summary report (JSNA 2017 Annual Update) provides a summary of all recent Needs Assessment activity.

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NHS Warwickshire North Clinical Commissioning Group Enc I

Work is now underway to produce a set of profiles that will provide a statistical overview for these geographical areas. This will then be followed by the production of detailed needs assessments for each area, enabling Health & Wellbeing partners to commission the most appropriate services for each locality. Further updates will be provided as the work develops.

Rugby Health and Wellbeing Partnership

The Rugby Joint Health and Wellbeing Partnership Group (formerly the Rugby Locality Partnership Group) had been established in 2013 when Coventry and Rugby CCG came into being, in order to provide a multidisciplinary forum for exchange of ideas and information re local issues, and to suggest local innovations and operational solutions to meet the overall CCG strategy. Due to staffing and other issues, CRCCG were no longer able to support the group but the members were keen for the forum to continue, and Public Health Warwickshire agreed to take over the support role. The membership draws from local stakeholders such as County and Borough Council members, CCG, Social Services, Warwickshire CAVA, Community Services including Mental Health, Public Health, local Primary Care, Healthwatch, Chaplaincy (representing all faith groups), and Warwickshire Racial Equalities Partnership, and the Group will continue to aim to achieve its purpose by aligning the strategic direction of the various bodies, prioritising actions and presenting clear plans of what will be done locally to address needs, improve health and reduce health inequalities. Using the JSNA to identify and prioritise the needs of the Rugby population,the partnership will agree it’s local Strategy and vision. A strategy will be developed to outline not only the needs and vision for Rugby population but translates this into local, practical action delivered in partnership within priority communities. July saw the re-launch of the Rugby Joint Health and Wellbeing Partnership Group (formerly the Rugby Locality Partnership Group). The first meeting looked at the purpose of the group, the health profile and priorities for the area and received updates from members of the group. The group agreed to meet on a monthly basis. The August meeting was used to focus and prioritize the work of the group. This will include improving lifestyles and reducing self-harm Warwickshire North Health and Wellbeing Partnership Warwickshire North Health and Wellbeing Partnership was formally established in 2012 to ensure local delivery of the Countywide Health and Wellbeing Strategy. The group meets bi-monthly and comprises elected members and officers from Nuneaton and Bedworth and North Warwickshire Borough Council’s, NHS Warwickshire North Clinical Commissioning Group, Warwickshire CAVA and Warwickshire County Council. Using the JSNA to identify and prioritise the needs of the North Warwickshire population, in 2012 the partnership agreed it’s local Strategy and vision for 2012-15. This was updated in 2016. The strategy outlines not only the needs and vision for Warwickshire North population but translates this into local, practical action delivered in partnership within priority communities. The Partnership is supported by a governance structure to deliver the work programme and outcome measures to monitor progress. The Partnership met on the 17th July focusing on Teenage Pregnancy and an update on End of Life Care.

Mental Health Employment Support Service

People with mental health conditions are one of the most disadvantaged groups in terms of accessing and retaining paid employment, yet there is strong evidence, that with the right provision, people with mental health conditions can be supported to participate in competitive employment, aiding their recovery and longer term wellbeing. Public Health, in partnership with Strategic Commissioning funds a Mental Health Employment Support Service provided by Rethink Mental Illness. The service works to the

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NHS Warwickshire North Clinical Commissioning Group Enc I

Individual Placement and Support Model, as recommended by the Centre for Mental Health, which aims to get people quickly into competitive employment and then provides ongoing support. Through an extended partnership with colleagues in Warwickshire County Council's Economy and Skills team, additional funding has been provided for this service through the European Social Fund, and the Active Inclusion in Warwickshire programme.

Reporting for the first quarter of 2017-18 (April to June) indicated that 63 individuals were being supported by the service, and this support included: -helping clients to apply for 400 vacancies -assisting clients to prepare for 57 interviews -supporting 34 clients to access specialist benefits advice - supporting 10 clients to start new employment - liaising with employers in regards to 18 clients - supporting 39 clients to maintain their employment.

The Service will be continuing to develop an enhanced relationship with Coventry and Warwickshire Partnership Trust to move towards closer integration with the mental health clinical teams. This will enable more effective referrals and partnership working between the two organisations, so that employment support is more formally embedded within the care planning process.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Report To: Governing Body in Common

Report Title: Communications and Engagement Report – July and August 2017

Report From: Jenni Northcote, Chief Strategy and Primary Care Officer

Date: 14 September 2017

Previously Considered by: Not applicable

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: This report provides an overview of communications and engagement activity undertaken during July and August 2017.

Key Points:

NHS Coventry and Rugby Clinical Commissioning Group and Warwickshire North Clinical Commissioning Group (CCG) have continued to undertake a full range of communications and engagement activity during July and August 2017. The highlights this period are detailed in the attached report, including:  External communications and engagement  Annual General Meeting (Warwickshire North CCG)  Media releases and updates  Stakeholder / partner communications

Recommendation: The Governing Bodies are requested to NOTE the report.

Implications

Objective(s) / Plans Supports CCG Communications and Engagement statutory obligations. Informs supported by this commissioning and service developments. report: Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any Equality and Diversity: decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public The report details patient and public engagement undertaken. Engagement: There has been clinical engagement in a range of communications and engagement Clinical Engagement: activity detailed within this report such as WNCCG AGM/Engagement. The report provides assurance that the CCG is undertaking its duties in respect to Risk and Assurance: patient/public/stakeholder and clinical engagement.

2

NHS Coventry and Rugby CCG (CRCCG) and NHS Warwickshire North CCG (WNCCG) - Communications and Engagement Report (July / August 2017)

NHS Coventry and Rugby CCG and NHS Warwickshire North CCG continued to undertake a full range of communications and engagement activity during July and August 2017. The following report includes external, internal and digital communications delivered during the reporting period.

1. External Communications & Engagement

1.2. Baby Box A Baby Box launch event was held at The Coventry Transport Museum (Coventry city centre) on Wednesday 19th July 2017 (10am -12noon) with over 60 expectant mums and new parents in attendance.

Following on from the launch, The Lullaby Trust raised concerns with The Baby Box Co. about the safety and ability to reduce infant mortality. NHS Coventry and Rugby Clinical Commissioning Group issued a statement highlighting that it will work with the Baby Box Company to ensure all future communications acknowledge the advice issued by the Lullaby Trust. The CCG was assured by The Baby Box Co. that all boxes provided comply with EN/UK standard for cribs and cradles, and the mattresses provided comply with UK and EU cot mattress standards.

1.3. Patient Group Forum The Warwickshire North CCG Patient Group Forum (PGF) had their bimonthly meeting in July at the George Eliot Hospital (GEH). The meeting included updates from the CCG and the main agenda items were given over to a stroke engagement which was carried out in July and a session on consultation and engagement from Arden and GEM Commissioning Support Unit.

Issues raised by the Patient Group Forum continue to be addressed by the CCG via the group’s issues log.

1.4. The People’s Commission (July 2017) The CCG has invited people who represent the diversity of the local population to come together to debate, inform, test and shape our responses to key local health care challenges. The People’s Commission will inform and scrutinise proposals, act as a critical friend and enable improved reach to a number of target audience groups so that the right, safe, sustainable high-quality health services for our local population are commissioned, whilst reducing inequalities and taking account of financial and workforce constraints.

The first meeting took place at Heron House on 18th July 2017 and discussions included the future purpose of the group, current stroke engagement, the GEH health campus and local planning. A Rugby meeting has been set up for September 2017.

1.5. Warwickshire North CCG Annual General Meeting (July 2017) The WNCCG Annual General Meeting took place on Thursday 20 July at Bulkington Village Community Centre, School Road, Bulkington, Bedworth, CV12 9JB from 2pm onwards.

The AGM provides a chance for the public and local stakeholders to find out how the CCG is meeting the challenges facing the NHS, how it has performed during this year and what it plans for the future in commissioning for the Nuneaton, Bedworth and North Warwickshire population. There was also an opportunity for members of the public to ask questions.

3

This AGM was also used an opportunity to carry out some public engagement on four key aspects which were: improving stroke services, primary care, better births/maternity services and self-care.

Also were a series of posters that were developed to showcase the rigorous programme of commissioning work carried out over the last twelve months. Members of the commissioning team were available to speak with the public on their specific areas.

1.6. Media interest this month and responses A range of health related press releases have been issued to the media in this reporting period. Releases on the on the CCGs’ websites covered the following subjects:

 Coventry care homes lead the way in preventing avoidable pressure ulcers for their residents  Five top tips to keep children with asthma safe this summer  August Bank Holiday Reduced Pharmacy Hours  SCHOOL’S OUT! Here are some great ways to be active as a family during the Summer break!  Have your say on plans to improve stroke services in Coventry and Warwickshire  Free Baby Boxes Offer Safe Beds for Coventry and Warwickshire Newborns  West Midlands parents urged to remind teenagers to get vaccinated against deadly meningitis and septicemia  Save the Date (for the Warwickshire North CCG AGM)  Your Chance to Feedback on Plans to Improve Stroke Services  Plan Ahead and Stay Safe at Summer Festivals  Help is at hand for anxious students awaiting exam results  Mums encouraged to breastfeed

2. Internal Communications

2.2. Head of Communications and Engagement appointed

During July, the CCGs appointed their new Head of Communications and Engagement, Stephen O’Hanlon.

Stephen brings with him a wealth of experience from previous work in the NHS and will be looking at how the CCGs work more closely and coordinated internal and external communications and engagement is delivered across both CCG areas.

4

2.3. Intranet The CCG intranet continues to be regularly updated with relevant content for staff. In the reporting period, significant changes have been made to the Infection Control section of the intranet – replacing a separate website holding this information.

3. Online

3.2. Social Media overview We use Facebook and Twitter, both proactively and reactively, on an ongoing basis including promotion of local and national health campaigns, events, changes to services.

3.3. CRCCG Social Media The CRCCG social media channels have covered a range of different areas, from promoting the AGM and NHS 111 service to healthy eating and reminding the public about the reduction in services during the bank holiday.

The Twitter account now has a total of 3,657 followers, 77 of which are new followers who have joined in the July/August period. There has been a total of 109 Tweets sent out over these two months gaining a total of 69,800 impressions and 535 likes/comments/shares.

The Facebook page has gained 52 new page likes during this time, taking the total to 1,277. During July/August 91 posts were sent out, gaining 69,600 impressions and 598 likes/comments/shares.

3.4. CRCCG Website During July and August 2017 there were 66,613 visits to CRCCG’s website.

The most popular pages in July and August include ‘Walk-in and Urgent Care Centres’, which had been promoted through our social media as services were reduced during the Bank Holiday period.

Also, our ‘Coventry Care Homes’ news story proved to be very popular, receiving the most likes and shares on our Twitter and Facebook account, which reflects on the website as it appears in the top 5 most viewed pages.

‘Governing Body Meetings’, ‘ Governing Body Members’, ‘Phlebotomy’ and ‘Prescription Ordering Service’ remain amongst the top most viewed pages on our website.

3.5. WNCCG Social Media To align with our press releases the CCG account is used to reinforce messages that we putting out. In addition the account is used to share local messages relating to Bank Holiday messaging, stroke engagement and the NHS England Cover Up Mate campaign to encourage those working outdoors to apply sunscreen, skin cancer in men is increasing at a faster rate than it is for women.

During July and August there were 73 new followers to the CCG Twitter account. In total there are now 2,493 followers to the CCG Twitter account.

3.6. WNCCG Website Weekdays remain the most popular days for people accessing the website and the site receives between 383 - 1339 views per day with a total of 39,087 for the reporting period of 1 July – 25 August 2017. This is an increase from the previous figure of 43,472; though the reporting period is not complete and therefore, covers fewer days.

The ‘Walk-in and Urgent Care Centres’ page of the site again remains the most popular during the reporting period, and this page has received increased awareness as we increased social media pushes and promotion during Bank Holiday breaks as our way of encouraging the public to choose well in their use of urgent care.

5

4. Coming up (Q3 & Q4 – 2017/18)

4.2. Commissioning Intentions Work continues on the development of the refresh of the commissioning intentions document for 2018/19 for both CCGs. Once formally agreed, the CCG will be looking to engage patients and stakeholders in various ways across multiple channels.

4.3. Preparation for the NHS Coventry and Rugby CCG AGM Preparation for the AGM is underway with the event scheduled to take place on 13th September 2017 2pm – 4pm at Coventry Transport Museum. The AGM will provide a chance for patients and stakeholders to find out more about the work of the CCG and ask any questions that they may have.

6

NHS Coventry and Rugby Clinical Commissioning Group Enc L

Report To: Governing Body in Common

Report Title: Finance and Contract Report Month 4

Report From: Clare Hollingworth, Chief Finance Officer

Date: 14 September 2017

Previously Considered by: Finance and Performance Committee - 24th August 2017

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report:

To provide an update to the Governing Body of the CCG’s financial and contractual position as at the end of Month 4.

Key Points:

The CCG is reporting an overall balanced at Month 4 compared with the agreed financial plan. The key points to note are:

• At Month 4 the CCG is forecasting an in-year surplus of £1.1m against its notified allocation which is in accordance with its NHS England agreed plan and the budget setting. This is then increased by the brought forward surplus of £3.35m carried forward from 2016/17 to give a cumulative surplus of £4.45m.

• Quarter 1 contract monitoring data has been received. Bbased on this information, an assessment of potential contract challenges and latest QIPP forecasting a position has been derived to reflect the most likely year end position. Over performance on Acute is forecast at £4.7m. This is offset with under-performance elsewhere, use of flexibilities and use of £1.5m (50%) of the CCG’s general contingency.

• The CCG continues to work with the CSU to address data quality issues pertaining to Continuing Healthcare and to independently validate package costs where possible.

• QIPP year to date is achieving with 96% achievement forecasted for year end. The QIPP outturn position is split 72% recurrent and 28% non-recurrent. Monitoring is in place to provide further assurance of delivery in line with planned profiles. Whilst much work has been undertaken to improve the QIPP forecasts, some remain best estimates and will need to continue to be refined (eg. CHC, MH/LD packages, Frailty)

• Running Cost Allowance (RCA) is showing a £0.5m underspend at month 4. This is mainly due to slippage in recruitment to vacant posts. The £0.35m forecast underspend reflects the achievement of the associated QIPP target.

• The use of NR flexibilities to offset the over-spend on the Commissioning portfolio is likely to result in an adverse movement in the CCG’s underlying position. This will be re-assessed next

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group Enc L

month once work to evaluate the full year effect of 16/17 QIPPs has been completed.

• The CCG is forecasting a net risk / headroom position of zero at Month 4. Risks and available mitigations will be kept under continuous review. It should be recognised that the scope for additional mitigations is now minimal.

• The Finance and Performance Committee has advised that the Acute position and the increased use of NR flexibilities should be highlighted to the Governing Body.

• Through the Financial Recovery Group and Executive Team recovery actions will continue to be developed, albeit these may in the main improve the recurrent rather than the in-year position.

Recommendation: The Governing Body are asked to: • NOTE the position for Month 4; and • NOTE the risk to the position from contract performance and QIPP under delivery

Implications

Objective(s) / Plans supported by this Leadership, Sustainability report: Conflicts of Interest: Not Applicable Non-Recurrent Expenditure: See detail in report Recurrent Expenditure: See detail in report Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Not Applicable Quality and Safety: Not Applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not Applicable Engagement: Clinical Engagement: Not Applicable Risk and Assurance: Risk to the statutory duty to breakeven. Risk AF1 on the Assurance Framework

Page 2 of 2

Enclosure L

Finance and Contract Report

Month 4

Page 1 of 10

CONTENTS

1. Executive Summary 3-7

Highlights Financial Duties Trends

2. Financial and Contractual Management 8-10

Summary Financial position QIPP – Financial Position

Page 2 of 10

1. Executive Summary

Page 3 of 10

1.1. Headlines

The CCG is reporting an overall balanced position for Month 4 in line with the agreed financial plan. The key points to note are:

• At Month 4 the CCG is forecasting an in-year surplus of £1.1m against its notified allocation which is in accordance with its NHS England agreed plan and the budget setting. This is then increased by the brought forward surplus of £3.35m carried forward from 2016/17 to reach a cumulative surplus of £4.45m.

• Quarter 1 contract monitoring data has been received. Based on this information, an assessment of potential contract challenges and latest QIPP forecasting a position has been derived to reflect the most likely year end position. Over performance on Acute is forecast at £4.7m. This is primarily driven by Non Elective over-performance (£2.8m). This is offset with under-performance elsewhere, use of flexibilities and use of £1.5m (50%) of the CCG’s general contingency.

• The CCG continues to work with the CSU to address data quality issues pertaining to Continuing Healthcare and to independently validate package costs where possible.

• QIPP year to date is achieving with 96% achievement forecasted for year end. The QIPP outturn position is split 72% recurrent and 28% non-recurrent. Monitoring is in place to provide further assurance of delivery in line with planned profiles. Whilst much work has been undertaken to improve the QIPP forecasts, some remain best estimates and will need to continue to be refined (eg. CHC, MH/LD packages, Frailty).

• Running Cost Allowance (RCA) is showing a £0.5m underspend at month 4. This is mainly due to slippage in recruitment to vacant posts. The £0.35m forecast underspend reflects the achievement of the associated QIPP target.

Page 4 of 10

• The use of NR flexibilities to offset the over-spend on the Commissioning portfolio is likely to result in an adverse movement in the CCG’s underlying position. This will be re-assessed next month once work to evaluate the full year effect of 16/17 QIPPs has been completed.

• The CCG is forecasting a net risk / headroom position of zero at Month 4. Risks and available mitigations will be kept under continuous review. It should be recognised that the scope for additional mitigations is now minimal.

• The Finance and Performance Committee has advised that the Acute position and the increased use of NR flexibilities should be highlighted to the Governing Body.

• Through the Financial Recovery Group and Executive Team recovery actions will continue to be developed, albeit these may in the main improve the recurrent rather than the in-year position.

Further work is being undertaken on the following areas:

• Providing assurance on QIPP scheme achievement through the FRG • Understanding the impact of HRG4+ on acute contracts • CHC in-housing • Development of reporting on total acute activity and finance position for the CCG including trend variation

Page 5 of 10

1.4. Financial Duties

Page 6 of 10

1.2. Trends Monthly Cash Drawdown PLAN CCG (Surplus)/Deficit (£m) Opening Cash Total Cash Cash Plan Actual Variance Balance Drawdown CCG Cash Available Net Spend Balance In Month (23.2) (25.5) (2.3) Period £000s £000s Drawdown £000s £000s £000s £000s Financial Year Outturn (4.5) (4.4) 0.0 April 48 81,500 81,500 81,548 81,410 138 In-Year Financial Position (1.5) (1.7) (0.2) May 138 37,500 37,500 37,638 37,623 15 Cumulative Outturn (1.48) (1.67) (0.19) June 15 44,500 44,500 44,515 44,509 6 July 6 69,000 69,000 69,006 68,941 65 Year to date (YTD) Forecast Outturn (FOT) August 65 40,500 - Gross Net Gross Net Income Income September - 35,000 - Service Area expenditure expenditure expenditure expenditure October - 74,000 - £000s £000s £000s £000s £000s £000s November - 41,000 - Programme Costs 228,050 (7,061) 220,989 659,026 (1,780) 657,246 December - 37,000 - Running Costs 3,201 (472) 2,729 10,672 (1,374) 9,298 January - 74,000 - 1% Non-Recurrent Reserve (2,678) 0 (2,678) (4,290) 0 (4,290) February - 40,000 - Grand Total 228,573 (7,533) 221,040 665,408 (3,154) 662,254 March - 27,512 - Total CCG Cash Drawdown 232,500 NHSBA Cash Drawdown 20,610 Total Drawdown 253,110

Maximum Cash Drawdown (MCD) 661,313 220,437.67 - 32,672 Monthly Expenditure Run Rate - 32,672 % of MCD utilised 38.3% 60,000 % of months completed 33.3%

55,000 16/17 actual 50,000 • Based on year to date data there are no trend issues on monthly

£000's 17/18 actual 45,000 run rate or in-year positions to report. 40,000 17/18 plan • Cash has been maintained at reasonable levels with only modest Jun Oct Apr Feb Dec Aug balances at the end of the month

Page 7 of 10

2. Financial and Contractual Management

Page 8 of 10

2.1 Summary Financial Position vs Annual Plan

2.3 Summary Position – Income and Expenditure & Underlying Position

• At Month 4, the CCG is forecasting a cumulative year-end surplus of £4.45m against its notified allocation which is in accordance with its NHS England agreed plan. • The overall year to date position £347k under spent against a target of £391k under spend.. • Month 4 position has been based on available monitoring information, QIPP and knowledge of contracts which reflect the most likely forecast • Running Cost Allowance (RCA) expenditure is currently underspent year to date and forecast outturn due to slippage and the achievement of QIPP. • Reserves have been released to mitigate the overspend against the Acute commissioning portfolio. • At this relatively early stage in the year, the CCG continues to forecast delivery of its agreed control total. Page 9 of 10

QIPP – Financial Position

The 2017/18 QIPP Programme target of £27.5m is spread across five key programme areas and other transactional schemes.

The CCG‘s total QIPP plan is £27.47m of which 69% was recurrent and 31% was non recurrent at the time of submission to NHSE.

The outturn position is split 72% recurrent and 28% non-recurrent.

The majority of schemes are on track to achieve with 96.0% achievement forecasted.

The PMO are working with the Project Leads and SROs to verify impact start dates to support accurate profiling and subsequent reporting to NHSE.

Page 10 of 10

NHS Warwickshire North Clinical Commissioning Group Enc M

Report To: Governing Body in Common

Report Title: Finance and Contract Report Month 4

Report From: Clare Hollingworth, Chief Finance Officer

Date: 14th September 2017 Commissioning, Finance and Performance Committee - 24th August Previously Considered by: 2017

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: To provide an update to the Governing Body of the CCG’s financial and contractual position as at the end of Month 4.

Key Points:

The CCG is reporting an overall balanced at Month 4 compared with the agreed financial plan. The key points to note are:

• At Month 4 the CCG is forecasting an in-year deficit of £4.3m against its notified allocation which is in accordance with its NHS England agreed plan and the budget setting. This is then increased by the brought forward combined deficit of £14.2m carried forward from 2016/17 to reach a cumulative deficit of £18.5m.

• The overall year to date position is a marginal improvement against the planned deficit of £6.2m predominantly due to phasing.

• QIPP forecast performance indicates £1m under-achievement. Of this £1.8m under-achievement relates to Elective and Urgent Care schemes that is reflected within the Acute performance. Higher than planned activity growth adds to this position resulting in a £2.65m forecast over-spend against the Acute portfolio. Reserves have been utilised as a mitigation, however, this removes a majority of the CCG’s remaining flexibility to manage any further deterioration in the financial position.

• QIPP year to date is achieving at 96% with 91% achievement forecasted for year end, with over- performance against non-recurrent cost avoidance schemes offsetting under-achievement on service redesign schemes. Monitoring is in place to provide further assurance of delivery in line with planned profiles. Whilst much work has been undertaken to improve the QIPP forecasts, some remain best estimates and will need to continue to be refined. Achievement of the 91% requires a significant step up in delivery in the second half of the year and this will require focussed management attention.

• The CCG continues to work with the CSU to address data quality issues pertaining to Continuing Healthcare and to independently validate package costs. CSU staff are now seconded across to the CCG and working as part of an integrated delivery team.

• Running costs are currently in balance, with a slight underspend year to date.

• The use of NR flexibilities to offset the over-spend on the Commissioning portfolio is likely to result in an adverse movement in the CCG’s underlying position. This will be re-assessed next month once work to evaluate the full year effect of 16/17 QIPPs has been completed.

Page 1 of 2

NHS Warwickshire North Clinical Commissioning Group Enc M

• The CCG is forecasting a net risk / headroom position of zero at Month 4. Risks and available mitigations will be kept under continuous review. It should be recognised that the scope for additional mitigations is now minimal.

• The Commissioning, Finance and Performance Committee have highlighted that the Acute position and the increased use of NR flexibilities should be highlighted to the Governing Body.

• Through the Financial Recovery Group and Executive Team, recovery actions will continue to be developed, albeit these may in the main improve the recurrent rather than the in-year position.

Recommendation:

The Commissioning, Finance and Performance Committee are asked to: • NOTE the position for Month 4; and • NOTE the risk to the position from contract performance and QIPP under-delivery

Implications

Objective(s) / Plans supported by this Leadership, Sustainability report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: See details within the report Recurrent Expenditure: See details within the report Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Risk to the statutory duty to breakeven. Risk AF1 on the Assurance Framework

Page 2 of 2

Enclosure M

Finance and Contract Report

Month 4

Page 1 of 10

CONTENTS

1. Executive Summary 3-7

Highlights Financial Duties Trends

2. Financial and Contractual Management 8-10

Summary Financial position QIPP – Financial Position

Page 2 of 10

1 Executive Summary

Page 3 of 10

1.1 Headlines

The CCG is reporting an overall balanced position for Month 4 in line with the agreed financial plan. The key points to note are:

• At Month 4 the CCG is forecasting an in-year deficit of £4.3m against its notified allocation which is in accordance with its NHS England agreed plan and the budget setting. This is then increased by the brought forward combined deficit of £14.2m carried forward from 2016/17 to reach a cumulative deficit of £18.5m.

• The overall year to date position is a marginal improvement against the planned deficit of £6.2m predominantly due to phasing.

• QIPP forecast performance indicates £1m under-achievement. Of this £1.8m under-achievement relates to Elective and Urgent Care schemes that is reflected within the Acute performance. Higher than planned activity growth adds to this position resulting in a £2.65m forecast over-spend against the Acute portfolio. Reserves have been utilised as a mitigation, however, this removes a majority of the CCG’s remaining flexibility to manage any further deterioration in the financial position.

• QIPP year to date is achieving at 96% with 91% achievement forecasted for year end, with over-performance against non- recurrent cost avoidance schemes offsetting some under-achievement on service redesign schemes. Monitoring is in place to provide further assurance of delivery in line with planned profiles. Whilst much work has been undertaken to improve the QIPP forecasts, some remain best estimates and will need to continue to be refined. Achievement of the 91% requires a significant step up in delivery in the second half of the year and this will require focussed management attention.

• The CCG continues to work with the CSU to address data quality issues pertaining to Continuing Healthcare and to independently validate package costs. CSU staff are now seconded across to the CCG and working as part of an integrated delivery team.

• Running costs are currently in balance, with a slight underspend year to date.

Page 4 of 10

• The use of NR flexibilities to offset the over-spend on the Commissioning portfolio is likely to result in an adverse movement in the CCG’s underlying position. This will be re-assessed next month once work to evaluate the full year effect of 16/17 QIPPs has been completed.

• The CCG is forecasting a net risk / headroom position of zero at Month 4. Risks and available mitigations will be kept under continuous review. It should be recognised that the scope for additional mitigations is now minimal.

• The Commissioning, Finance and Performance Committee have highlighted that the Acute position and the increased use of NR flexibilities should be highlighted to the Governing Body.

• Through the Financial Recovery Group and Executive Team recovery actions will continue to be developed, albeit these may in the main improve the recurrent rather than the in-year position.

Further work is being undertaken on the following areas:

• Providing assurance on QIPP scheme achievement through the FRG. • Net Risk has been reduced by improved contract management, coding reviews planned post Month 1, CHC tightening of controls, risk share with CWPT, community block contract, a plan to manage CSU stronger and a review of non- recurrent slippage on primary care investment. • Understanding the impact of HRG4+ on acute contracts • CHC in-housing • Development of reporting on total acute activity and finance position for the CCG including trend variation

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1.2 Financial Duties

RAG Rating Not achieving financial duty and Red unlikely to without remedial action. Based upon current information Ambe r there is a risk that the financial duty will not be achieved. Green Achieving financial duty

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1.4 Trends (Surplus)/Deficit (£m) Plan Actual Variance

In Month 1.5 2.5 0.9 Financial Year Outturn 18.5 18.5 (0.0) In-Year Financial Position 4.3 4.3 0.0 Deficit Brought Forward 14.2 14.2 (0.0) Cumulative Outturn 6.18 6.09 (0.10)

Year to date (YTD) Forecast Outturn (FOT)

Gross Net Gross Net Income Income expenditure expenditure expenditure expenditure Service Area £000s £000s £000s £000s £000s £000s Programme Costs 80,363 (811) 79,552 237,184 (1,315) 235,869 Running Costs 1,634 (361) 1,273 5,152 (1,186) 3,966 1% Non-Recurrent Reserve (1,700) 0 (1,700) 2,731 (900) 1,831 Grand Total 80,297 (1,172) 79,125 245,067 (3,401) 241,666

• Based on year to date data there are no trend issues on monthly run rate or in -year positions to report.

• Cash has been maintained at reasonable levels within limited balances at the end of the month

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2 Financial and Contractual Management

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2.1 Summary Financial Position vs Annual Plan

• At Month 4, the CCG is forecasting a cumulative year-end deficit of £18.55m against its notified allocation which is in accordance with its NHS England agreed in-year deficit plan.

• The overall year to date position shows a £0.1m improvement against the planned deficit of £6.2m.

• Month 4 position has been based on monitoring information and knowledge of contracts which reflect the most likely forecast once QIPP has been accounted for.

• Running Cost Allowance (RCA) expenditure is currently in line with the notified allocation of £3.96m

• Reserves have been released to mitigate the Acute overspend. Mitigating actions will be agreed with budget holders and reported backPage to 9 of 10 the Committee where appropriate.

2.2 QIPP – Financial Position

• The 2017/18 QIPP Programme target of £11.6m is spread across four key programme areas and other transactional schemes. This target is as per the CCG’s financial plan submission and agreed with NHSE.

• The CCG‘s total QIPP plan submitted to NHSE is £11.6m of which 77% was recurrent and 23% was non recurrent. As at month 4 NHSE have updated the QIPP plan which now reflects 84% recurrent and 16% non- recurrent.

• The forecast outturn against the £11.6m outturn position is split 81% recurrent and 19% non-recurrent.

• Both the Elective Care and Urgent Care programmes have a number of schemes that are off track. Adjustments have been made since reporting to NHS England with a £1.01m deterioration based on FRG discussions.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc N

Report To: Governing Body in Common

Report Title: Procurement Update

Report From: Clare Hollingworth, Chief Finance Officer

Date: 14 September 2017

Previously Considered by: CRCCG – Finance & Performance Committee – 21st August 2017 WNCCG – Commissioning, Finance & Performance Committee – 24th August 2017

Action Required (delete as appropriate)

Decision:  Assurance:  Information: Confidential

Purpose of the Report:

To provide an overview of the procurement work programme and a progress update for each of the individual projects.

Key Points: • As detailed in the main report, the status of the procurement pipeline of each CCG may be summarised as follows: CRCCG WNCCG Live procurements 0 0 Contract award stage 3 2 Contract mobilisation stage 0 0 Pre-procurement planning 6 4 Contract extensions enacted 1 0 Contract extensions recommended 1 1

• This paper seeks approval to extend the contracts with three providers for the provision of Age Related Macular Degeneration services for two years to March 2010. • Under delegated authority from the Governing Body, the CRCCG Finance & Performance Committee has approved the direct award of a new two year contract for the provision of a Walk In Centre to the incumbent provider, Virgin Healthcare. • The CRCCG Primary Care Committee has approved a direct award of a new one year contract to extend temporary arrangements for the provision of GP medical services to the Rugby Brownsover population whilst a full procurement of a longer term contract is undertaken. • A Procurement Panel (non-decision making) has been established to better co-ordinate procurement activities across the three Coventry & Warwickshire CCGs.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc N

Recommendation:

The Governing Bodies are asked to: • NOTE the progress of the current procurements. • NOTE the procurement pipeline and the decisions that will be required over the next few months. • APPROVE the extension of the current Age Related Macular Degeneration for a further two years to March 2010.

Implications

Objective(s) / Plans Procurement activities are primarily conducted as part of business as usual and/or in supported by this support of the CCGs’ stated Commissioning Intentions. report: Conflicts of Interest: Each Procurement is planned so as to manage Conflicts of Interest appropriately. Non-Recurrent Expenditure: Not applicable It is expected that all contract awards will be Recurrent Expenditure: contained within the available budget. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) The ability of service providers to achieve relevant performance targets is a key Performance: consideration when awarding contracts. The ability of service providers to achieve acceptable quality standards is a key Quality and Safety: consideration when awarding contracts. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Not required at this stage for the procurements listed. Patient and Public Engagement: Patient Engagement informed the Outcomes Framework that is being used within the Out of Hospital programme. Clinical Engagement: Not applicable. Risk and Assurance: Direct award decisions carry a risk of challenge.

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Enc N

NHS COVENTRY & RUGBY CLINICAL COMMISSIONING GROUP NHS WARWICKSHIRE NORTH CLINICAL COMMISSIONING GROUP

Report to: Governing Body – 14th September 2017

Report from: Clare Hollingworth, Chief Finance Officer

Title: Procurement Update – August 2017 ______

1. Purpose of Report

The purpose of this report is to provide an overview of the procurement work programme and a progress update for each of the current services that are in the live procurement phase.

2. Procurement Work Programme

2.1 Out of Hospital – Award stage In the spring of 2016, the three CCGs within Coventry and Warwickshire agreed to collaborate on a process to redesign Out of Hospital services. Local Providers have been collaborating to develop a new service model that they believe will deliver improved results against the single Outcomes Framework that the three CCGs have developed. At their July meetings, the three CCGs governing bodies approved the direct award of three year contracts to the incumbent providers: CWPT for the Coventry footprint and SWFT for the Warwickshire footprints. The intention is to move to contract signature by 1st November with a contract commencement date of 1st April 2018.

2.2 TCP Framework for specialist LD provision – Award Stage Following market engagement activities, the four CCGs and three Local Authorities that compromise the Coventry, Warwickshire and Solihull Transforming Care Partnership agreed to establish a framework of specialist providers able to deliver community options for people with a learning disability and/or autism who have a mental health condition or behaviours that challenge. Providers appointed to the framework will work to a common set of core service standards and outcome measures. The procurement was led by Warwickshire County Council on behalf of the seven partners. Following a robust evaluation process, covering both equality and price and including site visits, ‘call off’ contracts are to be awarded to four providers for an initial period of 2 years and 7 months (ie. to 31st March 2020) with the option to extend for up to two further years. Funding will be committed only as and when individual packages of care are approved by the responsible commissioner. CCG Governing Bodies can be assured that the framework for specialist providers for LD provision is now in place to support the LD Transforming Care Programme.

2.3 Coventry Walk In Centre – Award stage (CRCCG only) Last month, under authority delegated by the Governing Body, the Finance & Performance Committee agreed to approve the direct award of a new two year contract to the incumbent provider, Virgin Healthcare. The CCG preference was for the new contract to commence 1st September 2017 but the Provider have suggested 1st October as more feasible to achieve. A VEAT notice will be issued to inform the market of this direct award decision.

2.4 Age Related Macular Degeneration (ARMD) – Contract Extension Both Commissioning, Finance & Performance Committees have agreed to recommend to their respective Governing Body that the current ARMD contracts be extended for a further two years to 31st March 2010. The commissioning team is looking at additional performance metrics to be negotiated into the contract to provide assurance that referral routes are being optimised, enabling patients to access the lower cost treatment pathways.

2.5 Rugby Town Medical Practice – Direct Award (CRCCG only) This APMS contract covering the temporary caretaking arrangements is due to expire on 30th September 2017, with extension options having been exhausted. At its August meeting, the Primary Care Committee approved a direct award to the incumbent provider (for a twelve month period, with an option to extend for a further twelve months if the situation demands) whilst a full procurement is undertaken for more permanent provision for the Brownsover population.

2.6 Enteral Feeds – Pre-Procurement This is a collaborative procurement for all commissioners and acute trusts in the West Midlands which is being led by HealthTrust Europe (HTE). There is no update since last month ie. the procurement remains at the pre-procurement planning stage due to delays in the lead commissioners getting agreement for a risk share approach across the West Midlands.

2.7 Anchor & Meridian APMS contracts – Pre Procurement (CRCCG only) As previously reported, the CCG’s Primary Care Committee approved a twelve month extension to this contract which will now run until 30th April 2018. An options appraisal will be undertaken over the summer to inform decision making regarding future service design and procurement. A decision will need to be taken in September if the service is to be re-procured through open competition.

2.8 GP Notes Summarisation – Pre Procurement (CRCCG only) In late summer 2016, NHSE and the CCG supported a proposal put forward by the LMCs for PMS monies to be used to fund a patient notes summarisation service to improve the quality and consistency of coding within GP records in support of the wider record sharing agenda. A Market Testing event was held on 5th April in which six potential participants participated. A project team has now been established to review the specification and to obtain clinical sign-off during the Autumn.

2.9 Rugby Out of Hours Service – Pre Procurement (CRCCG only) The CRCCG Governing Body approved the Committee’s recommendation to extend this contract for six months to 31st March 2018. This decision has been communicated to the provider, Coventry & Warwickshire Partnership Trust, and the CCG is awaiting their response. A recommendation will be brought to the Governing Body in early Autumn as to how the service should be secured from 1st April 2018.

2.10 Leg Ulcer Service – Pre-Procurement (WNCCG only) This contract expires 31 March 2018 and does not have a contract extension option. The service is within scope of the agreed Out of Hospital contract; a dialogue will be initiated with the Lead Provider (SWFT) as to the preferred means of securing appropriate provision from the 1st April onwards.

2.11 Discharge to Assess Pathway 2 – Pre-Procurement (WNCCG only) These contracts (bedded provision plus associated GP cover) expire 31 March 2018 and do not have a contract extension option. Pathway 2 is within scope of the agreed Out of Hospital contract; a dialogue will be initiated with the Lead Provider (SWFT) as to the preferred means of securing appropriate provision from the 1st April onwards.

2.12 Brownsover Medical Practice – Pre Procurement (CRCCG only) As the housing developments at Brownsover progress, the CCG will need to procure more permanent general medical provision to replace the caretaking arrangements put in place whilst patient numbers were very low. This procurement will be overseen by the Primary Care Committee.

2.13 GP Extended Hours – Pre Procurement/Contract Extension Earlier in the year, CRCCG approved a direct award to the Coventry & Rugby GP Alliance to maintain the extended access arrangements previously commissioned by NHSE and funded through the Prime Ministers Access Fund. This contract expires 31st March 2018 with an option to extend for a further six months. A project group is being formed to develop commissioning intentions for GP extended access and a recommendation will be brought to the Governing Body in late Autumn as to how the service should be secured for 2018/19 and beyond. The WNCCG Governing Body will also need to consider commissioning recommendations in readiness for national funding becoming available from 1st April 2018 to begin to roll-out extended access to non-PMAF areas.

2.14 Care Homes Procurement (Coventry) - Pre Procurement The new Care Home contract developed jointly with Coventry City Council includes a new pricing structure for both Residential and Nursing Homes based on the Joseph Rowntree model. Care homes have previously engaged in discussions relating to the new pricing model and joint contract. Those homes supporting the D2A scheme are already working to the new pricing structure however, the next steps are to secure communication sessions with providers to reignite the discussions, share the success of D2A and complete an impact assessment on selected homes once practitioners are trained. Also for senior managers to agree the delivery programme of training sessions for operational staff within both the Council and the CCG to build confidence in applying the principles of the model to individual cases.

3.0 Recommendation

Members are asked to: • NOTE the progress of the current procurements • NOTE the procurement pipeline and the decisions that will be required over the next few months. • APPROVE the extension of the current Age Related Macular Degeneration for a further two years to March 2010.

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Report To: Governing Body in Common

Report Title: Draft CCGs’ Response to the Modern Slavery Act 2015

Report From: Maria Maltby – Deputy Director of Corporate Affairs

Date: 14 September 2017

Previously Considered by: CRCCG Clinical Quality and Governance Committee, 26 July 2017 WNCCG Clinical Quality, Safety and Governance Committee – 27 July 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To present the CCGs’ draft statement in response to the Modern Slavery Act 2015 for approval.

Key Points: • From 29 October 2015, the Modern Slavery Act 2015 (the Act) requires commercial organisations, including all NHS organisations, to make a public statement as to the actions they have taken to detect and deal with forced labour and trafficking in their supply chains – the Transparency in Supply Chains obligation. • Organisations with a year-end of 31 March 2016 are the first to be required to publish on their website a statement within 6 months of current year end. • The CCGs’ draft statement for 2016/17 is detailed at Appendix 1. • The statement has been developed by assessing existing practice undertaken within the business. The CCGs’ approach is governed by compliance with legislative and regulatory requirements and due to the nature of its business is a relatively low risk however we will continue to ensure that, where appropriate, we seek assurances via contractual mechanisms from our providers that they comply with the Act. • The draft statement was considered by the responsible sub-committees of both Governing Bodies and was recommended for approval and adoption.

Recommendation: The Governing Bodies are asked to: • APPROVE adoption, signing by the Accountable Officer and publication of the statement in response to the Modern Slavery Act 2015.

Implications

Objective(s) / Plans supported by this This statement supports the CCGs’ compliance with the Modern Slavery Act 2015. report: Conflicts of Interest: No conflicts of interest identified relating to this statement. Financial: Non-Recurrent Expenditure: Not applicable

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Recurrent Expenditure: Not applicable Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified relating to this statement. Quality and Safety: None identified relating to this statement. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Should the CCG not comply with the requirements of the Act, the UK Home Secretary can force the organisation (by way of proceedings for an injunction) to issue an annual Risk and Assurance: statement. A failure to comply with the provision, or a statement that the CCG has taken no steps, may result in reputational damage.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

1. Introduction 1.1. From 29 October 2015, the Modern Slavery Act 2015 (the Act) requires commercial organisations, including all NHS organisations, to make a public statement as to the actions they have taken to detect and deal with forced labour and trafficking in their supply chains – the Transparency in Supply Chains obligation. The guidance is available here. 1.2. Organisations with a year-end of 31 March 2016 are the first to be required to publish on their website a statement within 6 months of current year end. 1.3. The Act requires a slavery and human trafficking statement to be approved and signed at Governing Body level. This ensures senior level accountability, leadership and responsibility for modern slavery and gives it the serious attention it deserves.

2. What should the statement include? 2.1. The Government has not been prescriptive about the layout or specific content of a slavery and human trafficking statement. It is up to organisations how they present information in the statement and how much detail they provide. However, organisations must include in the statement all the steps they have taken. 2.2. The guidance provides a non-exhaustive list of information that may be included: i. The organisation’s structure, its business and its supply chains.

ii. Its policies in relation to slavery and human trafficking.

iii. Its due diligence processes in relation to slavery and human trafficking in its business and supply chains.

iv. The parts of its business and supply chains where there is a risk of slavery and human trafficking taking place, and the steps it has taken to assess and manage that risk.

v. Its effectiveness in ensuring that slavery and human trafficking is not taking place in its business or supply chains, measured against such performance indicators as it considers appropriate.

vi. The training about slavery and human trafficking available to its staff.

3. What are the consequences of failing to issue an annual statement? 3.1. The UK Home Secretary can force an organisation (by way of proceedings for an injunction) to issue an annual statement. 3.2. A failure to comply with the provision, or a statement that an organisation has taken no steps, may damage the reputation of the organisation.

4. Coventry and Rugby CCG and Warwickshire North CCG’s Statement 4.1. The draft statement for 2016/17 for both CCG’s is detailed at Appendix 1. The content guide detailed in paragraph 2.2 has been used to develop the statement. 4.2. The statement has been developed by assessing existing practice undertaken within the business. Both the CCGs approach is governed by compliance with legislative and regulatory requirements and due to the nature of their business is a relatively low risk however moving forward, we will seek to ensure that, where appropriate, we seek assurances from our providers that they comply with the Act.

5. Recommendations 5.1. It is recommended that the Governing Bodies APPROVE the statement for adoption by their CCGs, signing by the Accountable Officer and publication.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Appendix A - NHS Coventry and Rugby and NHS Warwickshire North Clinical Commissioning Group’s Response to the Requirements of the Modern Slavery Act 2015

This statement comprises the slavery and human trafficking statement of NHS Warwickshire North Clinical Commissioning Group (the organisation) for the financial year ending 31st March 2017 in accordance with Section 54, Part 6 of the Modern Slavery Act 2015.

The organisation recognises that it has a responsibility to take a robust approach to slavery and human trafficking and is absolutely committed to preventing slavery and human trafficking in its corporate activities.

Definition of Offences

Slavery, servitude and forced or compulsory labour.

A person commits an offence if:

i. The person holds another person in slavery or servitude and the circumstances are such that the person knows or ought to know that the other person is held in slavery or servitude, or; ii. The person requires another person to perform forced or compulsory labour and the circumstances are such that the person knows or ought to know that the other person is being required to perform forced or compulsory labour.

Human Trafficking

A person commits an offence if:

i. The person arranges or facilitates the travel of another person (victim) with a view to being exploited; ii. It is irrelevant whether the victim consents to travel and whether or not the victim is an adult or a child.

Exploitation

A person is exploited if one or more of the following issues are identified in relation to the victim:

i. Slavery, servitude, forced or compulsory labour; ii. Sexual exploitation; iii. Removal of organs; iv. Securing services by force, threats and deception; v. Securing services from children, young people and vulnerable persons.

Organisational Structure

As an authorised statutory body, the CCG is the lead commissioner for health care services (including acute, community, mental health and primary care) in the North Warwickshire and Nuneaton and Bedworth areas – covering a population in excess of 188,000. We are an NHS organisation with 47 employees and an annual turnover in 2016/17 of approximately £242.6m.

The Membership, Governing Body, Executive Team and all employees are committed to ensuring that there is no modern slavery or human trafficking in any part of our business activity and in so far as is possible to holding our suppliers to account to do likewise.

Our approach

Our overall approach is governed by compliance with legislative and regulatory requirements and the maintenance and development of best practice in the fields of contracting and employment.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

The CCG recognises safeguarding as a high priority for the organisation. In order to achieve this we ensure that we have arrangements in place to provide strong leadership, vision and direction for safeguarding. We make sure we have clear accessible policies and procedures in line with relevant legislation, statutory guidance and best practice.

The organisational structure, business and supply chain

We have a clear line of accountability for safeguarding within the CCG.

The CCG’s Accountable Officer has ultimate accountability for ensuring that the health contribution to safeguarding and promoting the welfare of children and adults is discharged effectively across the whole health economy through commissioning arrangements.

The Chief Quality Officer is the Governing Body executive lead for safeguarding, and has responsibility for providing leadership and gaining assurance in relation to safeguarding issues within the CCG and locality.

The CCG employs the expertise of a designated safeguarding doctor and safeguarding nurses for both children and adults. These roles are an integral part of the CCG’s activity and support the delivery of the safeguarding adult and children agenda.

Procurement

The CCG ensures that organisations commissioned to provide services have appropriate systems that safeguard children in line with section 11 of the Children Act (2004), and adults in line The Mental Capacity Act 2005, The Care Act 2014 and The Modern Slavery Act 2015.

With regards specifically to the Modern Slavery Act 2015, there is a specific question in our standard set in the pre- qualification questionnaire so that we can be assured of the approach of potential providers at the outset of a procurement.

In addition, the CCG’s contractual agreements (Standard NHS Contract) contain an obligation within clause SC1.2.2 for providers of services to ‘perform all of its obligations under the Contract in accordance with’:

1.1.1 the terms of this Contract; and

1.1.2 the Law; and

1.1.3 Good Practice’

Further, under SC32 Safety and Safeguarding there is a requirement upon all of our providers to have in place programmes for safeguarding and to co-operate with the Commissioner in pursuance of these.

The policies in relation to Slavery and Human Trafficking

Across the West Midlands there is a multi-agency policy and procedures for the protection of adults with care and support needs. This policy covers Modern Slavery and Trafficking. Across Warwickshire organisations will report any concerns direct to the police or into adult safeguarding.

Any concerns are directed to the police or into adult safeguarding.

The due diligence processes in relation to Slavery and Human Trafficking in its business and supply chains

The CCG is committed to ensuring that there is no Modern Slavery or Human Trafficking in our supply chains or in any part of our business.

Safe recruitment principles are adhered to which includes strict requirements in respect of identity checks, work permits and criminal records. The pay structure is derived from national collective agreements and is based on equal pay principles with rates of pay that are nationally determined. The Remuneration Committee holds the organisation to account in adhering to these standards.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Systems are in place to encourage the reporting of concerns and the protection of whistle blowers.

With regards to providers and supply chains, we expect these entities to have suitable anti-slavery and human trafficking policies and processes in place. We will use our routine contract management meetings with major providers to hold them explicitly to account for compliance with the Act and we will implement any relevant clauses contained within the Standard NHS Contract for 2017/18.

All providers are contractually required to report compliance with safeguarding standards to the CCG using the agreed frameworks

The parts of its business and supply chains where there is a risk of Slavery and Human Trafficking taking place, and the steps it has taken to assess and manage that risk

The CCG is committed to social and environmental responsibility and has zero tolerance for Modern Slavery and Human Trafficking. Any identified concerns regarding Modern Slavery and Human Trafficking would be escalated as part of the organisational safeguarding process and in conjunction with partner agencies; such as the Local Authority and Police.

The effectiveness in ensuring that Slavery and Human Trafficking is not taking place in its business or supply chains, measured against such performance indicators as it considers appropriate

The CCG aims to be as effective as possible in ensuring that modern slavery and Human Trafficking is not taking place in any part of our business or supply chains by:

i. Effective interagency working with local authorities, the police and third sector organisations which includes appropriate arrangements for preventing and responding to modern slavery and Human Trafficking; ii. Signing up to the West Midlands multi-agency policy and procedures for the protection of adults with care and support needs; iii. Undertaking robust NHS employment checks and payroll systems; iv. Ensuring good communication through contract management meetings, with our commissioned providers in the supply chain and their understanding of, and compliance with, our expectations in relation to the NHS terms and conditions. These conditions relate to issues including bribery, slavery and other ethical considerations. v. Requiring the CCG’s providers to provide the CCG with assurance around safeguarding compliance within the agreed framework.

Training about Slavery and Human Trafficking

Slavery and Human Trafficking is part of the organisation’s Mandatory Safeguarding Children and Adults training programme.

This statement is made pursuant to Section 54(1) of the Modern Slavery Act 2015 and constitutes our organisation’s modern slavery and human trafficking statement for the current financial year.

Signed: Date:

Andrea Green

Chief Officer

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NHS Warwickshire North Clinical Commissioning Group Enc P

Report To: Governing Body in Common

Report Title: WNCCG Audit Committee Annual Report to Governing Body

Report From: David Allcock, Lay Member for Audit and Governance

Date: 14 September 2017

Previously Considered by: WNCCG Audit Committee – 3 August 2017

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: This report to the Governing Body outlines the work of Warwickshire North CCG’s Audit Committee for the year 2016/17.

Key Points:

• The Audit Committee is required to report annually on its work in relation to its terms of reference and highlight any significant issues. • The report outlines the business conducted by Warwickshire North CCG’s Audit Committee from 1 April 2016 to 31 March 2017.

Recommendation: The Governing Body is asked to NOTE the annual report content and receive confirmation that the Audit Committee has fulfilled its statutory obligations.

Implications

Objective(s) / Plans This report complies with the Audit Committee Terms of Reference as set out in the supported by this CCG’s Constitution. report: Conflicts of Interest: No conflicts of interest identified relating to this statement. Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified relating to this report. Quality and Safety: None identified relating to this report. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable

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NHS Warwickshire North Clinical Commissioning Group Enc P

Engagement: Clinical Engagement: Not applicable The Audit Committee is a statutory committee of the CCG and must fulfil its statutory Risk and Assurance: duties as outlined in its terms of reference.

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Enclosure P

Audit Committee Annual Report to Governing Body

1) Introduction

1.1 The Health and Social Care Act 2012 set out the requirement for Clinical Commissioning Groups (CCGs) to establish an Audit Committee.

1.2 This report to the Governing Body covers the work of the Audit Committee for the year 2016/17.

2) Terms of Reference

2.1 The Committee’s terms of reference are set out in the CCG’s Constitution. They are reviewed annually and were last reviewed by the Committee in February 2017 when they were amended to include provision for the establishment of an Audit Panel to be responsible for making arrangements for the selection of the CCG’s external (local) auditor, including recommending a contract award to the Governing Body.

3) Membership

3.1 Good governance practice requires membership of the Audit Committee to exclude members of the Governing Body, staff and others working for the CCG who have an executive, operational role in the organisation. The CCG’s three Lay Members and the Hospital Doctor member of the Governing Body comprise the voting membership of the Committee.

3.2 The membership of the Audit Committee during the year was as follows:

Chair:

• David Allcock –Lay Member for Audit and Governance (formerly Lay Member for Patient and Public Involvement) (Committee Chair from March 2017).

• Neil Hart – Lay Member Audit and Governance (Committee Chair from April 2013 to March 2017).

Members:

• David Allcock – Lay Member for Patient and Public Involvement (Became Chair from March 2017).

• Graham Nuttall – Lay Member for Primary Care.

• Chris Pycock – Secondary Care Doctor.

3.3 The Chief Finance Officer (or deputy) attends all meetings of the Audit Committee, and other directors/senior managers as appropriate. Representatives of the internal and external auditors, counter fraud service and local security management service also attend. The Head of Corporate Affairs also attends all meetings. These attendees are not members of the Committee.

3.4 The Chair may invite any other person(s) to attend meetings, including the CCG’s Chair and Chief Officer.

4) The Operation of the Audit Committee

4.1 The Audit Committee meets at least five times a year. At these meetings it considers the robustness of the CCG’s governance arrangements, including its financial, risk management and clinical governance systems. One of the main ways it does this is through agreeing the annual internal and external audit plans and monitoring the reports that they produce. These audits provide a strong element of external assurance. The Audit Committee oversees the production and submission of the CCG’s annual report, annual governance statement and annual accounts, and receives the Head of Internal Audit’s opinion and Annual Management letter from the external auditor. It also occasionally selects subjects for a “deep dive”, inviting appropriate directors and managers to present to committee members on the management arrangements in place. A deep dive of contractual arrangements was undertaken by Finance and Contract Management during Quarter 3 to confirm compliance with the CCG’s Procurement Policy.

4.2 The Committee agendas regularly include the following items:

• Compliance with Standing Orders and Standing Financial Instructions;

• Governing Body Assurance Framework;

• Internal audit progress reports;

• External audit progress reports;

• Counter fraud progress reports;

• Local Security Management reports.

4.3 The Committee agreed a work plan for 2016/17 at its meeting held on 25 May 2016.

4.4 The Committee maintains an Action Log progress on which it reviews at each meeting.

5) Meetings

5.1 The Audit Committee met on the following dates:

• 20 April 2016;

• 25 May 2016;

• 21 July 2016;

• 15 September 2016;

• 17 November 2016;

• 16 February 2017.

5.2 All meetings were quorate. Details of attendance are shown below:

Member Attendance during 2016/17 David Allcock 4 out of 6 Neil Hart 6 out of 6 Graham Nuttall 6 out of 6 Chris Pycock 6 out of 6

5.3 The Chief Officer had an open invitation to attend all meetings and attended twice.

5.4 There was an open invitation to the Internal and External Auditors and the local Counter Fraud Officer to contact the Chair of the Audit Committee if they had any concerns.

5.5 Reports outlining items discussed and decisions made from all Audit Committee meetings were considered and noted at subsequent Governing Body meetings.

6) Review of the Committee’s Work

6.1 The Committee has an Annual work plan that structures the agendas for each meeting. This was updated during the year as required.

6.2 The Committee undertook a self-assessment exercise in May 2016 and an improvement action plan was developed. Progress against the self-assessment action plan was discussed at all Audit Committee meetings during the year. There were no areas of significant concern and all actions were completed by July 2017.

6.3 The Committee will undertake another Committee Effectiveness self-assessment in August 2017.

7) Internal Audit

7.1 Coventry and Warwickshire Audit (CW Audit) provide the internal audit services for the CCG. The work of Internal Audit has focused on Risk Management and Organisational Controls and was part of an agreed plan for the year, which had been based on a risk assessment for the organisation.

7.2 A summary of the Internal Audit work carried out during the year is shown below:

Area of Audit Level of Assurance Given Month 3/4 Special Financial Significant Review Joint Commissioning Significant Quality Monitoring Significant Committee Review Significant Financial Systems Significant Financial Management Significant Contract Management Significant Procurement Moderate Conflicts of Interest Moderate IT Equipment Moderate Review of Service Auditor Report Advisory Assurance Framework Advisory IG Toolkit Advisory

7.3 An Internal Audit Recommendations Tracker monitors the progress of recommendations with updates provided by management. Updates are provided to the Audit Committee to give it assurance that recommendations are being implemented on a timely basis.

7.4 Following completion of the planned audit work for the financial year for the CCG, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the CCG’s system of risk management, governance and internal control. The Head of Internal Audit concluded:

‘Significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk.’

7.5 The external auditors continue to place reliance on the work of the internal audit service to assist with their assessment of the CCG.

7.6 During the year, the Audit Committee formed an Audit Panel which oversaw a joint procurement exercise with Coventry and Rugby CCG and South Warwickshire CCG to award a new internal audit and counter fraud services contract for a three year period from 1 April 2017. As a result of this process CW Audit were awarded a contract to provide the CCG’s internal audit and counter fraud services for three years form 1 April 2017. The recommendation of the Audit Panel was ratified by Governing Body on 11 May 2017.

8) External Audit

8.1 Ernst and Young LLP (EY) are the CCG’s External Auditors.

8.2 The External Auditors formally give a qualified or unqualified opinion on the CCG’s financial statements and value for money arrangements each year through their Governance Report. EY also provide very helpful reports on emerging issues and developments.

2016/17 Accounts

8.3 Meetings were held to review the draft 2016/17 accounts on 24 April 2017 and the final accounts on 26 May 2017. These were approved by the Audit Committee, under its delegated authority from the Governing Body.

8.4 The Committee also received the External Auditor’s report on the annual audit for 2016/17 and noted that the External Auditor had provided an unqualified opinion on the financial statements. There were no unadjusted audit differences to report. The Value for Money conclusion was qualified ‘except-for’ on the grounds of financial resilience.

8.5 The Committee also noted that EY had issued a section 30 referral to the Secretary of State for Health due to due to the breach in the statutory financial duty.

9) Counter Fraud

9.1 The CCG is committed to developing and maintaining a counter fraud culture. The CCG has appointed a specialist contractor (CW Audit) to deliver counter fraud services. The local counter fraud specialist (LCFS) takes the lead on all areas of fraud including the prevention and detection of fraud, the investigation of fraud, and the creation of an anti-fraud culture.

9.2 The LCFS ensures that all CCG staff are aware of the implications of The Bribery Act 2010 to protect the CCG and individual staff members.

9.3 The LCFS agreed an annual work programme with the Audit Committee which reflected national self-review counter fraud standards for commissioners. The CCG was required to undertake a self-assessment against these standards and rated itself as ‘green’; recognising there are areas for improvement. This was however an improvement from the self-assessed amber rating in 2014/15.

9.4 During the year, the LCFS conducted an investigation on behalf of the CCG relating to concerns raised about one Personal Health Budget (PHB) where spending exceeded the allocated funds. Criminal action was not possible due to the difficulty in gathering robust evidence, however as a result of the contract in place between the budget holder and the management organisation (supporting the delivery of the payroll function) the CCG was not liable for the deficit incurred.

9.5 As a result of the investigation lessons were learned and implemented including the process for ongoing monitoring of PHB’s being made more robust to mitigate against future mismanagement.

10) Security Management

10.1 CCG’s as Commissioners of healthcare, have a responsibility to ensure that:

• anyone working in the NHS, receiving NHS treatment or visiting NHS premises, feels safe and secure from violence and abuse; • funds and assets belonging to the NHS or used to provide NHS services, are also kept safe and secure.

10.2 The CCG has appointed a specialist contractor (CW Audit) to deliver security management services to ensure these obligations are adhered to.

10.3 The Security Management specialist agreed an annual work programme with the Audit Committee which included proactive work to ensure national standards for commissioners for Security Management are being achieved and reactive work on investigations that need to take place. Progress reports have been regularly considered by the Committee with no key issues raised.

11) Governance, Risk Management and Internal Control

11.1 Financial Reporting - The CCG’s financial position was reported at all Audit Committee meetings during 2016/17, where it was discussed and thoroughly challenged. The Chief Finance Officer presented an update at each meeting to ensure that members were fully apprised of the CCG’s financial position against its statutory duties.

11.2 Compliance with Standing Orders and Standing Financial Instructions - The Committee has had regular updates and assurances from the Chief Finance Officer regarding the CCG’s compliance with Standing Orders and Standing Financial Instructions. There were no known compliance issues with the SFIs

11.3 Financial Control Environment Self-Assessment (FCEA) Actions – the Committee has regularly reviewed and scrutinised the CCG’s FCEA action plan and confirmed that it is satisfied with progress.

11.4 Service Auditor Reports – The Committee has reviewed these reports on services provided to the CCG by the CSU and SBS to gain additional assurance.

11.5 Delegated Financial limits – The Committee has reviewed and recommended to Governing Body changes to these limits.

11.6 Procurement Policy – The Committee considered and recommended to Governing Body amendments to the CCG’s procurement policy.

11.7 Annual Governance Statement – A half year Governance Statement was considered by the Committee on 17 November 2016 with amendments to content being made. A further updated Statement was reviewed alongside the Annual Report and Accounts at the Audit Committee meeting on 25 May 2017, where the statement was approved for submission to NHS England.

11.8 Assurance Framework - The Audit Committee held the Executive to account for maintaining an effective Assurance Framework throughout the year. The Assurance Framework identified the key risks to non-achievement of strategic CCG objectives along with the controls, mitigations and systems in place to manage each risk - as well as the type and source of assurance obtained to ensure that the controls/systems were operating effectively. Any gaps in controls or assurance were identified and action plans to close gaps and mitigate risk put in place. The Audit Committee has reported its reviews of the Assurance Framework to the Governing Body on a regular basis throughout 2016/17.

11.9 Management of Conflicts of Interest - The Committee has had regular updates and assurances regarding the CCG’s progress in achieving full compliance with NHS England’s Statutory Guidance for Management of Conflicts of Interest. Due to challenges from the LMC in relation to differing guidance issued by the BMA for GPs for reporting of gifts and hospitality, the CCG has reported partial compliance throughout the year. The Governing Body approved the CCG’s Gifts and Hospitality policy in May 2017 and now confirms full compliance, with NHS England confirming that it is acceptable for practices to report in line with the BMA guidance providing individuals who have a specific role with the CCG comply with the CCG’s policy. 11.10 Corporate Registers - The Committee has reviewed and scrutinised the Gifts and Hospitality and Commercial Sponsorship Registers throughout the year.

11.11 Other Governing Body Committees - The Audit Committee received reports from the Chairs of the Clinical Quality, Safety and Governance Committee and the Commissioning, Finance and Performance Committee to provide assurance on their working and decision processes.

12) Conclusion

12.1 The Audit Committee can confirm that it has fulfilled its duties as outlined in its Terms of Reference and has scrutinised the reports presented to the Committee requiring answers to pertinent questions and putting actions in place - all of which are recorded in the minutes of the Committee.

12.2 The Audit Committee also confirms that there are no areas of concern to highlight to the Governing Body.

13) Recommendation

13.1 The Governing Body is asked to accept and note this report on the work of the Audit Committee as part of its overall governance and assurance programme for 2016/17.

David Allcock Chair of the Audit Committee

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc Q

Report To: Governing Body in Common

Report Title: Updated Managing Conflicts of Interest Policy

Report From: Maria Maltby, Deputy Director of Corporate Affairs

Date: 12 September 2017

Previously Considered by: CRCCG Audit Committee, 12 September 2017 WNCCG Audit Committee by email during August 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To present the revised Managing Conflicts of Interest Policy for approval by the Governing Bodies.

Key Points: • In July 2017, NHS England published an update to the 2016 CCG statutory guidance on managing conflicts of interest to ensure that it is fully aligned with the recently published NHS-wide conflicts of interest guidance - Managing conflicts of interest in the NHS: Guidance for staff and organisations. • The key changes from the 2016 version of the guidance include: • Registers of interest: A requirement that CCGs have systems in place to satisfy themselves as a minimum on an annual basis that their registers of interest are accurate and up-to-date, and to require that only decision-making staff are included on the published register. • Gifts from suppliers or contractors: In line with the NHS-wide guidance, gifts of low value (up to £6), such as promotional items, can now be accepted. • Gifts from other sources: Also in line with the wider guidance, gifts of under £50 (rather than £10) can be accepted from non-suppliers and non-contractors, and do not need to be declared; and gifts with a value of over £50 can now be accepted on behalf of an organisation, but not in a personal capacity. • Hospitality: meals and refreshments: An amendment to the thresholds to advise that hospitality under £25 does not need to be declared. Hospitality between £25 and £75 can be accepted, but must be declared, and hospitality over £75 should be refused unless senior approval is given. • Commercial Sponsorship: The previous guidance made no reference to this. The new guidance states that sponsorship is welcomed providing specific principles are followed. • New care models: a new annex relating to new care models summarises elements of the guidance advice on identifying, declaring and managing conflicts of interest in the commissioning of new care models. • The CCGs’ policy has been updated to fully reflect the updated statutory guidance and reflects joint working arrangements between the two CCGs. • Coventry and Rugby CCG’s Audit Committee considered the policy at its meeting on 12 August 2017. Due to the timing of the meeting, being two days before the Governing Body meeting, verbal confirmation will be given as to whether the Committee recommends the policy for ratification. • Due to the Warwickshire North CCG Audit Committee being rescheduled and therefore no opportunity for the Committee to formally consider, the policy was circulated by email to Warwickshire North CCG’s Audit Committee and the Chair confirmed that it should be recommended to Governing Body for ratification.

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc Q

Recommendation:

The Governing Bodies are asked to APPROVE the Managing Conflicts of Interest policy for adoption.

Implications

Objective(s) / Plans This policy supports the requirement for the CCG to be compliant with NHS England supported by this Statutory Guidance in relation to managing conflicts of interest and is in line with the report: CCG’s Constitution. Conflicts of Interest: No conflicts of interest are identified in relation to this policy. Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified in relation to this policy. Quality and Safety: None identified in relation to this policy. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public None relevant to this policy. The policy will be available on the CCG’s website. Engagement: No local engagement requirements identified. Clinical engagement has been Clinical Engagement: undertaken by NHS England at a national level. The CCG has a duty to ensure that it is compliant with NHS England Statutory Guidance relating to the management of conflicts of interest. Risk and Assurance: The CCG’s Assurance Rating could be impacted if there is no compliance with the statutory guidance.

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Enclosure Q

Managing Conflicts of Interest Policy

VERSION CONTROL

Version: 5.1

Ratified by: Not yet ratified

Date ratified: Not yet ratified

Name of originator/author: Deputy Director of Corporate Affairs

Name of responsible committee: Governing Body

Date issued: Not yet issued

Review date: September 2020

VERSION HISTORY

Date Version Comment / Update

October 2012 V1 Draft prepared by Integrated Governance Lead

Updated as final version for Governing Body review and January 2013 V2 approval on 17 Jan 2013 and ratified 4th April 2013

Updated by Director of Integrated Governance following April May 2013 V3 2013 guidance from NHS England

May 2013 V3 Ratified by the Governing Body 23rd May 2013

Updated to reflect statutory guidance and presented to the January 2015 V4 Governing Body for review and approval for adoption on 22nd January 2015

The Governing Body approved the adoption of the updated January 2015 V4 policy on 22nd January 2015

July 2015 V 4.1 Updated to reflect revised statutory guidance

03 November V5.0 Version approved by Governing Body 2016

Updated version to reflect revised statutory guidance July 2017 V5.1 published by NHS England in June 2017

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Contents 1. Introduction ...... 4 2. Statutory and Legal Requirements ...... 4 3. Policy Statement ...... 4 4. Scope ...... 4 5. Policy Review ...... 6 6. What are Conflicts of Interest? ...... 6 7. Principles...... 8 8. Declaring Conflicts of Interest ...... 9 9. Register of Interests ...... 11 10. Declaration of Offers and Receipt of Gifts and Hospitality ...... 12 11. Roles and responsibilities in the CCGs ...... 15 12. Governance Arrangements and Decision Making ...... 17 13. Managing conflicts of interest throughout the commissioning cycle ...... 22 14. Raising Concerns and Breaches ...... 26 15. Implications of non-compliance ...... 28 16. Conflicts of interest training...... 29 17. Monitoring Compliance and Effectiveness of the Policy ...... 30 18. Equality and Diversity Statement ...... 30 Appendix 1 – Template Declaration of Interest Form for Employees and Members ...... 32 Appendix 2 – Register of Interests Template ...... 34 Appendix 3 – Decision Making Staff ...... 35 Appendix 4 – Template Declaration of Gifts and Hospitality Form ...... 36 Appendix 5 - Register of Gifts and Hospitality Template ...... 37 Appendix 6 - Declaration of Interest Checklist for Meeting Chairs ...... 38 Appendix 7- Procurement Checklist Template ...... 40 Appendix 8 – Template Register of Procurement Decisions ...... 42 Appendix 9 – Template Declaration of Interest Form for Bidders/Contractors ...... 43 Appendix 10 – Equality Impact Assessment ...... 45

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1. Introduction

1.1. Managing conflicts of interest appropriately is essential for protecting the integrity of the overall NHS commissioning system and to protect the NHS from any perceptions of wrongdoing. The CCG needs to demonstrate the highest levels of transparency so that it can demonstrate that conflicts of interest are managed in a way that cannot undermine the probity and accountability of the organisation.

1.2. It will not be possible to avoid conflicts of interest. They are inevitable in many aspects of public life, including the NHS. However, by recognising where and how they arise and dealing with them appropriately, the CCG will be able to ensure proper governance, robust decision-making, and that appropriate decisions about the use of public money are made.

1.3. This policy sets out how NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby CCGs (the CCGs) will manage conflicts of interest arising from the operation of the organisations.

2. Statutory and Legal Requirements

2.1. This policy complies with:

• Section 14O of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012);

• NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013;

• Substantive guidance on the Procurement, Patient Choice and Competition Regulations, Monitor;

• NHS England Managing Conflicts of Interest, Revised Statutory guidance for CCGs 2017.

• Managing Conflicts of Interest in the NHS – Guidance for staff and organisations.

3. Policy Statement

3.1. This policy supports a culture of openness and transparency in business transactions and aims to:

• Safeguard clinically led commissioning, whilst ensuring objective investment decisions; • Enable the CCGs to demonstrate that it is acting fairly and transparently and in the best interests of its patients and local population; • Uphold confidence and trust in the NHS; • Support staff and members to understand when conflicts (whether actual, potential or perceived) may arise and how to manage them if they do; • Ensure that the CCGs operate within its legal framework. 4. Scope

4.1. This policy applies to all those who are employed by the CCGs and/or act in an official capacity on its behalf. This includes:

• All CCG employees, including: • All full and part time staff;

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• Any staff on sessional or short term contracts; • Any students and trainees (including apprentices); • Agency staff; and • Seconded staff In addition, any self-employed consultants or other individuals working for the CCG under a contract for services should make a declaration of interest in accordance with this policy, as if they were CCG employees. • Members of the Governing Body: All members of the CCGs’ committees, and any sub-groups, including: • Co-opted members; • Appointed deputies; and • Any members of committees/groups from other organisations. • All members of the CCGs (ie, partners or directors within each practice): This includes each provider of primary medical services which is a member of the CCG under Section 14O (1) of the 2006 Act. 4.2. It is the responsibility of all individuals to familiarise themselves with this policy and comply with its provisions.

4.3. The policy should be read in conjunction with the following documents, which also set out guidelines and responsibilities for the CCGs, NHS organisations generally and General Practitioners and Nurses in relation to conflicts of interests:

• The CCG’s Constitutions, in particular the section relating to conflicts of interest which describes in generic terms the types of conflict of interest, as well as the CCG’s Standing Orders, Scheme of Reservation and Delegation of Powers and Standing Financial Instructions. • The CCGs’ Procurement Policy; • The CCGs’ Gifts and Hospitality Policy; • The CCGs’ Commercial Sponsorship Policy; • The CCGs’ Whistleblowing Policy; • Guidance issued by NHS England including guidance on procurement; • Code of Conduct for NHS Managers; • General Medical Council: Good Medical Practice 2013; • Nursing and Midwifery Council: Code of Professional Conduct.

4.4. Members should also refer to their respective professional codes of conduct relating to the declaration of conflicts of interest.

4.5. The CCGs will ensure that all employees and contractors who take decisions are aware of the existence of this policy. The following will be undertaken as appropriate to ensure such awareness:

• Introduction to the policy during local induction for new starters to the organisations; • Annual reminder of the existence and importance of the policy via internal communication methods; • Annual reminder to update declaration forms sent to all CCG members and staff.

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• Annual reminder to complete mandatory managing conflicts of interest training by 31 January each year.

5. Policy Review

5.1. The policy will be reviewed every three years or sooner should new guidance be issued by NHS England. All individuals identified in paragraph 4.1 will be reminded of the policy and register of interests at least annually.

6. What are Conflicts of Interest?

6.1. For the purposes of this policy a conflict of interest is defined “as a set of circumstances by which a reasonable person would consider that an individual's ability to apply judgement or act in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.

6.2. A conflict of interest may be:

• Actual – there is a material conflict between one or more interests

• Potential – there is the possibility of a material conflict between one or more interests in the future.

6.3. Staff may hold an interest for which they cannot see potential conflict. However, caution is always advisable because others may see it differently. It will be important to exercise judgement and to declare such interests where there is otherwise a risk of imputation of improper conduct. The perception of an interest can be as damaging as an actual conflict of interest.

6.4. Conflicts of interest can arise in many situations, environments and forms of commissioning. There is an increased risk in primary care commissioning, out-of- hours commissioning and involvement with integrated care organisations, and new care models, as the CCG may here find itself in a position of being commissioner and provider of services. Conflicts of interest can arise throughout the whole commissioning cycle from needs assessment, to procurement exercises, to contract monitoring including in relation to ‘new care models’, Multi-speciality Community Providers (MCP), Primary and Acute Care Systems (PACS) or other arrangements of a similar scale or scope. NHS England has published an annex to its statutory guidance which summarises the key aspects from the guidance on managing conflicts of interest in the commissioning of new care models1.

6.5. Interests fall into the four categories outlined below. A benefit may arise from the making of a gain or the avoidance of a loss.

6.6. Financial interests: This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

• A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. This includes involvement with a potential provider of a new care model; • A shareholder (or similar ownership interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or

1 https://www.england.nhs.uk/wp-content/uploads/2017/06/revised-ccg-coi-guidance-jul-17.pdf NHS Warwickshire North Clinical Commissioning Group Page 6 of 45 Conflict of Interest Policy v5.0

which is likely, or possibly seeking to do, business with health or social care organisations; • A management consultant for a provider. • A provider of clinical private practice. This could also include an individual being: • In employment outside of the CCG; • In receipt of secondary income; • In receipt of a grant from a provider; • In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider; • In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and • Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). 6.7. Non-financial professional interests: This is where an individual may obtain a non- financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

• An advocate for a particular group of patients; • A GP with special interests eg, in dermatology, acupuncture etc; • An active member of a particular specialist professional body (although routine GP membership of the RCGP, British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); • An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE); • Engaged in a research role; • The development and holding of patents and other intellectual property rights which allow staff to protect something that they create, preventing unauthorised use of products or the copying of protected ideas; or • GPs, other professionals and practice managers, who are members of the Governing Body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices. 6.8. Non-financial personal interests: This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

• A voluntary sector champion for a provider; • A volunteer for a provider; • A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation; • Suffering from a particular condition requiring individually funded treatment; • A member of a lobby or pressure group with an interest in health. 6.9. Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-

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financial personal interest in a commissioning decision (as those categories are described above) for example:

• Spouse / partner; • Close family member or relative eg, parent, grandparent, child, grandchild or sibling; • Close friend or associate; • Business partner. A declaration of interest for a “business partner” in a GP partnership should include all relevant collective interests of the partnership, and all interests of their fellow GP partners (which could be done by cross referring to the separate declarations made by those GP partners, rather than by repeating the same information verbatim). Whether an interest held by another person gives rise to a conflict of interests will depend upon the nature of the relationship between that person and the individual, and the role of the individual within the CCGs. 6.10. A range of conflicts of interest case studies can be found in NHS England’s June 2016 publication Managing conflicts of interest: Case Studies2.

6.11. The above categories and examples are not exhaustive and discretion will be exercised on a case by case basis, including in relation to new care model arrangements, in deciding whether any other role, relationship or interest may impair or otherwise influence the individual’s judgement or actions in their role within the CCGs. If so, this should be declared and appropriately managed.

7. Principles

7.1. This section outlines principles for those who are serving as members of the CCGs’ Governing Body, CCGs’ committees, or take decisions where they are acting on behalf of the public or spending public money.

7.2. All CCG staff and members should observe the principles of good governance in the way they do business. These include:

• The Nolan Principles3 (as set out below) • The Good Governance Standards for Public Services (2004), Office for Public Management (OPM) and Chartered Institute of Public Finance and Accountancy (CIPFA)4 • The seven key principles of the NHS Constitution5 • The Equality Act 20106 • The UK Corporate Governance Code7 • Standards for members of NHS boards and CCG governing bodies in England8

2 https://www.england.nhs.uk/publication/managing-conflicts-of-interest-ccg-case-studies/ 3 The 7 principles of public life https://www.gov.uk/government/publications/the-7-principles-of-public-life 4 The Good Governance Standards for Public Services , 2004, OPM and CIPFA http://www.opm.co.uk/wp- content/uploads/2014/01/Good-Governance-Standard-for-Public-Services.pdf 5 The seven key principles of the NHS Constitution http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx 6 The Equality Act 2010 http://www.legislation.gov.uk/ukpga/2010/15/contents 7 UK Corporate Governance Code https://www.frc.org.uk/Our-Work/Codes-Standards/Corporate-governance/UK-Corporate- Governance-Code.aspx 8 Standards for members of NHS boards and CCG governing bodies in England http://www.professionalstandards.org.uk/publications/detail/standards-for-members-of-nhs-boards-and-clinical-commissioning-group- governing-bodies-in-england NHS Warwickshire North Clinical Commissioning Group Page 8 of 45 Conflict of Interest Policy v5.0

7.3. All those with a position in public life should adhere to the Nolan principles, which are:

• Selflessness – Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends; • Integrity – Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties; • Objectivity – In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit; • Accountability – Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office; • Openness – Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands; • Honesty – Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest; • Leadership – Holders of public office should promote and support these principles by leadership and example. 7.4. In addition, to support the management of conflicts of interest, CCG staff and members are expected to:

• Do business appropriately: Conflicts of interest become much easier to identify, avoid and/or manage when the processes for needs assessments, consultation mechanisms, commissioning strategies and procurement procedures are right from the outset, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny; • Be proactive, not reactive: the CCGs should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity; • Be balanced, sensible and proportionate: Rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision-making is transparent and fair whilst not being overly constraining, complex or cumbersome; • Be transparent: Document clearly the approach and decisions taken at every stage in the commissioning cycle so that a clear audit trail is evident; • Create an environment and culture where individuals feel supported and confident in declaring relevant information and raising any concerns. 7.5. In addition to the above, CCG staff and members need to bear in mind:

• A perception of wrongdoing, impaired judgement or undue influence can be as detrimental as any of them actually occurring; • If in doubt, it is better to assume the existence of a conflict of interest and manage it appropriately rather than ignore it; • For a conflict of interest to exist, financial gain is not necessary. 8. Declaring Conflicts of Interest

8.1. Conflicts of interest are a common and sometimes unavoidable part of the delivery of healthcare. As such, it may not be possible or desirable to completely eliminate the

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risk of conflicts. Instead, it may be preferable to recognise the associated risks and put measures in place to manage the conflicts appropriately when they do arise.

8.2. There will be occasions where an individual declares an interest in good faith but, upon closer consideration, it is clear that this does not constitute a genuine conflict of interest.

8.3. There will be other occasions where the conflict of interest is profound and acute. In such scenarios (such as where an individual has a direct financial interest which gives rise to a conflict, eg, secondary employment or involvement with an organisation which benefits financially from contracts for the supply of goods and services to the CCGs or aspires to be a new care model provider) it is likely that the CCGs will want to consider whether, practically, such an interest is manageable at all. This can arise in relation to both clinical and non-clinical staff/roles. If it is not, the appropriate course of action may be to refuse to allow the circumstances which gave rise to the conflict to persist. This may require an individual to step down from a particular role and/or move to another role within the CCG. Regular reviews of HR policies, governing body and committee terms of reference and standing orders will be carried out to ensure the CCGs can take appropriate action to manage conflicts of interest robustly and effectively in such circumstances.

8.4. The CCGs will ensure that, as a matter of course, declarations of interest are made and regularly confirmed or updated. The CCGs’ template declaration of interest form can be found at Appendix 1.

8.5. All persons referred to in Section 4 of this policy must declare any interests. Declarations of interest should be made as soon as reasonably practicable and by law within 28 days after the interest arises (this could include an interest an individual is pursuing).

8.6. Further occasions when declarations must be made are:

• On appointment - Applicants for any appointment to the CCGs or Governing Bodies or any committees will be asked to declare relevant interests. When an appointment is made, a formal declaration of interests will again be made and recorded. • Annually – The Register of Interests will be confirmed as accurate and up to date at least annually; • At meetings - all attendees will be required to declare their interests as a standing agenda item for every Governing Body, committee, sub-committee or working group meeting, before the item is discussed. Even if an interest is declared in the Register of Interests, it should be declared in meetings where matters relating to that interest are discussed. Declarations of interest will be recorded in the minutes of meetings; • On changing role, responsibility or circumstances - Where an individual’s role, responsibility or circumstances change in a way that affects the individual’s interests (eg, where an individual takes up a new role outside the CCG’, enters into a new business or relationship, starts a new project/piece of work or may be affected by a procurement decision, eg, if their role may transfer to a proposed new provider), a further declaration should be made to reflect the change in circumstances as soon as possible, and in any event within 28 days. This could involve a conflict of interest ceasing to exist or a new one materialising. It is the responsibility of the individual to make their declaration rather than waiting to be asked. 8.7. Whenever interests are declared they should be promptly reported to the Deputy Director of Corporate Affairs who will ensure that the register of interests is updated accordingly.

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8.8. Where individuals are unsure whether a situation gives potential for a conflict of interest they should seek advice from the Deputy Director of Corporate Affairs or the Conflicts of Interest Guardians (Governing Body Lay Members for Audit and Governance). If in doubt, the individual concerned should assume that a potential conflict of interest exists and declare it.

8.9. Any declaration of interest will be included in the Register of Interests.

9. Register of Interests

9.1. Each CCG has a Register of Interests which is held centrally as an electronic joint register. The registers record declared interests for:

• All CCG employees, including: • All full and part time staff; • Any staff on sessional or short term contracts; • Any students and trainees (including apprentices); • Agency staff; and • Seconded staff In addition, any self-employed consultants or other individuals working for the CCGs under a contract for services should make a declaration of interest in accordance with this policy, as if they were CCG employees. • Members of the Governing Body: All members of the CCG’s committees, and any sub-committees/sub-groups, including: • Co-opted members; • Appointed deputies; and • Any members of committees/groups from other organisations. Where the CCGs are participating in a joint committee alongside other CCGs, any interests which are declared by the committee members should be recorded on the register(s) of interest of each participating CCG. • All members of the CCGs (ie, Partners and Directors within each practice): This includes each provider of primary medical services which is a member of the CCG under Section 14O (1) of the 2006 National Health Service Act. Declarations should be made by the following groups: • GP partners (or where the practice is a company, each director); • Any individual directly involved with the business or decision-making of the CCGs. 9.2. The Register will be confirmed as accurate and up to date at least annually and then reviewed by the Governing Body. A template of the register of interests can be found at Appendix 2.

9.3. The Register of Interests will be published at least annually for decision making staff (see Appendix 3 for definition of decision making staff) and made publicly available via the following methods:

Coventry and Rugby CCG Warwickshire North CCG

• Published on the CCG's website: • Published on the CCG's www.coventryrugbyccg.nhs.uk; website: www.warwickshirenorthccg.nhs. • On request for inspection at the CCG's uk; headquarters; • On request for inspection at the CCG's • On request either by post to Parkside headquarters;

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House, Quinton Road Coventry, CV1 • On request either by post to NHS 2NJ or email to : Warwickshire North CCG, Second Floor, [email protected] Heron House, Newdegate Street, Nuneaton, CV11 4EL or email to : [email protected] k.

9.4. Interests of decision making staff will remain on the public register for a minimum of six months after the interest has expired. In addition, the CCG will retain a private record of historic interests for a minimum of 6 years after the date on which it expired. The CCGs’ published register of interests will indicate that historic interests are retained by the CCGs with details of who to contact to submit a request for this information.

9.5. In exceptional circumstances, where the public disclosure of information could give rise to a real risk of harm or is prohibited by law, an individual’s name and/or other information may be redacted from the publicly available register. Where an individual believes that substantial damage or distress may be caused, to him/herself or somebody else by the publication of information about them, they are entitled to request that the information is not published. Such requests must be made in writing. Decisions not to publish information will only be made by the respective CCGs Conflicts of Interest Guardian, who will seek appropriate legal advice where required, and the CCG will retain a confidential un-redacted version of the register.

9.6. All decision making staff will be made aware that the register will be published in advance of publication. This will be done by the provision of a fair processing notice that details the identity of the data controller, the purposes for which the registers are held and published, and contact details for the data protection officer. This information will additionally be provided to individuals identified in the registers because they are in a relationship with the person making the declaration.

9.7. All staff who are not decision making staff but who are still required to make a declaration of interest will be made aware that a register is kept. This will be done by the provision of fair processing notice that details the identity of the data controller, the purposes for which the register is held, how the information on the register may be used or shared and contact details for the data protection officer. This information should be additionally be provided to individuals identified in the register because they are in a relationship with the person making the declaration.

9.8. The Register will form part of the respective CCGs’ Annual Report and Annual Governance Statements.

10. Declaration of Offers and Receipt of Gifts and Hospitality

10.1. Staff in the NHS offer support during significant events in people’s lives. For this work they may sometimes receive gifts as a legitimate expression of gratitude. However, situations where the acceptance of gifts could give rise to conflicts of interest should be avoided. CCG staff and members should be mindful that even gifts of a small value may give rise to perceptions of impropriety and might influence behaviour if not handled in an appropriate way.

10.2. As outlined in the CCGs’ Gifts and Hospitality Policies, all individuals listed in paragraph 4 must not accept gifts, hospitality or benefits of any kind from a third party which might affect, or be seen to affect, their professional judgement.

10.3. GPs and other staff within the CCGs’ member practices are not required to declare offers/receipt of gifts and hospitality to the CCGs which are unconnected with their role or involvement with the CCG. GP staff will however be expected to adhere to other relevant guidance issued by professional bodies.

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10.4. Individuals need to consider the risks associated with accepting offers of gifts, hospitality and entertainment when undertaking activities for or on behalf of the CCGs or their GP practice. This is especially important during procurement exercises, as the acceptance of gifts could give rise to real or perceived conflicts of interests, or accusations of unfair influence, collusion or canvassing.

10.5. All offers of gifts and hospitality should be notified to the Deputy Director of Corporate Affairs as soon as reasonably practicable and by law within 28 days after the interest arises (this could include an interest an individual is pursuing). The offer will be recorded on the CCGs’ Register of Gifts and Hospitality. A template Declaration of Gifts and Hospitality Form can be found at Appendix 4 and a template of the Register of Gifts and Hospitality can be found at Appendix 5.

10.6. The Register of Gifts and Hospitality will be published at least annually for decision making staff (see Appendix 3 for definition) and made publicly available via the following methods:

Coventry and Rugby CCG Warwickshire North CCG

• Published on the CCG's website: • Published on the CCG's www.coventryrugbyccg.nhs.uk; website: www.warwickshirenorthccg.nhs. • On request for inspection at the CCG's uk; headquarters; • On request for inspection at the CCG's • On request either by post to Parkside headquarters; House, Quinton Road Coventry, CV1 • On request either by post to NHS 2NJ or email to : Warwickshire North CCG, Second Floor, [email protected] Heron House, Newdegate Street, Nuneaton, CV11 4EL or email to : [email protected] k.

10.7. Offers of gifts and hospitality for decision making staff will remain on the public register for a minimum of six months after the interest has expired. The CCGs will also retain a private record of historic offers/receipt of gifts and hospitality for a minimum of 6 years after the date on which it expired.

Gifts

10.8. A 'gift' is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value.

10.9. Gifts from suppliers or contractors doing business (or likely to do business ) with the CCG’ should be declined, whatever their value (subject to this, low cost branded promotional aids may be accepted and not declared where they are under the value of a common industry standard of £6). The person to whom the gifts were offered should also declare the offer to the Deputy Director of Corporate Affairs so the offer which has been declined can be recorded on the gifts and hospitality register.

10.10. Gifts from other sources (eg, patients, families, service users) under a value of £50 may be accepted and do not need to be declared. A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value), however:

• CCG staff should not ask for any gifts;

• Gifts valued at over £50 should be treated with caution and only be accepted on behalf of an organisation (i.e. to an organisation’s charitable funds), not in a personal capacity. These should be declared by the individuals concerned.

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• Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50.

10.11. Any personal gift of cash or cash equivalents (eg, vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCGs) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the Deputy Director of Corporate Affairs and recorded on the register.

Hospitality

10.12. Delivery of services across the NHS relies on working with a wide range of partners (including industry and academia) in different places and, sometimes outside of ‘traditional’ working hours. As a result, CCG staff will sometimes appropriately receive hospitality. However, individuals should be able to justify why it has been accepted, and be mindful that even hospitality of a small value may give rise to perceptions of impropriety and might influence behaviour.

10.13. Hospitality means offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education, and training events etc. Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

10.14. CCG staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement. Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors, these can be accepted if modest and reasonable, but individuals should always obtain senior approval and declare these.

10.15. Offers of meals and refreshments under £25 may be accepted and need not be declared. Offers of a value between £25 and £75 may be accepted and must be declared. Offers over a value of £75 should be refused unless (in exceptional circumstances) approval from the Chief Officer (Accountable Officer) is given.

10.16. A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

Travel and Accommodation 10.17. Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

10.18. Offers which go beyond modest, or are of a type not usually offered by the CCGs need to be approved by the Chief Officer (Accountable Officer) and should only be accepted in exceptional circumstances and must be declared. A non-exhaustive list of examples includes:

• offers of business class or first class travel and accommodation (including domestic travel); and

• offers of foreign travel and accommodation.

Sponsored Events

10.19. Sponsorship of NHS events by external parties is valued. Offers to meet some or part of the costs of running an event secures their ability to take place, benefitting NHS staff and patients. Without this funding there may be fewer opportunities for learning, development and partnership working. However, there is potential for conflicts of interest between the organiser and the sponsor, particularly regarding the

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ability to market commercial products or services. As a result the CCGs will put in place safeguards to present conflicts occurring.

10.20. When sponsorships are offered, the CCGs will adopt the following principles:

• Sponsorship of CCG events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in a clear benefit for the CCG and the NHS.

• During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

• No information should be supplied to the sponsor from which they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

• At the CCG’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.

• The involvement of a sponsor in an event should always be clearly identified in the interest of transparency.

• The CCGs should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.

• Staff should declare involvement with arranging sponsored events to the Deputy Director of Corporate Affairs.

10.21. The CCG will maintain records regarding sponsored events in line with the above principles. The CCGs’ Commercial Sponsorship Policies set out the authorisation process for sponsorship.

10.22. Other forms of sponsorship: organisations external to the CCG’ (or NHS) may sponsor posts or research. However, there is potential for conflicts of interest to occur, particularly when research funding by external bodies does or could lead to a real or perceived commercial advantage, or if sponsored posts cause a conflict of interest between the aims of the sponsor and the aims of the organisation, particularly in relation to procurement and competition. There needs to be transparency and any conflicts of interest should be well managed. If such circumstances arise the CCGs’ Commercial Sponsorship Policies set out how this will be managed.

11. Roles and responsibilities in the CCGs

11.1. Everyone in the CCG has responsibility to appropriately manage conflicts of interest however some roles within the CCG have specific accountabilities and responsibilities which are outlined below.

Chief (Accountable) Officer

11.2. The Chief (Accountable) Officer has overall accountability for the CCGs’ management of conflicts of interest. Day to day executive accountability has been delegated to the Chief Operating Officer.

Chief Operating Officer

11.3. The Chief Operating Officer is the accountable Executive Team member for management of conflicts of interest.

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Chief Finance Officer

11.4. The Chief Finance Officer is responsible for ensuring that conflicts of interest are managed and recorded appropriately, and in accordance with this policy, throughout all procurements and contract monitoring. This includes maintenance and publication of the register of procurements.

Chief Strategy and Primary Care Officer

11.5. The Chief Strategy and Primary Care Officer is responsible for ensuring that conflicts of interest are managed and recorded appropriately, and in accordance with this policy, throughout the whole service design/re-design and commissioning cycle. The Chief Strategy and Primary Care Officer is responsible for ensuring a Procurement Checklist is completed for all services commissioned.

Deputy Director of Corporate Affairs

11.6. The Deputy Director of Corporate Affairs has responsibility for the day-to-day management of conflicts of interest matters and queries, including maintenance and publication of the register of declarations and the gifts and hospitality register.

Conflicts of Interest Guardians

11.7. The respective CCGs’ Lay Members for Audit and Governance undertake the role of Conflicts of Interest Guardians. The Conflicts of Interest Guardians, in collaboration with the CCG’s Deputy Director Corporate Affairs:

• Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest;

• Are a safe point of contact for employees or workers of the CCGs to raise any concerns in relation to this policy;

• Support the rigorous application of conflict of interest principles and policies;

• Provide independent advice and judgment where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation;

• Provide advice on minimising the risks of conflicts of interest.

11.8. The Deputy Director of Corporate Affairs has a responsibility to keep the Conflicts of Interest Guardians and the Chief Operating Officer well briefed on conflicts of interest matters and issues arising.

11.9. Whilst the Conflicts of Interest Guardians have an important role within the management of conflicts of interest, executive members of the CCG’s Governing Bodies have an on-going responsibility for ensuring the robust management of conflicts of interest, and all CCG employees, Governing Body and committee members and member practices will continue to have individual responsibility in playing their part on an ongoing and daily basis.

CCG Lay Members

11.10. Lay members play a critical role in the CCG, providing scrutiny, challenge and an independent voice in support of robust and transparent decision-making and management of conflicts of interest. They chair a number of CCG committees, including the Commissioning, Finance and Performance Committee, Remuneration Committee, Audit Committee and Primary Care Joint Commissioning Committee.

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11.11. By statute, all CCGs must have at least two lay members (one of whom must have qualifications, expertise or experience such as to enable the person to express informed views about financial management and audit matters9 and serve as the chair of the audit committee10; and the other, knowledge of the geographical area covered in the CCG’s constitution such as to enable the person to express informed views about the discharge of the CCG’s functions11). In light of lay members’ expanding role in primary care co-commissioning, in April 2015 both CCGs increased the number of lay members on the Governing Body to three.

11.12. In instances where one of the CCGs has difficulties in recruiting lay members, the CCGs will consider sharing lay members providing that the lay member has the knowledge and insight of the geographical area covered in the CCG Constitution.

12. Governance Arrangements and Decision Making

Appointing Governing Body or committee members and senior employees

12.1. On appointing Governing Body, committee or sub-committee members and senior staff, the CCGs will consider whether conflicts of interest should exclude individuals from being appointed to the relevant role. This will be considered on a case-by-case basis.

12.2. The CCGs will assess the materiality of the interest, in particular whether the individual (or any person with whom they have a close association as listed in paragraph 6.9) could benefit (whether financially or otherwise) from any decision the CCGs might make. This will be particularly relevant for Governing Body and committee appointments, but will also be considered for all employees and especially those operating at senior level.

12.3. The CCGs will also determine the extent of the interest and the nature of the appointee’s proposed role within the CCGs. If the interest is related to an area of business significant enough that the individual would be unable to operate effectively and make a full and proper contribution in the proposed role, then that individual would not be appointed to the role.

12.4. Any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to the CCGs (whether as a provider of healthcare, including ‘new care model’ providers or commissioning support services, or otherwise) should recognise the inherent conflict of interest risk that may arise and will not be a member of the Governing Body or of a committee or sub-committee of the CCGs. In particular, if the nature and extent of their interest and the nature of their proposed role is such that they are likely to need to exclude themselves from decision-making on so regular a basis that it significantly limits their ability to effectively perform that role.

Outside employment

12.5. Employees, members, contractors and others engaged under contract are required to inform and obtain prior permission by the CCGs if they are employed or engaged in, or wish to be employed or engage in, any employment or consultancy work in addition to their work with the CCGs (eg. in relation to new care model arrangements). The CCGs reserve the right to refuse permission where they believe a conflict will arise which cannot be effectively managed. Any existing outside employment should be declared on the individuals declaration of interest form on appointment, and when any new outside employment when it arises.

9 Section 12(3) NHS (CCG) Regulations 2012 http://www.legislation.gov.uk/uksi/2012/2996/pdfs/uksi_20122996_en.pdf 10 Section 14(2) NHS (CCG) Regulations 2012 http://www.legislation.gov.uk/uksi/2012/2996/pdfs/uksi_20122996_en.pdf 11 Section 12(4) NHS (CCG) Regulations 2012 http://www.legislation.gov.uk/uksi/2012/2996/pdfs/uksi_20122996_en.pdf NHS Warwickshire North Clinical Commissioning Group Page 17 of 45 Conflict of Interest Policy v5.0

12.6. Examples of work which might conflict with the business of the CCGs, including part- time, temporary and fixed term contract work, include:

• Employment with another NHS body;

• Employment with another organisation which might be in a position to supply goods/services to the CCGs including paid advisory positions and paid honorariums which relate to bodies likely to do business with the CCGs;

• Directorships e.g. of a GP federation or non-executive roles; and

• Self-employment, including private practice, charitable trustee roles, political roles and consultancy work, in a capacity which might conflict with the work of the CCGs or which might be in a position to supply goods/services to the CCGs.

• In particular, it is unacceptable for pharmacy advisers or other advisers, employees or consultants to the CCG on matters of procurement to themselves be in receipt of payments from the pharmaceutical or devices sector.

Managing Conflicts of Interests at Meetings

12.7. The chair of a meeting of the CCGs’ Governing Body or any of its committees, sub- committees or groups has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action in order to manage the conflict of interest.

12.8. In the event that the chair of a meeting has a conflict of interest, the vice chair is responsible for deciding the appropriate course of action in order to manage the conflict of interest. If the vice chair is also conflicted then the remaining non- conflicted voting members of the meeting should agree between themselves how to manage the conflict(s).

12.9. In making such decisions, the chair (or vice chair or remaining non-conflicted members as above) may wish to consult with the Conflicts of Interest Guardian or another member of the Governing Body.

12.10. The CCGs’ Deputy Director of Corporate Affairs, CCGs’ Directors and, if required, the Conflicts of Interest Guardian, will proactively consider ahead of meetings what conflicts are likely to arise and how they should be managed, including taking steps to ensure that supporting papers for particular agenda items of private sessions/meetings are not sent to conflicted individuals in advance of the meeting where relevant.

12.11. To support chairs in their role, they will be provided with declaration of interest checklist prior to meetings, which includes details of any declarations of conflicts which have already been identified or made by members of the group. A template declaration of interest checklist can be found at Appendix 6. A copy of the Register of Interests will also be available to chairs.

12.12. As a standing agenda item for both public and confidential meetings, the chairs of CCG meetings will ask at the beginning of each meeting if anyone has any conflicts of interest to declare in relation to the business to be transacted at the meeting. Each member of the group should declare any interests which are relevant to the business of the meeting whether or not those interests have previously been declared. Any new interests which are declared at a meeting are to be included on the CCGs’ relevant register of interests to ensure it is up-to-date.

12.13. Similarly, any new offers of gifts or hospitality (whether accepted or not) which are declared at a meeting will be included on the CCGs’ register of gifts and hospitality to ensure it is up-to-date.

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12.14. It is the responsibility of each individual member of the meeting to declare any relevant interests which they may have. However, should any other member of the meeting be aware of facts or circumstances which may give rise to a conflict of interest but which have not been declared then they should bring this to the attention of the chair who will decide whether there is a conflict of interest and the appropriate course of action to take in order to manage the conflict of interest.

12.15. When a member of the meeting (including the chair or vice chair) has a conflict of interest in relation to one or more items of business to be transacted at the meeting, the chair (or vice chair or remaining non-conflicted members where relevant as described above) must decide how to manage the conflict. The appropriate course of action will depend on the particular circumstances, but could include one or more of the following:

• Where the chair has a conflict of interest, deciding that the vice chair (or another non-conflicted member of the meeting if the vice chair is also conflicted) should chair all or part of the meeting;

• Requiring the individual who has a conflict of interest (including the chair or vice chair if necessary) not to attend the meeting;

• Ensuring that the individual concerned does not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict;

• Requiring the individual to leave the discussion when the relevant matter(s) are being discussed and when any decisions are being taken in relation to those matter(s). In private meetings, this could include requiring the individual to leave the room and in public meetings to either leave the room or join the audience in the public gallery;

• Allowing the individual to participate in some or all of the discussion when the relevant matter(s) are being discussed but requiring them to leave the meeting when any decisions are being taken in relation to those matter(s). This may be appropriate where, for example, the conflicted individual has important relevant knowledge and experience of the matter(s) under discussion, which it would be of benefit for the meeting to hear, but this will depend on the nature and extent of the interest which has been declared;

12.16. Noting the interest and ensuring that all attendees are aware of the nature and extent of the interest, but allowing the individual to remain and participate in both the discussion and in any decisions. This is only likely to be the appropriate course of action where it is decided that the interest which has been declared is either immaterial or not relevant to the matter(s) under discussion. NHS England’s June 2016 publication Managing conflicts of interest: Case Studies12 includes examples of material and immaterial conflicts of interest.

12.17. Where the conflict of interest relates to outside employment and an individual continues to participate in meetings pursuant to the preceding two bullet points, he or she should ensure that the capacity in which they continue to participate in the discussions is made clear and correctly recorded in the meeting minutes. Where it is appropriate for them to participate in decisions they must only do so if they are acting in their CCG role.

Occasions where more multiple members of a meeting are required to withdraw

12.18. In many cases, for example, where a limited number of GPs have an interest, it should be straightforward for relevant individuals to be excluded from decision- making. In some cases however, all of the GPs or other practice representatives

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could have a material interest in a decision, particularly where the CCG is proposing to commission services on a direct award basis from all GP practices in the area, or where it is likely that all or most practices would wish to be qualified providers for a service under Any Qualified Provider (AQP).

12.19. Where more than 50% of the members of a meeting are required to withdraw from a meeting or part of it, owing to the arrangements agreed for the management of conflicts of interests or potential conflicts of interests, the Chair (or Deputy) will determine whether or not the discussion can proceed.

12.20. In making this decision the Chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the standing orders and/or terms of reference for the meeting in question. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interests, the Chair of the meeting shall consult with the Conflicts of Interest Guardian or the Deputy Director Corporate Affairs on the appropriate action to be taken. This may include:

• Where the initial responsibility for the decision does not rest with the Governing Body: • Requiring another of the Governing Body's committees or sub- committees (as appropriate) which can be quorate to progress the item of business, or if this is not possible; • refer the decision to the Governing Body and exclude all GPs or other practice representatives with an interest in the decision from the decision making process, ie, so that the decision is made only by the non-GP members of the Governing Body including the Lay and Executive Members and the Registered Nurse and Secondary Care Doctor; • Where the initial decision rests with the Governing Body, consider: • Co-opting individuals from the Health and Wellbeing Board or from another CCG onto it (taking care in ensuring that they do not also have a conflict of interest); • Inviting the Health and Wellbeing Board or another CCG to review the proposal – to provide additional scrutiny. 12.17. These arrangements must be recorded in the minutes.

Primary Care Commissioning Committee (Coventry and Rugby CCG) / Joint Commissioning Committee (Warwickshire North CCG)

12.18. Decisions, including procurement decisions, relating to the commissioning of primary care medical services will be made by the Primary Care Commissioning Committee for Coventry and Rugby CCG and the Primary Care Joint Commissioning Committee for Warwickshire North CCG.

12.19. The membership of the respective Committees is constituted so as to ensure that the majority is held by Lay Members and executive members. Both the Chair and Vice- Chair are Lay Members. The meetings will be held in public unless the CCGs conclude it appropriate to exclude the public where it would be prejudicial to the public interest to hold that part of the meeting in public. Examples of where it may be appropriate to exclude the public are:

• Information about individual patients or other individuals which includes sensitive personal data is to be discussed;

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• Commercially confidential information is to be discussed, for example the detailed contents of a provider’s tender submission; • Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings is to be discussed; • To allow the meeting to proceed without interruption and disruption. 12.20. Although not forming part of the membership of the Primary Care Commissioning Committee or the Primary Care Joint Commissioning Committee, a standing invitation to attend these Committees will be open to the appropriate Health Watch representative (Coventry or Warwickshire HealthWatch), the Local Medical Council (LMC) and the Warwickshire Health and Wellbeing Board. Where appropriate, this will include attendance for items where the public is excluded from a particular item or meetings for reasons of confidentiality.

12.21. To ensure sufficient clinical input, the arrangements for primary medical care decision making do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision making on procurement issues and the deliberations leading up to the decision. To ensure sufficient clinical input the CCGs may appoint retired GPs or out- of-area GPs to the committee to ensure clinical input whilst minimising the risk of conflicts of interest.

Sub-Groups of the Primary Care Commissioning Committee / Joint Commissioning Committee

12.22. Whilst sub-committees or sub-groups of the Primary Care Commissioning Committee or the Primary Care Joint Commissioning Committee can be established eg, to develop business cases and options appraisals, ultimate decision-making responsibility for the primary medical services functions rests with the respective Committees. For example, whilst a sub-group could develop an options appraisal, it should take the options to the Committees for their review and decision-making. The CCGs will carefully consider the membership of any sub-committees or sub-groups and will also consider appointing a lay member as the chair.

12.23. It is important that the CCGs ensure that conflicts of interests are managed appropriately within sub-committees and sub-groups. As an additional safeguard, any sub-groups formed will submit their minutes to the respective Committees, detailing any conflicts and how they have been managed. The Committee should be satisfied that conflicts of interest have been managed appropriately in its sub- committees/sub-groups and will take action where there are concerns.

Minute-taking

12.24. It is imperative that the CCGs ensure complete transparency in decision-making processes through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the chair should ensure the following information is recorded in the minutes:

• who has the interest; • the nature of the interest and why it gives rise to a conflict, including the magnitude of any interest; • the items on the agenda to which the interest relates; • how the conflict was agreed to be managed; and • evidence that the conflict was managed as intended (for example recording the points during the meeting when particular individuals left or returned to the meeting).

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13. Managing conflicts of interest throughout the commissioning cycle

13.1. Conflicts of interest need to be managed appropriately throughout the whole commissioning cycle. At the outset of a commissioning process, the relevant interests of all individuals involved will be identified and clear arrangements put in place to manage any conflicts of interest. This includes consideration as to which stages of the process a conflicted individual should not participate in, and, in some circumstances, whether that individual should be involved in the process at all. NHS England’s June 2016 publication Managing conflicts of interest: Case Studies13 includes examples of this.

13.2. In instances where staff might transfer to a provider (or their role may materially change) following the award of a contract this will be treated as a relevant interest and managed appropriately.

Designing Service Requirements

13.3. The way in which services are designed can either increase or decrease the extent of perceived or actual conflicts of interest. Particular attention will be given to public and patient involvement in service development.

13.4. Public involvement supports transparent and credible commissioning decisions. It should happen at every stage of the commissioning cycle from needs assessment, planning and prioritisation to service design, procurement and monitoring. The CCGs have legal duties under the Health and Social Care Act 2012, to properly involve patients and the public in their respective commissioning processes and decisions.

Provider Engagement

13.5. It is good practice to engage relevant providers, especially clinicians, in confirming that the design of service specifications will meet patient needs. This may include providers from the acute, primary, community, and mental health sectors, and may include NHS, third sector and private sector providers. Such engagement, done transparently and fairly, is entirely legal. However, conflicts of interest, as well as challenges to the fairness of the procurement process, can arise if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid. The CCGs will be particularly mindful of these issues when engaging with existing/potential providers in relation to the development of new care models.

13.6. The CCGs will, as far as possible, specify the outcomes that it wishes to see delivered through a new service, rather than the way in which these outcomes are to be achieved. As well as supporting innovation, this will help to prevent bias towards particular providers in the specification of services.

13.7. Such engagement will follow the three main principles of procurement law, namely equal treatment, non-discrimination and transparency. This includes ensuring that the same information is given to all at the same time and procedures are transparent. This mitigates the risk of potential legal challenge.

13.8. The following principles will also be followed when engaging with potential service providers:

• Engagement will be used to help shape the requirement to meet patient need and the CCGs will take care not to gear the requirement in favour of any particular provider(s). Where appropriate, the advice of an independent clinical advisor on the design of the service will be secured;

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• At all stages potential providers will be made aware of how the service will be commissioned, eg, through competitive procurement or through the ‘Any qualified provider’ route; • Participants will be engaged on an equal basis, eg, ensuring openness of access to staff and information; • Procedures will be transparent; • Commercial confidentiality of information received from providers will be maintained.

Procurement and awarding grants

13.9. The CCGs needs to be able to recognise and manage any conflicts or potential conflicts of interest that may arise in relation to the procurement of any services or the administration of grants. “Procurement” relates to any purchase of goods, services or works and the term “procurement decision” should be understood in a wide sense to ensure transparency of decision making on spending public funds. The decision to use a single tender action, for instance, is a procurement decision and if it results in the CCGs entering into a new contract, extending an existing contract, or materially altering the terms of an existing contract, then it is a decision that should be recorded.

13.10. Currently NHS England and CCGs must comply with two different regimes of procurement law and regulation when commissioning healthcare services: the NHS procurement regime, and the European procurement regime:

• The NHS procurement regime – the NHS (Procurement, Patient Choice and Competition (No.2)) Regulations 2013: made under S75 of the 2012 Act; apply only to NHS England and CCGs; enforced by NHS Improvement; and

• The European procurement regime – Public Contracts Regulations 2015 (PCR 2015): incorporate the European Public Contracts Directive into national law; apply to all public contracts over the threshold value (€750,000, currently £589,148); enforced through the Courts. The general principles arising under the Treaty on the Functioning of the European Union of equal treatment, transparency, mutual recognition, non-discrimination and proportionality may apply even to public contracts for healthcare services falling below the threshold value if there is likely to be interest from providers in other member states.

13.11. Whilst the two regimes overlap in terms of some of their requirements, they are not the same – so compliance with one regime does not automatically mean compliance with the other.

13.12. The National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 201314 state:

CCGs must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract; and

CCGs must keep a record of how it managed any such conflict in relation to NHS commissioning contracts it has entered into.

The National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013

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13.13. Paragraph 24 of PCR 2015 states: “Contracting authorities shall take appropriate measures to effectively prevent, identify and remedy conflicts of interest arising in the conduct of procurement procedures so as to avoid any distortion of competition and to ensure equal treatment of all economic operators”. Conflicts of interest are described as “any situation where relevant staff members have, directly or indirectly, a financial, economic or other personal interest which might be perceived to compromise their impartiality and independence in the context of the procurement procedure”.

13.14. The Procurement, Patient Choice and Competition Regulations (PPCCR) place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, run a fair, transparent process that does not discriminate against any provider, do not engage in anti-competitive behaviour that is against the interest of patients, and protect the right of patients to make choices about their healthcare. Furthermore the PPCCR places requirements on commissioners to secure high quality, efficient NHS healthcare services that meet the needs of the people who use those services. The PCR 2015 are focussed on ensuring a fair and open selection process for providers.

13.15. An obvious area in which conflicts could arise is where the CCGs commission (or continues to commission by contract extension) healthcare services, including GP services, in which a member of a CCG has a financial or other interest. This may most often arise in the context of commissioning of primary care, where GPs are current or possible providers or in relation to the commissioning of new care models.

13.16. A procurement checklist template, provided in Appendix 7, sets out factors that the CCGs will address when drawing up its plans to commission general practice services.

13.17. The CCGs will make the evidence of its management of conflicts publicly available, and the relevant information from the procurement template will be used to complete the register of procurement decisions. Complete transparency around procurement will provide:

• Evidence that the CCGs are seeking and encouraging scrutiny of its decision- making process; • A record of the public involvement throughout the commissioning of the service; • A record of how the proposed service meets local needs and priorities for partners such as the Health and Wellbeing Boards, local Healthwatch and local communities; • Evidence to the Audit Committee and internal and external auditors that a robust process has been followed in deciding to commission the service, in selecting the appropriate procurement route, and in addressing potential conflicts. Support from Commissioning Support Services

13.18. External services such as commissioning support services (CSS) can play an important role in helping the CCGs to decide the most appropriate procurement route, undertake procurements and manage contracts in ways that manage conflicts of interest and preserve the integrity of decision-making. When using a CSS, the Chief Finance Officer will assure themselves that the CSS business processes are robust and enable the CCGs to meet their duties in relation to procurement (including those relating to the management of conflicts of interest). This requires the CSS to declare any conflicts of interest it may have in relation to the work commissioned by the CCGs.

13.19. The CCGs acknowledge that it cannot lawfully delegate commissioning decisions to an external provider of commissioning support. Although the CCGs may require a CSS to play a key role in helping to develop specifications, preparing tender

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documentation, inviting expressions of interest and inviting tenders, the CCGs themselves will:

• Determine and sign off the specification and evaluation criteria; • Decide and sign off decisions on which providers to invite to tender; and • Make final decisions on the selection of the provider. Register of procurement decisions

13.20. The Chief Finance Officer will maintain a register of procurement decisions taken for each CCG, either for the procurement of a new service or any extension or material variation of a current contract. This will include:

• The details of the decision; • Who was involved in making the decision (including the name of the CCG clinical lead, the CCG contract manager, the name of the decision making committee and the name of any other individuals with decision-making responsibility); • A summary of any conflicts of interest in relation to the decision and how this was managed by the CCG; and • The award decision taken. 13.21. The register of procurement decisions will be updated whenever a procurement decision is taken. A template of the Register of Procurement Decisions can be found at Appendix 8.

13.22. The Register of Procurement Decisions will be publicly available via the following methods:

Coventry and Rugby CCG Warwickshire North CCG

• Published on the CCG's website: • Published on the CCG's www.coventryrugbyccg.nhs.uk; website: www.warwickshirenorthccg.nhs. • On request for inspection at the CCG's uk; headquarters; • On request for inspection at the CCG's • On request either by post to Parkside headquarters; House, Quinton Road Coventry, CV1 • On request either by post to NHS 2NJ or email to : Warwickshire North CCG, Second Floor, [email protected] Heron House, Newdegate Street, Nuneaton, CV11 4EL or email to : [email protected] k.

Declarations of interests for bidders / contractors

13.23. As part of a procurement process, the CCGs will ask bidders to declare any conflicts of interest. This allows the CCGs to ensure that it complies with the principles of equal treatment and transparency. When a bidder declares a conflict, the CCGs will decide how best to deal with it to ensure that no bidder is treated differently to any other. A declaration of interests for bidders/ contractors template can be found at Appendix 9.

13.24. It will not usually be appropriate to declare such a conflict on the register of procurement decisions, as it may compromise the anonymity of bidders during the procurement process. However, the CCGs’ Finance Team will retain an internal audit trail of how the conflict or perceived conflict was dealt with to allow them to provide information at a later date if required. Commissioners are required under regulation 84 of the Public Contract Regulations 2015 to make and retain records of contract award decisions and key decisions that are made during the procurement process

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(there is no obligation to publish them). Such records must include “communications with economic operators and internal deliberations” which should include decisions made in relation to actual or perceived conflicts of interest declared by bidders. These records must be retained for a period of at least three years from the date of award of the contract.

Contract Monitoring

13.25. The management of conflicts of interest applies to all aspects of the commissioning cycle, including contract management.

13.26. Any contract monitoring meeting needs to consider conflicts of interest as part of the process ie, the chair of a contract management meeting will invite declarations of interests; record any declared interests in the minutes of the meeting; and manage any conflicts appropriately and in line with this policy. This equally applies where a contract is held jointly with another organisation such as the Local Authority or with other CCGs under lead commissioner arrangements.

13.27. The individuals involved in the monitoring of a contract will not have any direct or indirect financial, professional or personal interest in the incumbent provider or in any other provider that could prevent them, or be perceived to prevent them, from carrying out their role in an impartial, fair and transparent manner.

13.28. The CCGs will be mindful of any potential conflicts of interest when disseminating any contract or performance information/reports on providers, and manage the risks appropriately.

14. Raising Concerns and Breaches

Raising Informal Concerns

14.1. The CCGs are committed to the principle of public accountability. It is the duty of every CCG employee, Governing Body member, committee member or sub- committee and GP practice member to speak up about genuine concerns in relation to the administration of the CCGs’ policy on conflicts of interest management, and to report these concerns. These individuals should not ignore their suspicions or investigate themselves, but rather speak to the Conflicts of Interest Guardians or the Deputy Director of Corporate Affairs.

14.2. Individuals wishing to discuss any concerns on a strictly confidential basis should initially make contact with the Deputy Director of Corporate Affairs by telephone on 02476 324377 or by email at [email protected] and arrangements will be made to speak to either the Chief Operating Officer, the appropriate Conflicts of Interest Guardian or the Deputy Director of Corporate Affairs, as per the individual’s requirements.

Formal procedure for raising a concern or breach

14.3. It is anticipated that concerns arising as a result of conflicts of interest will normally be resolved informally, without recourse to a formal process. If, however, the concern cannot be resolved informally or there is a clearly perceived breach, the process to be followed is set out below.

14.4. Any non-compliance with the CCGs’ conflicts of interest policy should be reported in accordance with the terms and procedure outlined in this policy, and the CCGs’ Whistleblowing Policy (where the breach is being reported by an employee or worker of the CCG) or with the whistleblowing policy of the relevant employer organisation (where the breach is being reported by an employee or worker of another

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organisation). In accordance with the Public Interest Disclosure Act 199815, protection will be provided for employees from possible reprisals, subsequent discrimination, victimisation or disadvantage if they have a reasonable belief that they have made any disclosure in good faith.

14.5. Any matter raised under this procedure will be investigated thoroughly, promptly and confidentially and the outcome of the investigation reported back to the employee who raised the issue.

14.6. A confidential record of concerns or breaches raised, how they have been investigated and the outcomes will be held securely by the Deputy Director of Corporate Affairs.

14.7. Anonymised details of breaches will be published on the respective CCG’s website for the purpose of learning and development.

14.8. The NHS England Regional Team will be advised of all breaches.

Procedure for Formally Reporting a Concern or Breach:

14.9. The CCGs’ formal procedure for raising a concern or breach in relation to conflicts of interests is made up of the following stages:

Stage 1: Raising the concern or breach - Details must be submitted to the Chief Officer in writing. Receipt will be acknowledged within three working days.

Stage 2: Triage – Following receipt, the CCG may contact the individual to request clarification or further information. If the concern is not deemed by the Chief Officer to warrant proceeding further, the individual will be notified that no investigation will proceed and rationale for this decision explained.

If the concern should be fast tracked to another organisation for legal, governance or safety reasons, the individual will be informed of the course of action.

Where a concern is in scope and not subject to fast tracking, it will proceed to the next stage.

In most cases, the triage process will be carried out within five working days.

Stage 3: Chief Officer Review – Following triage, the Chief Officer, supported as required by the Deputy Director of Corporate Affairs, will review the details of the concern and any supporting evidence to determine whether a swift resolution can be achieved without the need to involve the Governing Body. The Chief Officer may call a meeting of the parties concerned to discuss the matter without prejudice. If the Chief Officer is unavailable or if the concern involves the Chief Officer, the Chief Operating Officer will review the concern and act in accordance with this procedure as appropriate. The Conflicts of Interest Guardian will be made aware, and will make him/herself available for advice.

Stage 4: The Governing Body – If the concern cannot be resolved by the Chief Officer, an appropriate committee of the Governing Body, chaired by the CCG’s Chair and involving the Conflicts of Interest Guardian will then formally review the details of the concern (with external advice as required) and may refer on to the Audit Committee to advise on the appropriateness of the procedure followed.

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Stage 5: The Decision – Following review of the concern, the CCG will notify the individual of the decision, explaining the rationale and, if necessary, any required course of action.

Stage 6: Audit Committee - Details of all concerns and breaches investigated will be reported to the next available meeting of the Audit Committee.

Stage 7: Notification to NHS England: Where a breach has occurred, the CCG will notify the NHS England regional team.

Stage 8: Publication of Breaches: Where a breach has occurred, anonymised details of breaches will be published on the CCG’s website for the purpose of learning and development.

It is expected that the procedure as a whole should not take longer than three months.

Concerns by providers, patients and other third parties

14.10. Providers, patients and other third parties can make a complaint to NHS Improvement16 in relation to a commissioner’s conduct under the Procurement Patient Choice and Competition Regulations. The regulations are designed as an accessible and effective alternative to challenging decisions in the courts.

Fraud or Bribery

14.11. Any suspicions or concerns of acts of fraud or bribery can be reported online via https://www.reportnhsfraud.nhs.uk/ or via the NHS Fraud and Corruption Reporting Line on 0800 0284060. This provides an easily accessible and confidential route for the reporting of genuine suspicions of fraud within or affecting the NHS. All calls are dealt with by experienced trained staff and any caller who wishes to remain anonymous may do so.

15. Implications of non-compliance

15.1. Failure to comply with the CCGs’ policy on conflicts of interest management can have serious implications for the CCG and any individuals concerned.

Civil implications

15.2. If conflicts of interest are not effectively managed, the CCGs’ could face civil challenges to decisions it makes. For instance, if breaches occur during a service re- design or procurement exercise, the CCGs risk a legal challenge from providers that could potentially overturn the award of a contract, lead to damages claims against the CCGs, and necessitate a repeat of the procurement process. This could delay the development of better services and care for patients, waste public money and damage the CCGs’ reputation. In extreme cases, staff and other individuals could face personal civil liability, for example a claim for misfeasance in public office.

Criminal implications

15.3. Failure to manage conflicts of interest could lead to criminal proceedings including for offences such as fraud, bribery and corruption. This could have implications for the CCGs and linked organisations, and the individuals who are engaged by them.

15.4. The Fraud Act 2006 created a criminal offence of fraud and defines three ways of committing it:

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• Fraud by false representation; • Fraud by failing to disclose information; and, • Fraud by abuse of position. 15.5. An essential ingredient of the offences is that, the offender’s conduct must be dishonest and their intention must be to make a gain, or cause a loss (or the risk of a loss) to another. Fraud carries a maximum sentence of 10 years imprisonment and /or a fine if convicted in the Crown Court or 6 months imprisonment and/or a fine in the Magistrates’ Court. The offences of fraud can be committed by a body corporate.

15.6. Bribery is generally defined as giving or offering someone a financial or other advantage to encourage that person to perform their functions or activities. The Bribery Act 2010 reformed the criminal law of bribery, making it easier to tackle this offence proactively in both the public and private sectors. It introduced a corporate offence which means that commercial organisations, including NHS bodies, will be exposed to criminal liability, punishable by an unlimited fine, for failing to prevent bribery. The offences of bribing another person, being bribed and bribery of foreign public officials can also be committed by a body corporate. The Act repealed the UK’s previous anti-corruption legislation (the Public Bodies Corrupt Practices Act 1889, the Prevention of Corruption Acts of 1906 and 1916 and the common law offence of bribery) and provides an updated and extended framework of offences to cover bribery both in the UK and abroad. The offences of bribing another person, being bribed or bribery of foreign public officials in relation to an individual carries a maximum sentence of 10 years imprisonment and/or a fine if convicted in the Crown Court and 6 months imprisonment and/or a fine in the Magistrates’ Court. In relation to a body corporate the penalty for these offences is a fine.

Disciplinary implications

15.7. Individuals who fail to disclose any relevant interests or who otherwise breach the CCGs’ rules and policies relating to the management of conflicts of interest are subject to investigation and, where appropriate, to disciplinary action. The outcomes of such action may, if appropriate, result in the termination of their employment or position with the employing CCG.

Professional regulatory implications

15.8. Statutorily regulated healthcare and other professionals who work for, or are engaged by the CCGs are under professional duties imposed by their relevant regulator to act appropriately with regard to conflicts of interest. The CCGs will report statutorily regulated healthcare professionals to their regulator if it believes that they have acted improperly, so that these concerns can be investigated. The consequences for inappropriate action could include fitness to practise proceedings being brought against them, and they could, if appropriate, be struck off by their professional regulator as a result.

16. Conflicts of interest training

16.1. The CCGs will ensure that training is offered to all staff, Governing Body members and members of CCGs’ committees and sub-committees and practice staff with involvement in CCG business on the management of conflicts of interest. This is to ensure staff and others within the CCGs understand what conflicts are and how to manage them effectively.

16.2. NHS England is expected to launch an online training package for CCG staff, Governing Body members, members of CCG committees and sub-committee members and practice staff with involvement in CCG business during Autumn 2017. Once available this training will become mandatory and will need to be completed by

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all staff by 31 January of each year. Completion rates will be recorded as part of the CCGs’ annual conflicts of interest internal audit.

17. Monitoring Compliance and Effectiveness of the Policy

Internal Audit

17.1. All CCGs are required to undertake an audit of conflicts of interest management as part of their internal audit plan on an annual basis. . To support CCGs to undertake the audit and ensure consistency in the approach, NHS England has published a template audit framework.

17.2. The results of the audit will be reflected in the respective CCG’s annual governance statement and will be discussed in the end of year governance meeting with NHS England regional teams.

CCG Improvement and Assessment Framework

17.3. The management of conflicts of interest is a key indicator of the CCG Improvement and Assessment Framework. As part of the framework, all CCGs will be required on an annual basis to confirm via self-certification:

• That the CCG has a clear policy for the management of conflicts of interest in line with the statutory guidance and a robust process for the management of breaches; • That the CCG has a minimum of three lay members; • That the CCG audit chair has taken on the role of the Conflicts of Interest Guardian; • The level of compliance with the mandated conflicts of interest on-line training, as of 31 January annually. 17.4. In addition, CCGs will be required to report on a quarterly basis via self-certification whether the CCG:

• Has processes in place to ensure individuals declare any interests which may give rise to a conflict or potential conflict as soon as they become aware of it, and in any event within 28 days, ensuring accurate up to date registers are complete for: • conflicts of interest; • procurement decisions; and • gifts and hospitality. • Has made these registers available on its website and, upon request, at the CCG’s headquarters. • Is aware of any breaches of its policies and procedures in relation to the management of conflicts of interest and how many: • To include details of how they were managed; • Confirmation that anonymised details of the breach have been published on the CCG website; • Confirmation that they been communicated to NHS England. 18. Equality and Diversity Statement

18.1. The CCGs are committed to ensuring that it treats all its members fairly, equitably and reasonably and that it does not discriminate against individuals or groups on the basis of their ethnic origin, physical or mental abilities, gender, age, religious beliefs

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or sexual orientation. Accordingly an Equality Impact Assessment has been completed for this policy.

18.2. If you have any concerns or issues with the contents of this policy or have difficulty understanding how this policy relates to you or your role, please discuss them with the Conflicts of Interests Guardians or the Deputy Director Corporate Affairs.

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Appendix 1 – Template Declaration of Interest Form for Employees and Members

Name:

Relevant CCG: Coventry and Rugby CCG / Warwickshire North CCG / Both CCGs *Delete as appropriate

Position within, or relationship with, the CCG (or NHS England in the event of joint committees:

Detail of interests held (complete all that are applicable). If there are no interests please indicate a ‘nil’ response: Type of Description of Interest Date interest Actions to be taken to Interest* (including, for Indirect Relates from and mitigate risk *See reverse Interests, details of the to: (to be agreed with line of form for relationship with the person manager) details who has the interest) From To

The information submitted will be held by the CCGs for personnel or other reasons specified on this form and to comply with the organisations’ policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and, in the case of decision making staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs) may be published in registers that the CCGs hold. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result. [This paragraph applies to decision making staff only] I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons in the box below:

Employee/Member Signature:

Print Name: Signature: Date:

Line Manager or Senior CCG Manager

Print Name: Signature: Date:

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Types of conflicts of interest

Type of Interest Description Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could, for example, include being: • A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. This includes involvement with a potential provider of a new care model; • A shareholder (or similar ownership interests), a partner or owner of a private or not- forprofit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations; • A management consultant for a provider; or • A provider of clinical private practice. This could also include an individual being: • In employment outside of the CCG (see paragraph 79-81); • In receipt of secondary income; • In receipt of a grant from a provider; • In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider; • In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and • Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional Interests reputation or status or promoting their professional career. This may, for example, include situations where the individual is: • An advocate for a particular group of patients; • A GP with special interests e.g., in dermatology, acupuncture etc; • An active member of a particular specialist professional body (although routine GP membership of the Royal College of General Practitioners (RCGP), British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); • An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE); • Engaged in a research role; • The development and holding of patents and other intellectual property rights which allow staff to protect something that they create, preventing unauthorised use of products or the copying of protected ideas; or • GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices. Non-Financial This is where an individual may benefit personally in ways which are not directly linked Personal to their professional career and do not give rise to a direct financial benefit. This could Interests include, for example, where the individual is: • A voluntary sector champion for a provider; • A volunteer for a provider; • A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation; • Suffering from a particular condition requiring individually funded treatment; • A member of a lobby or pressure group with an interest in health and care. Indirect This is where an individual has a close association with an individual who has a financial Interests interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above) for example, a: • Spouse / partner; • Close family member or relative e.g., parent, grandparent, child, grandchild or sibling; • Close friend or associate; or • Business partner.

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Appendix 2 – Register of Interests Template

Title First Initial Last Current Declared Type of Interest Date of interest Action Name Name position(s) Interest (Name taken to held in CCG, of the mitigate ie Governing organisation and risk Body member, nature of the Committee business) member, Member Practice; CCG employee or other From To

financial financial Financial Financial - - Indirect Personal Financial Professional Non Non

Appendix 3 – Decision Making Staff

Each individual and their role within the CCGs will be considered individually and a decision recorded as to whether their declaration is to be published, however, the following non-exhaustive list describes who these individuals are likely to be:

• All governing body members;

• Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services such as working groups involved in service redesign or stakeholder engagement that will affect future provision of services;

• Members of the Primary Care Commissioning Committee (PCCC)/Joint Commissioning Committee;

• Members of other committees of the CCGs ie, Audit Committees, Remuneration Committee Finance and Performance/ Commissioning Finance and Performance, and Clinical Quality and Governance Committees;

• Members of new care models joint provider / commissioner groups / committees;

• Those at Agenda for Change band 8d and above;

• Management, administrative and clinical staff who have the power to enter into contracts on behalf of the CCG; and

• Management, administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of good, medicines, medical devices or equipment, and formulary decisions.

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Appendix 4 – Template Declaration of Gifts and Hospitality Form

Name:

Relevant CCG: Coventry and Rugby CCG / Warwickshire North CCG / Both CCGs *Delete as appropriate

Position within, or relationship with, the CCG (or NHS England in the event of joint committees:

Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason Other Name of Receipt (if Gift / Value Offeror Previous Offers officer reviewing or for Comments Offer applicable) Hospitality Name and or Acceptance and approving the Accepted? Accepting Nature of by this Offeror/ declaration made or Business Supplier and date Declining

The information submitted will be held by the CCGs for personnel or other reasons specified on this form and to comply with the organisations’ policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and, in the case of decision making staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs) may be published in registers that the CCGs hold. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result. [This paragraph applies to decision making staff only] I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons in the box below:

Employee/Member Signature:

Print Name: Signature: Date:

Line Manager or Senior CCG Manager

Print Name: Signature: Date:

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Appendix 5 - Register of Gifts and Hospitality Template

Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason Other Name of Receipt (if Gift / Value Offeror Previous Offers officer reviewing or for Comments Offer applicable) Hospitality Name and or Acceptance and approving the Accepted? Accepting Nature of by this Offeror/ declaration made or Business Supplier and date Declining

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Appendix 6 - Declaration of Interest Checklist for Meeting Chairs

Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings. This checklist has been developed with the intention of providing support in conflicts of interest management to the Chair of the meeting- prior to, during and following the meeting. It does not cover the requirements for declaring interests outside of the committee process.

Timing Checklist for Chairs Responsibility

1. The agenda to include a standing item on declaration of interests Meeting Chair and secretariat In advance to enable individuals to raise any issues and/or make a declaration of the meeting at the meeting.

2. A definition of conflicts of interest should also be accompanied Meeting Chair and secretariat with each agenda to provide clarity for all recipients.

3. Agenda to be circulated to enable attendees (including visitors) to Meeting Chair and secretariat identify any interests relating specifically to the agenda items being considered.

4. Members should contact the Chair as soon as an actual or Meeting members potential conflict is identified.

5. Chair to review report front sheet which details any previous Meeting Chair conflicts of interest declared and how this was managed ie, at sub-committee, working group, etc., or any anticipated conflicts identified.

6. A copy of the members’ declared interests is checked to Meeting Chair establish any actual or potential conflicts of interest that may occur during the meeting.

7. Check and declare the meeting is quorate and ensure that this Meeting Chair During the meeting is noted in the minutes of the meeting.

8. Chair requests members to declare any interests in agenda Meeting Chair items- which have not already been declared, including the nature of the conflict.

9. Chair makes a decision as to how to manage each interest Meeting Chair and secretariat which has been declared, including whether / to what extent the individual member should continue to participate in the meeting, on a case by case basis, and this decision is recorded.

10. As minimum requirement, the following should be recorded in Secretariat the minutes of the meeting: • Individual declaring the interest; • At what point the interest was declared; • The nature of the interest; • The Chair’s decision and resulting action taken; • The point during the meeting at which any individuals retired from and returned to the meeting - even if an interest has not been declared; • Visitors in attendance who participate in the meeting must also follow the meeting protocol and declare any interests in a timely manner. A template for recording any interests during meetings is detailed overleaf. 11. All new interests declared at the meeting should be promptly Individual(s) declaring interest(s) Following the meeting updated onto the declaration of interest form;

12. All new completed declarations of interest should be transferred Head of Corporate Services onto the register of interests.

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Declarations of Interest at Meetings Coventry and Rugby CCG / Warwickshire North CCG / Both ie, meeting in common CCG: *Delete as appropriate Meeting: Meeting Date: Chair: Minute Taker:

Type of Interest When was the (see guidance) interest identified? (tick) (tick) Agenda Item Attendees with Details of Potential Action Taken at the meeting Potential Interest (Description) identified Interest /Declared (to be determined at the Interest declared

conflicts of Interest meeting by the Chair) identified at the

interest or Direct before meeting? the Financial Financial Financial - - meeting? Financial Non Professional Non Personal Indirect

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Appendix 7- Procurement Checklist Template

CCG: Coventry and Rugby CCG / Warwickshire North CCG/ Both CCGs

*Delete as appropriate

Service:

Question Comment/ Evidence

1. How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities? How does it comply with the CCG’s commissioning obligations?

2. How have you involved the public in the decision to commission this service?

3. What range of health professionals have been involved in designing the proposed service?

4. What range of potential providers have been involved in considering the proposals?

5. How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?

6. What are the proposals for monitoring the quality of the service?

7. What systems will there be to monitor and publish data on referral patterns?

8. Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers?

9. In respect of every conflict or potential conflict, you must record how you have managed that conflict or potential conflict. Has the management of all conflicts been recorded with a brief explanation of how they have been managed?

10. Why have you chosen this procurement route e.g., single action tender?17

17 Taking into account all relevant regulations (e.g. the NHS (Procurement, patient choice and competition) (No 2) Regulations 2013 and guidance (e.g. that of Monitor). NHS Coventry and Rugby CCG Page 40 of 45 NHS Warwickshire North Clinical Commissioning Group Managing Conflicts of Interest Policy v5.1

CCG: Coventry and Rugby CCG / Warwickshire North CCG/ Both CCGs

*Delete as appropriate

Service:

Question Comment/ Evidence

11. What additional external involvement will there be in scrutinising the proposed decisions?

12. How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process and award of any contract?

Additional question when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) or direct award (for services where national tariffs do not apply)

13. How have you determined a fair price for the service?

Additional questions when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) where GP practices are likely to be qualified providers

14. How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?

Additional questions for proposed direct awards to GP providers

15. What steps have been taken to demonstrate that the services to which the contract relates are capable of being provided by only one provider? 16. In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract? 17. What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.

Signed:

On behalf of:

Date:

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Appendix 8 – Template Register of Procurement Decisions

Ref Contract/ Procurement Existing Procurement CCG CCG Decision making Summary of Contract Contract Contract No Service description contract or type – CCG clinical contract process and conflicts of Award value value to title new procurement, lead manager name of interest declared (supplier (£) CCG procurement collaborative decision making and how these name & (Total) (if existing procurement committee were managed registered include with partners and justification address) details) for action

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Appendix 9 – Template Declaration of Interest Form for Bidders/Contractors

Declaration of conflict of interests for bidders/contractors (part 1)

Name of Organisation: Details of interests held:

Type of Interest Details Provision of services or other work for the CCG or NHS

England

Provision of services or other work for any other potential bidder in respect of this project or procurement process Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.

Signed:

On behalf of:

Date:

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Declaration of conflict of interests for bidders/contractors (part 2)

Name of Relevant Person [complete for all Relevant Persons]

Details of interests held: Personal interest or that of a family member, close Type of Interest Details friend or other acquaintance? Provision of services or other work for the CCG or NHS

England

Provision of services or other work for any other potential bidder in respect of this project or procurement process

Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.

Signed:

On behalf of:

Date:

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Appendix 10 – Equality Impact Assessment

Equality Impact Assessment

Policy Managing Conflicts of Person Maria Maltby, Deputy Interest Policy completing EIA Director Corporate Affairs, WNCCG Date of EIA 22 August 2017 Accountable Debbie Pook, Chief CCG Lead Operating Officer

Aim of Work This policy and procedure ensures an auditable approach to ensuring compliance with legislation and NHS England requirements with regards to the management of conflicts of interest Who Affected

Protected Group Likely to be Protected Group Likely to be a a differential differential impact? impact? Sex No Age No Race No Gender Reassignment No Disability No Marriage and Civil Partnership No Religion / belief No Pregnancy and Maternity No Sexual orientation No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc R

Report To: Governing Body in Common Diagnosis and Management of Chronic Fatigue Syndrome (CFS) and Report Title: Myalgic Encephalomyelitis (ME) policy. Report From: Dr S Allen, Clinical Director Chris Pycock, Secondary Care Doctor

Date: 14 September 2017 Policy Development Group Previously Considered by: CRCCG Clinical Executive Group WNCCG Commissioning, Finance and Performance Group, 27 July 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To recommend the Diagnosis and Management of Chronic Fatigue Syndrome (CFS) and Myalgic Encephalomyelitis to Governing Bodies for ratification.

Key Points: • The Policy Development Group have discussed and developed the policy which formalises the pathway for patients with CFS and ME; • The policy confirms that the CCG will not commission or provide funding to out of area specialist units for inpatient or outpatient services; • Assessment and treatment of patients to be managed in primary care in the community; • Local secondary care specialist services can be used for diagnosis and management advice; • CRCCG Clinical Executive Group has reviewed and discussed the policy and recommends it to Governing Body for ratification. • WNCCG Commissioning, Finance and Performance Committee has reviewed and discussed the policy and recommends it to Governing Body for ratification. Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Supports Objective(s) / Plans • Care closer to home; supported by this • report: Specialist care in the right place, at the right time; • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Adherence to the policy may result in a reduction Recurrent Expenditure: Financial: in costs for activity in secondary care.

Is this expenditure included Yes  No N/A within the CCG’s Financial

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc R

Plan? (Delete as appropriate) Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the Performance: contract. The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to Policy) Patient and Public Not applicable Engagement: WNCCG - Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to Clinical Engagement: submission to Clinical Executive Group and Governing Body. WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: Not applicable

Page 2 of 2

Enclosure R

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Commissioning Policy: Warwickshire North CCG (WNCCG)

Treatment Diagnosis and Management of Chronic Fatigue Syndrome (CFS) and Myalgic Encephalomyelitis (ME)

Indication Chronic Fatigue Syndrome and Myalgic Encephalomyelitis

Criteria The assessment and management of chronic fatigue syndrome (CFS) and myalgic encephalomyelitis (ME) at out of area specialist inpatient or outpatient units is not commissioned or funded by the CCG.

The assessment and treatment of chronic fatigue syndrome (CFS) and myalgic encephalomyelitis (ME) should usually be managed by primary care, in the community, in line with assessment and treatment recommendations given in NICE guidance1. This may include referral to commissioned local secondary care specialist services for diagnosis and management advice, if required.

Ref: 1 National Institute for Health and Clinical Excellence (NICE) August 2007 Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management (Available on line from: https://www.nice.org.uk/Guidance/cg53)

Equality Impact See attached Assessment

Version Control:

Version 1.0 Ratified by Governing Body Date ratified Name of Originator/Author Policy Development Group Name of Responsible Committee Clinical Executive Group Date Issued Review Date

Equality Impact Assessment (EIA)

Policy/Service Diagnosis and Management Person completing Kay Holland of Chronic Fatigue Syndrome EIA (CFS) and Myalgic Encephalomyelitis (ME)

Date of EIA 7th June 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be a Protected Group Likely to be a differential differential impact? impact?

Age No Race No

Disability No Religion or belief No

Gender reassignment No Sex No

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

The impact of this policy has been considered against all protected characteristics and Human Rights values.

Chronic Fatigue Syndrome (CFS), also known as Myalic Encephalomylitis (ME), is a condition characterised by fatigue, which is often debilitating, it is not relieved by rest or sleep, it is exacerbated by minimal exertion and is associated with a constellation of other symptoms, the severity of which tends to vary with the severity of the fatigue. An individual’s symptoms may vary in severity and there is a variation between patients; although some patients improve over time, others do not.

CFS/ME falls under the category of Medically Unexplained Symptoms (MUS) which account for 30-50% of all consultations in primary care and 35-50% of all new medical outpatients. The World Health Organisation classifies CFS/ME as a neurological illness.

CFS/ME has an incidence and prevalence in the general population ranging from 0.4-1% based on geographical variation, with high incidence in urban populations. It is more common in women, and in Caucasians, although recent increase in the recognition and correct diagnosis of the condition may influence the prevalence.

Many different interventions for CFS/ME have been investigated in clinical trials of varying quality. There is currently insufficient evidence to support many interventions in terms of clinical or cost effectiveness.

There is currently no evidence to support the use of in-patient or residential settings to deliver effective interventions for CFS/ME. There is currently no evidence to suggest that any group or sub-group of patients with CFS/ME will benefit particularly from any specific intervention or that patients who have failed to improve on one intervention may do better on another.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc S

Report To: Governing Body in Common

Report Title: Complex and Specialised Obesity Surgery (Bariatric Surgery) Policy

Report From: Dr S Allen, Clinical Director Chris Pycock, Secondary Care Doctor, WNCCG

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group WNCCG Executive Group, 07 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To recommend the adoption of the NHS England policy for bariatric surgery, following the move of the commissioning responsibility from NHS England to the CCG

Key Points: • As already 4 months into the financial year, then for consistency and continuity of patient services, the recommendation is to maintain and apply the NHS England policy for 2017/18; • CCG to adopt NHS England policy dated April 2013 with a covering CCG front sheet to record ratification process; • The Policy Development Group supports the adoption of the policy for review when CCG activity information is available after either Year 1 or Year 2; • CRCCG’s Clinical Executive Group and WNCCG’s Executive Group supports the review of the policy within 2 years.

Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Objective(s) / Plans Supports supported by this • Specialist care in the right place, at the right time; report: • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Adherence to the policy may result in a reduction Recurrent Expenditure: in costs for activity in secondary care. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc S

contract. The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers.

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to Policy) Patient and Public not applicable Engagement: CRCCG - Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to Clinical Engagement: submission to Clinical Executive Group and Governing Body. WNCCG – Chris Pycock, the CCG’s Secondary Care Doctor is a member of the policy review group. Risk and Assurance: not applicable

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Clinical Commissioning Policy: Complex and Specialised Obesity Surgery

April 2013

Reference : NHSCB/A05/P/a

NHS Commissioning Board

Clinical Commissioning Policy: Complex and Specialised Obesity Surgery

First published: April 2013

Prepared by the NHS Commissioning Board Clinical Reference Group for

Severe and Complex Obesity

© Crown copyright 2013 First published January 2013 Published by the NHS Commissioning Board, in electronic format only.

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

Contents

Policy Statement ...... 4

Equality Statement ...... 4

Plain Language Summary ...... 4

1. Introduction ...... 5

2. Definitions ...... 6

3. Aim and Objectives ...... 7

4. Criteria for commissioning ...... 8

5. Patient pathway ...... 10

6. Governance arrangements...... 11

7. Epidemiology and needs assessment ...... 12

8. Evidence Base ...... 14

9. Rationale behind the policy statement...... 15

10. Mechanism for funding ...... 16

11. Audit Requirements ...... 16

12. Documents which have informed this policy...... 16

13. Links to other policies ...... 17

14. Date of Review ...... 17

References ...... 17

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a Policy Statement

The NHS Commissioning Board (NHS CB) will commission complex and specilaised surgery as a treatment for selected patients with severe and complex obesity that has not responded to all other non-invasive therapies, in accordance with the criteria outlined in this document.

In creating this policy the NHS CB has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources.

This policy document outlines the arrangements for funding of this treatment for the population in England.

Equality Statement

The NHS CB has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved as enshrined in the Health and Social Care Act 2012.The NHS CB is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, the NHS CB will have due regard to the different needs of protected equality groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. This applies to all activities for which they are responsible, including policy development, review and implementation.

Plain Language Summary

People whose weight to height ratio (or Body Mass Index, BMI) is significantly high are more likely to suffer from a range of illnesses (e.g. type-2 diabetes) and have a lower life expectancy.

Programmes designed to support people in losing weight include lifestyle changes such as diet, exercise and behavioural change. Low and very low calorie diets, drug treatments, psychological support and specialist weight management programmes are also available. Bariatric (or weight-loss) surgery (e.g. gastric bypass) is a highly specialised intervention used in appropriate, selected patients with severe and complex obesity that have not responded to all other non-invasive therapies.

Within these patient groups bariatric surgery has been shown to be highly cost effective in reducing BMI and the associated illnesses, promoting longer term health.

Patients need to be motivated and adequately prepared for surgery and for the post surgical treatment and monitoring which is necessary for success.

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a 1. Introduction

Obesity and being overweight is a global epidemic. The World Health Organisation (WHO) predicts that by 2015 approximately 2.3 billion adults worldwide will be 1 overweight and more than 700 million will be obese.

The prevalence of obesity in England is one of the highest in the European Union. In England just over a quarter of adults (26% of both men and women aged 16 or 2 over) were classified as obese in 2010 (Body Mass Index (BMI) 30kg/m2 or over).

Using both BMI and waist circumference to assess risk of health problems, 22% of men were estimated to be at increased risk; 12% at high risk and 23% at very high risk in 2010. Equivalent figures for women were: 14%, 19% and 25%. There has been a marked increase in the proportion (doubling) that are obese, a proportion that has gradually increased over the period from 13.2% in 1993 to 26.2% in 2010 2 for men and from 16.4% to 26.1% for women.

Obesity is directly associated with many different illnesses, chief among them insulin resistance, type 2 diabetes, metabolic syndrome, dyslipidaemia, hypertension, left atrial enlargement, left ventricular hypertrophy, gallstones, several types of cancer, gastro-oesophageal reflux disease, non alcoholic fatty liver disease (NAFLD), degenerative joint disease, obstructive sleep apnoea syndrome, psychological and psychiatric morbidities. It lowers life expectancy by 5 to 20 years. Direct costs of 3 obesity are estimated to be £4.2 billion.

As BMI increases the number of obesity-related comorbidities increases. The number of patients with ≥ 3 comorbidities increases from 40% for a BMI of < 40 to more than 50% for BMI 40-49.9 to almost 70% for BMI 50-59.9 and ultimately to 89% for BMI > 59-9.

The treatment of obesity should be multi-component. All weight management programmes should include non-surgical assessment of patients, treatments and lifestyle changes such as improved diet, increased physical activity and behavioural interventions. There should be access to more intensive treatments such as low and very low calorie diets, pharmacological treatments, psychological support and specialist weight management programmes.

Surgery to aid weight reduction for adults with morbid/severe obesity should be considered when there is recent and comprehensive evidence that an individual patient has fully engaged in a structured weight loss programme; and that all appropriate non-invasive measures have been tried continuously and for a sufficient period; but have failed to achieve and maintain a clinically significant weight loss for the patients clinical needs (NICE CG43 recommendations).4 The patient should in addition have been adequately counselled and prepared for bariatric surgery.

This surgery, which is known to achieve significant and sustainable weight reduction within 1-2 years, as well as reductions in co-morbidities and mortality, is commonly known as bariatric surgery. The current standard bariatric operations are gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. These are usually undertaken laparoscopically.

Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on patients with Type 2 diabetes. The economic effect of the

5

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a clinical benefits of bariatric surgery for diabetes patients with BMI 35 kg/m has been estimated in patients aged 18-65 years. Surgery costs were fully recovered after 26 months for laparoscopic surgery. The data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI 35 kg/m. Other groups have been less well studied but bariatric surgery is reported to be cost effective against a wider range of co-morbidities.

2. Definitions

Table 1: Body Mass Index (BMI) categories

Definition BMI range (kg/m2)

Underweight Under 18.5

Normal 18.5 to less than 25

Overweight 25 to less than 30

Obese 30 to less than 40

Obese I 30 to less than 35

Obese II 35 to less than 40 Morbidly obese 40 and over Overweight including obese 25 and over Obese including morbidly obese 30 and over

Gastric banding

The gastric band (or sometimes referred to more fully as laparoscopic adjustable gastric band – LAGB) helps reduce the amount of food eaten. It acts like a belt around the top portion of the stomach, creating a small pouch. Patients feel full after eating only a small quantity of food. It is adjustable and reversible.

Gastric bypass

There are a number of variations of gastric bypass operation but the most popular one conducted in the UK is called a Roux–en–Y gastric bypass (RNY). At surgery, the top section of the stomach is divided off by a line of staples, creating a small 'pouch' stomach. A new exit from this pouch is made into a 'Y' loop from the small intestine so that food bypasses your old stomach and part (about 100-150cm) of the small intestine. The size of stomach pouch and the length of small intestine that is bypassed are carefully calculated to ensure that patients will be able to eat enough for their body's needs at normal weight.

Sleeve gastrectomy

The sleeve gastrectomy reduces the size of the stomach by about 75%. It is divided vertically from top to bottom leaving a banana shaped stomach along the inside

6

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a curve and the pyloric valve at the bottom of the stomach, which regulates the emptying of the stomach into the small intestine, remains intact. This means that although smaller, the stomach function remains unaltered.

Duodenal switch

The duodenal switch (DS) works primarily by malabsorption. The operation can be performed as an open operation through a midline incision from the base of the breastbone, or laparoscopically. Technically it is a complex operation which can take 5–7 hours to complete, and will usually require a post–op hospital stay of 4–6 days.

Following a sleeve gastrectomy a short segment of the duodenum at the base of the stomach is left but the remainder cut and the second half of the small intestine bought up and joined to the duodenum (this part of the operation is very similar to a RNY gastric bypass but is slightly lower down in the digestive tract). The bypassed section of small intestine is then rejoined to carry bile and pancreatic juices to the latter part of the small intestine near where it joins the large intestine (colon).

Digestion and absorption of fat depends on it mixing with bile (from the liver and normally entering the duodenum). As this mixing does not occur until much further on in the intestine after a DS, the body's ability to digest and absorb calories from fat is severely reduced. As a result weight drops, even when eating quite normally. 5 Definitions adapted from BOSPA

Models of care

A typical model for managing obesity is outlined as follows:

 Tier 4 - Specialised Complex Obesity Services (including bariatric surgery)  Tier 3 - A primary/community care based multi-disciplinary team (MDT) to provide an intensive level of input to patients.  Tier 2 - Primary Care with Community Interventions  Tier 1 - Primary Care and Community Advice.

From: South East Coast Specialised Commissioning Group, 2010

3. Aim and Objectives

To define eligibility criteria for NHS commissioned complex and specialised obesity surgery.

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

4. Criteria for commissioning

Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-invasive therapies. Within these patient groups bariatric surgery has been shown to be highly cost effective.

Bariatric surgery is recommended by NICE as a first-line option for adults with a BMI of more than 50kg/m2, in whom surgical intervention is considered appropriate. However, it will be required that these patients also fulfil the criteria below.

Selection criteria of patients for bariatric surgery should prevent perverse incentives for example patients should not become more eligible for surgery by increasing their body weight. Similarly the selection criteria should not forbid bariatric surgery for patients who have lost weight with non-surgical methods

Eligibility for bariatric surgery

Surgery will only be considered as a treatment option for people with morbid obesity providing all of the following criteria are fulfilled:

 The individual is considered morbidly obese. For the purpose of this policy bariatric surgery will be offered to adults with a BMI of 40kg/m2 or more, or between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant diseases.  There must be formalised MDT led processes for the screening of co-morbidities and the detection of other significant diseases. These should include identification, diagnosis, severity/complexity assessment, risk stratification/scoring and appropriate specialist referral for medical management. Such medical evaluation is mandatory prior to entering a surgical pathway.  Morbid/severe obesity has been present for at least five years.  The individual has recently received and complied with a local specialist obesity service weight loss programme (non surgical Tier 3 / 4), described as follows: This will have been for duration of 12-24 months. For patients with BMI > 50 attending a specialist bariatric service, this period may include the stabilisation and assessment period prior to bariatric surgery. The minimum acceptable period is six months. The specialist obesity weight loss programme and MDT should be decided locally. This will be led by a professional with a specialist interest in obesity and include a physician, specialist dietician, nurse, psychologist and physical exercise therapist, all of whom must also have a specialist interest in obesity. There are different models of local MDT structure. Important features are the multidisciplinary, structured and organised approach, lead professional, assessment of evidence that all suitable non invasive options have been explored and trialled and individualised patient focus and targets. In addition to offering a programme of care the service will select and refer appropriate patients for consideration for bariatric surgery.

The non-surgical Tier 3 / 4 service may be community or hospital-based but will have as their role

8

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  Education  Dietary advice/support (which may be delivered through specialist obesity dieticians, or slimming clubs – Weight Watchers, Slimming World etc.)  Enabling access to appropriate level of physical activity where not limited due to obesity related problems such as osteoarthritis, cardio respiratory disease  Exclusion of underlying contributory disease e.g. hypothyroidism, Cushing’s  Evaluation of co-morbidities (diabetes, sleep disorder breathing, etc) and instigation of appropriate management plans  Evaluation of patient’s engagement with non-surgical measures  Evaluation of psychological factors relevant to obesity, eating behaviour, physical activity and patient engagement.  There is evidence of attendance, engagement and full participation in the above non surgical Tier 3 / 4 service Engagement can be judged by attendance records and achievement of pre-set individualised targets (for example steady and sustained weight loss of 5-10%, or maintaining constant weight whilst stopping smoking).  The patient has been assessed and referred by the lead physician/ clinician for the specialist obesity weight loss MDT.  The patient has been unable to lose clinically significant weight (i.e. enough to modify co-morbidities) during the period of intervention. Patients who lose sufficient weight to fall beneath the NICE guidance should not be considered appropriate for surgery.

The final decision on whether an operation is indicated should be made by the specialist hospital bariatric MDT. For all bariatric surgery candidates, an individual risk benefit evaluation will be done by the Bariatric Surgery MDT, this will be informed by their own clinical assessment and information provided by primary care and by non-surgical Tier 3 / 4. In some locations there may be close liaison (and perhaps even overlap of personnel) between non-surgical Tier 3/4 and Bariatric Surgery MDT. For example, a specialist bariatric physician would be on both MDTs.

The risk:benefit evaluation will consider:

 Existing co-morbidities and their reversibility  Risk of future co-morbidities and their reversibility  Patients age and general level of health  Anticipated weight reduction  Alternatives if bariatric surgery is not undertaken  Peri-operative mortality  Post-operative complications of bariatric surgery

The Bariatric Surgery Team will satisfy itself that:

 Bariatric surgery is in accordance with relevant guidelines  There are no specific clinical or psychological contraindications to this type of surgery  The individual is aged 18 years or above.  The patient has engaged with non-surgical Tier 3 / 4 Services.

9

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  The anaesthetic and other peri-operative risks have been appropriately minimised  the patient has engaged in appropriate support or education groups/schemes to understand the benefits and risks of the intended surgical procedure  the patient is likely to engage in the follow up programme that is required after any bariatric surgical procedure to ensure  Safety of the patient,  Best clinical outcome is obtained and then maintained.  Change eating behaviour  Change physical behaviour as advised  The overall risk:benefit evaluation favours bariatric surgery

Revisional procedures will only be considered electively for clinical reasons due to complications and will require prior approval unless they are required on an acute emergency basis. (A separate policy will need to be developed for revisional procedures).

Any new/novel bariatric surgery procedures outside of this policy will not be routinely commissioned. Where a clinician wishes to make a request for a new device/procedure, an application for exceptional funding through the NHS CB Individual Funding Request (IFR) process should be made in the first instance. The latter should be free to seek advice from the CRG leads. This request will then serve as an indicator for the CRG to undertake an evidence based review prior to developing a policy agreed by the CRG for the device/procedure requested.

5. Patient pathway

Non surgical and intensive management

The non surgical and intensive management of morbidly obese patients in Tier 3/4 settings to optimise risk and subsequent referral process of eligible patients is an integral part of this pathway. This has already been described in section 4.

Pre-operative preparation

As it is an elective procedure it is critical that individuals being considered for bariatric surgery are carefully selected, appropriately referred, fully evaluated and their medical condition optimised in order to achieve the best operative, post operative and long term outcomes. This is best done by MDTs at Tier 3 / 4 services and also after referral to the Bariatric Surgical Centre.

This patient population has unique and challenging issues including an extensive range of medical and psychological and potentially psychiatric comorbidities. Often patients have unrealistic expectations of the surgery. Therefore a multidisciplinary, comprehensive and timely assessment pre-operatively is of great importance.

The diagnostic work up, pre operative evaluation, risk stratification and provision of counselling, education and information is best undertaken by a dedicated hospital

10

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a multidisciplinary team specialising in the management of morbidly obese patients including:

 Surgeons

 Anaesthetists

 Physicians

 Psychologists – will provide assessments and targeted interventions e.g. Cognitive Behavioural Therapy and also post operative support

 Dieticians

 Nurses

 Radiologist

 Dedicated administrative support

 Access to Psychiatry*

 Access to Pharmacists*

 Access to Physiotherapists or sports and exercise medicine specialists*

* with special interest in bariatric surgery

This team should also have links to independent patient support groups and also provides in-house patient support groups.

The surgical provider will have robust arrangements for surgical follow up and for receiving, assessing patients with post-operative complications and their emergency management by bariatric surgeons. This includes access to a fully staffed emergency theatre on a 24 hour basis. There will also be a contact point for advice on queries.

Structured, systematic and team-based follow up should be organised by the surgical provider for 2 years after surgery. Life long specialist follow up is also advocated although will usually be provided by the Tier 3 / 4 services. Such an approach will monitor weight loss outcomes, complications, adherence to iron, vitamin D/Calcium and Vitamin B12 supplementation, facilitate clinical suspicion of specific or combined micronutrient deficiencies leading to appropriate laboratory tests for confirmation. Psychological input, management of comorbidities, dietary and lifestyle advice and liaison with general practice will also be other functions of the follow up process. (A separate policy including consideration of automated annual recall systems will need to be developed for this).

6. Governance arrangements

 Providers, surgeons, premises, on site services and bariatric surgery throughput should at least meet the IFSO Guidelines6 for Safety, Quality, and Excellence in Bariatric Surgery.

11

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  However, it is recognised that the IFSO hospital and surgeon volume standards were meant to imply minimum volumes only (125 per hospital and 50 per surgeon). There is clear data show that mortality and complication rates, both for bypass and banding are better with greater volumes, and the data are a continuum, so the more cases that are done the better the outcomes are likely to be, just as for all other examples of elective surgery. In addition there are two benefits of commissioning only high volume providers: higher volumes bring in more funding to support the infrastructure (nurses, dieticians, psychologists), and they allow several surgeons to take part in an on call rota e.g. 1 in 4 is practical whereas 1 in 2 is not.7 Thus major centres should be built up and other centres started only when capacity is reached. There are no hospital or surgeon volume data for sleeve gastrectomy or duodenal switch but there is no reason to doubt that the same relationship exists and therefore the same governance rules should apply.

 Appropriate MDT composition, professional inputs and process design for all stages of the pathway. Organisational arrangements for patient safety (elective and emergency) should be risk assessed, regularly tested and improved. Protocols should be audited especially the use of questionnaires for clinical assessment, generic interdisciplinary roles and substitution / expansion of professional roles i.e. use of GPs or other therapists for band-fills as an alternative to consultant radiologists; use of Skype, telephone etc. for consultations.

 The surgical service should be seamless both pre- and post operatively with the medical Tier 3 / 4 service and decided by local arrangements,

 The mandatory collection and submission of data to the National Bariatric Surgical Register. Audit timeliness and completeness of data submitted.

 The bariatric surgical provider will be responsible for the organisation of structured, systematic and team based follow up for 2 years. Just before this period is finished the surgical provider will make arrangements to hand over care to the tier 3 service.

7. Epidemiology and needs assessment

The Health Survey for England8 shows that the proportion of adults (aged 16+) who are morbidly obese with a BMI 40kg/m2 or more has risen from 0.9% in 1993-95 to 1.9% in 2006-08. Over this period, the prevalence of morbid obesity was consistently higher in women (increasing from 1.5% in 1993-95 to 2.6% in 2006-08) than in men (increasing from 0.3% in 1993-95 to 1.3% in 2006-08), although the rate of increase in recent years has been higher in men. Based on these figures, the number of adults with morbid obesity in England would be around 800,000; in a CCG covering a population of 500,000, one would expect around 8,000 adults with morbid obesity.

Predicting future trends in morbid obesity has proven difficult. Two different models

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a have estimated markedly different prevalence figures. The first predicts a prevalence of almost 3% in men and 6% in women by 2030; the second predicts a prevalence of 1% for men and 4% for women by 2050. Straight-line extrapolation of the prevalence of adult men with BMI greater than 40 kg/m2 predicts a level of around 3% by 2050.

Estimated NHS Commissioning Board Population Estimated Population Region Obese (‘000) Morbidly Obese (‘000)

London 1,286 122

Midlands & East of England 2,689 202

North of England 2,528 231

South England 2,331 165

Grand Total 8,836 722

Notes:

% Obese and Morbidly obese taken from Table 2.10; HSE 2007 (NHS IC 2009)

Population Statistics taken from PCO Population Estimates 2010 (Release September 2011)

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

In 2006 the National Institute for Health and Clinical Excellence (NICE) estimated a total prevalence of patients, meeting NICE BMI threshold criteria, of approximately 2.22% of the population, or approximately 1.1 million people. NICE further adjusted this figure to allow for those patients who may not be considered clinically eligible for surgery and again to allow for patient choice of treatment and those who would not accept surgery even if offered.

Applying the NICE algorithm indicates that there is a potential cohort of patients who may be eligible for, and who wish to take up, bariatric surgery of approximately 0.53% of the adult population in England or 257,000 people.

2010/2011 SUS data indicates that less than 9,000 patients were admitted in that year.

Analysis of the Health Survey for England data suggest that, of those recorded as having Morbid Obesity, 7% have a BMI of 50 kg/m2. Therefore there is a population, estimated at 51,000 people, in England who are eligible for bariatric surgery as first- line treatment for their obesity. For the remainder surgery is only considered after all other forms of medical management have been attempted, but adequate, clinically beneficial weight loss has not been achieved or maintained.

8. Evidence Base

In the short term, providing bariatric surgery as a solution to weight loss is significantly more expensive than conservative management and this cost has often been used as a reason for not commissioning surgical services, or limiting access. However the remission of co-morbidities as a result of surgery or the associated weight-loss means that the overall cost of managing a patient on a care pathway that includes surgery is more cost effective in the long term than one without. , 9, The Canadian and New Zealand Health Technology Assessment (HTA) agencies 10 both reported the cost per quality-adjusted life year (QALY) for bariatric surgery compared to non-surgical interventions for obesity to be within acceptable cost- effectiveness thresholds and concluded that bariatric surgery is cost effective. However, they also reported the relative paucity of data on cost effectiveness, the poor quality of the economic evaluations undertaken to date and inability to make recommendations for bariatric surgery techniques. In 2009 a UK National Institute for Health Research (NIHR) HTA11 updated the economic review on bariatric surgery for obesity, broadening its scope to include obese as well as morbidly obese people. The HTA reviewed five original economic evaluations (including four economic models) and undertook a primary economic evaluation adopting an NHS and personal social services perspective to develop a state-transition model comparing surgical to non-surgical interventions with a time horizon of 20 years. The UK HTA authors concluded that bariatric surgery appears to be a cost-effective treatment for obesity compared with non-surgical interventions. However, their findings suggested that bariatric surgery is likely to be

14

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a less cost effective in less obese subjects and there was limited evidence to enable conclusions to be drawn on the relative cost effectiveness of different bariatric procedures. Quality Improvement Scotland (2010)12 noted that economic analyses to date have typically assumed observed weight loss lowers both the severity and incidence of obesity-related comorbidities and associated treatment costs which, while reasonable assumptions, remain to be verified.

In 2011 the NHS South East Coast Health Policy Support Unit released a policy recommendation incorporating an economic analysis with a time-horizon of10 years.13 This showed bariatric surgery is cost-effective in the medium term, reaching a break-even point within 3-years of surgery. This analysis supported the UK HTA conclusions that surgery is less cost effective in less obese patients. A study of cost-utility of bariatric surgery for morbid Obesity in Finland14 was published in 2011, showing similar results

9. Rationale behind the policy statement

Bariatric surgery for the morbidly obese is an increasingly available intervention. However, surgical intervention is not the whole solution and appropriate clinical selection of fully informed patients is important.

It is also important to ensure that surgery is not offered prematurely in a patient’s weight loss pathway. Bariatric surgery is only one component of the multimodal lifetime treatment pathway: multidisciplinary medical assessment, pre operative management of comorbidities, conservative treatments and life-long follow–up care.

Patients need to be informed of the benefits and risks as well as the life- long implications of bariatric surgery.

With informed choice patients are better able to cope with the eating restrictions of a post surgically altered gastrointestinal anatomy and mandatory follow up for nutritional supplementation and monitoring to prevent nutritional deficiencies; the management of comorbidities; and adjustment of medications and dosage post operatively.

Preparation will improve patient awareness of their role in following a healthy lifestyle to consolidate surgically achieved weight loss and resolution of comorbidities.

Patients also need information about when and where and from whom to seek help, advice and to attend for regular follow up and the actions to take in the event of the onset of surgical complications as well as gastrointestinal symptoms/ side effects arising from an altered anatomy.

Morbid obesity is a complex syndrome for which bariatric surgery is a highly specialised intervention reserved for patients with a high clinical case of need and in whom all prior efforts of intensive weight reduction have failed. Patients should also

15

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a be motivated and adequately prepared for surgery to ensure their post surgical compliance which is necessary for success. Patient selection processes should ensure that only those patients who stand to benefit the most from surgery are offered it. As a highly specialised intervention, bariatric surgery should only be undertaken by appropriately specialist trained and experienced surgeons with appropriately high caseloads working within multidisciplinary specialist teams in hospitals where these operations are commonly performed and who have the requisite institutional experience.

10. Mechanism for funding

Specialised Complex Obesity services, including bariatric surgery pre-assessment, perioperative management, postoperative and longer term follow up where it occurs within the specialised service will be funded by the NHS Commissioning Board.

Tier 1, 2, 3 services will be commissioned and funded by Clinical Commissioning Groups (CCGs). Population prevention / health promotion measures and strategies will be funded from local authority budgets.

11. Audit Requirements

Mandatory compliance by Bariatric Surgery providers with National Bariatric Surgery Registry15 requirements, including 100% provision of required data.

12. Documents which have informed this policy

Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS). Provision of Services document 2011). Available from: http://www.augis.org/pdf/reports/AUGIS_Provision_of_Services_Document.pdf Accessed 21/08.2012.

South East Coast Specialised Commissioning Group. Obesity management model for adults.2010

North West Specialised Commissioning Group. Evidence Based Commissioning of Specialist Morbid Obesity Services: Commissioning Standards and Summaries of Relevant Studies. November 2007.

National Institute for Health and Clinical Excellence. Bariatric surgical service commissioning guide. 2010. Available from: http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/BariatricSur

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a gicalService.jsp?domedia=1&mid=87F5267C-19B9-E0B5-D47104E7147082E9 Accessed 12/08/2012.

National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. CG43, 2006. Available from: http://guidance.nice.org.uk/CG43 Accessed 12/08/2012. Accessed 12/08/2012.

13. Links to other policies

Primary care commissioning policies on cosmetic plastic surgery procedures Policies on referral to private sector providers The mechanism operated by the NHS CB for funding requests outside of the clinical criteria in this policy is yet to be finalised

14. Date of Review

This policy will be reviewed in April 2014 unless data received indicates that the proposed review date should be brought forward or delayed.

References

1. World Health Organisation. Obesity and overweight. Fact sheet N°311. September 2006. Available from: http://www.mclveganway.org.uk/Publications/WHO_Obesity_and_overweight.pdf Accessed 16/08/2012.

2. Association for the Study of Obesity. Statistics – England 2012. Available from: http://www.aso.org.uk/useful-resources/statistics-england-2012/ Accessed 16/08/2012.

3. Department of Health. Obesity General information 2011. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Obes ity/DH_078098 Accessed 16/08/2012.

4. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. CG43, 2006. Available from: http://guidance.nice.org.uk/CG43 Accessed 12/08/2012.

5. British Obesity Surgery Patient Association. Available from: http://bospa.waxwing.co.uk/Default.aspx Accessed 20/08/2012

6. International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). IFSO guidelines for safety, quality and excellence in bariatric surgery,

17

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a 2007. Available from: http://www.eac-bs.com/eacbs/en/4/58.html Accessed 12/08.2012 . Accessed 20/08/2012.

7. Association of Upper Gastrointestinal Surgeons of Great Britain and ureland (AUGIS). Provision of Services document 2011). Available from: http://www.augis.org/pdf/reports/AUGIS_Provision_of_Services_Document.pdf Accessed 21/08.2012.

8. The Health Survey for England. Available from: http://www.ic.nhs.uk/hsee Accessed 21/08/2012.

9. Boudreau R, Hodgson A. Laparoscopic adjustable gastric banding for weight loss in obese adults:clinical and economic review. Ottawa: Canadian Agency for Drugs and Technologies in Health (CADTH), 2007:38. Available from: http://www.cadth.ca/en/products/health-technology-assessment/publication/739 Accessed 21/08/2012.

10. New Zealand Health Technology Assessment (NZHTA). The safety, effectiveness and cost‐effectiveness of surgical and non‐surgical interventions for patients with morbid obesity. Christchurch: New Zealand Health Technology Assessment (NZHTA).2007. Available from: http://www.otago.ac.nz/christchurch/otago014009.pdf Accessed 21/08/2012.

11. Picot J, Jones J, Colquitt J L, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13(41).

12. Quality Improvement Scotland Bariatric surgery in adults. Evidence note 28, 2010. Available from: http://www.healthcareimprovementscotland.org/previous_resources/hta_report/ev idence_note_28.aspx Accessed 21/08/2012.

13. NHS South East Coast Health Policy Support Unit. 2011

14. Mäklin S, Malmivaara A, Linna M, et al. Cost-utility of bariatric surgery for morbid Obesity in Finland. Br J Surg. 2011 Oct;98(10):1422-9.

15. National Bariatric Surgical Registry. Available from: http://hostn3.e- dendrite.com/csp/bariatric/FrontPages/nbsrfront.csp Accessed 12/08/2012.

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Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

Enc S

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Commissioning Policy Warwickshire North CCG (WNCCG)

Treatment Complex and Specialised Obesity Surgery (Bariatric Surgery)

Indication Severe and complex obesity

Treatment: NHS England policy (attached) adopted by CCG

The purpose of the adoption of the NHS England policy is to provide guidance for the commissioning and funding of bariatric surgery

With the commissioning responsibility passing to CCGs, following the same policy as NHS England (in line with NICE guidance CG43) ensures continuity of evidence based care

Equality Part of NHS England policy Impact

VERSION CONTROL

Version 1.0 Ratified by Governing Body Date ratified Name of originator/author NHS England Name of responsible Clinical Executive Group committee Date issued Review date March 2019

Coventry and Rugby Clinical Commissioning Group Complex and Specialised Obesity Surgery (Bariatric Surgery) August 2017

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

Report To: Governing Body in Common

Report Title: Treatments designed to improve aesthetic appearance policy

Report From: Dr S Allen, Clinical Director Chris Pycock, WNCCG Secondary Care Doctor

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group WNCCG Executive Group, 7 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To recommend amendments to the policy following concerns raised by Breast Surgeons at University Hospitals of Coventry & Rugby.

Key Points: • The policy was updated in July 2016 and stated surgery to the contra lateral unaffected breast would not be funded; • Following discussions with UHCW clinicians and management it has been recognised that it is common practice to undertake symmetrical surgery to both breasts to achieve the most clinically appropriate outcomes for cancer patients; • The policy has been revised as follows:  Section 2.4 has been amended to clarify that any treatment needs to be part of an agreed plan within given timescales and that any further revision for cosmetic improvement will not be funded;  Policy clarifies that surgery to the unaffected breast will be commissioned in accordance with section 2.4; • CRCCG’s Clinical Executive group and WNCCG’s Executive Group have discussed and agreed the amendments and recommend the policy for ratification by Governing;

NOTE: ONLY ONE VERSION (CRCCG) OF THE POLICY IS INCLUDED WITHIN THE GOVERNING BODY PAPERS. THE POLICIES ARE THE SAME AND WILL BE BRANDED ACCORDINGLY ONCE PUBLISHED.

Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Objective(s) / Plans Supports supported by this • Specialist care in the right place, at the right time; report: • Care delivered within a financially sustainable system.

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Adherence to the policy may result in a reduction Recurrent Expenditure: in costs for activity in secondary care. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the Performance: contract.

The policy aims to make the limits and eligibility criteria for NHS-funded cosmetic Quality and Safety: procedures fair, clear and explicit to the public, patients and providers.

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to submission to Clinical Executive Group and Governing Body Clinical Engagement:

WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: Not applicable

Page 2 of 2

Enclosure T

Treatments designed to improve aesthetic appearance

VERSION CONTROL

Version: 4.0

Ratified by: Governing Body

Date ratified:

Name of originator/author: Joint CCG Clinical Commissioning Policy Development Group Name of responsible committee: Clinical Executive Group

Date issued:

Review date: July 2020

VERSION HISTORY

Date Version Comment / Update

April 2009 1.0 Previous PCT policy

June 2013 2.0 Version to Governing Body – approved on 12 June 2013

Area Reviewed Amendments July 2016 3.0 Surgical treatment of pigeon Section in policy to advise not funded chest/chest wall deformity Mastopexy Section in policy to advise not funded Split ear lobe repair Section in policy to advise not funded Browlifts Moved to blepharoplasty section so that where there are functional problems (ie effecting visual fields) then funded Breast surgery Age quoted in all relevant sections and minimum age 18 maintained Breast augmentation Section in policy to advise not funded Breast surgery following Section in policy to advise that surgery cancer for unaffected breast not funded. Gynaecomastia Maintain current local policy Pinnaplasty Section in policy to advise not funded Laser treatment Retain same policy but exclude age restriction Laser treatment for hair Agreed to fund and additional wording removal for pilonidal sinus. added to policy Skin resurfacing techniques Continue not to fund – additional for acne and other scarring wording added to policy conditions Treatments for scars and Continue not to fund – additional keloids wording added to policy Abdominoplasty Maintain current policy and criteria Body contouring Continue not to fund – additional wording added to policy to be more explicit General exception for Retain but wording more explicit and for situations resulting from planned treatment in agreed timescales

Page 2 of 18

trauma, burns, destructive surgery, cancer treatment or congenital malformation. Summary of benign skin List expanded lesions (removal not funded)

Amendment to Section 2.4 4.0 Amendment to Breast surgery following cancer treatment relating to the unaffected breast to state commissioned in line with section 2.4

Page 3 of 18

Contents

1. Policy Statement ...... 5 2. Introduction ...... 5 3. Policy ...... 7

Page 4 of 18

1. Policy Statement

1.1. NHS Coventry and Rugby Clinical Commissioning Group consider funding of treatments designed to improve aesthetic appearance to be of low priority in allocating limited NHS resources. However, the Clinical Commissioning Group recognises that, in certain cases, a cosmetic procedure may be justified to alleviate or improve a physical deformity that most people would recognise as being severely abnormal, or to meet a clinical need other than improvement of aesthetic appearance. This policy sets out principles and examples of eligibility criteria for funding treatment in such cases.

2. Introduction

2.1. This policy relates to procedures and treatments that are primarily aimed at improving aesthetic appearance - the term “cosmetic procedures” is used in this document to denote these procedures and treatments. It is important to note that this includes not only some of the procedures that may be undertaken in the specialty of plastic and reconstructive surgery, but also in other specialties (including dermatology, ENT surgery, ophthalmology, maxillofacial surgery and general surgery).

2.2. Compared to healthcare interventions that improve health and that save lives, NHS Coventry and Rugby Clinical Commissioning Group considers cosmetic procedures to be of low priority when it comes to allocating limited NHS resources. However, it is recognised that cosmetic procedures may sometimes be justified to alleviate or improve a physical deformity that most people would recognise as being severely abnormal; or needed to improve the functioning of a body part, even if the surgery also improves or changes the appearance of that part of the body. This policy sets out principles and examples of eligibility criteria for funding treatment in such cases.

Rationale

2.3. This is a planned policy revision, which aims to make the limits and eligibility criteria for NHS-funded cosmetic procedures fair, clear and explicit to the public, patients and providers.

Scope

2.4. This policy does not apply to situations where patients require a cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, cancer treatment or a recognised congenital malformation. These cases are eligible for NHS funding as part of the treatment plan under routine commissioning arrangements and would be subject to a planned course of treatment within an agreed timescale, which may be long term in some cases. However, further revision for cosmetic improvement will not be funded

2.5. This policy applies to any and all procedures or treatments which are primarily aimed at improving aesthetic appearance (excluding the situations outlined above). It includes all the procedures and treatments listed below and in section 2.2, but this is not an exhaustive list of conditions and procedures, If there is any doubt about whether a treatment would be considered as cosmetic, advice should be sought from the Clinical Commissioning Group.

• Female breast reduction (reduction mammoplasty) • Correction of breast asymmetry • Male breast reduction • Breast enlargement (augmentation mammoplasty) • Revision of breast augmentation • Face lifts and brow lifts (rhytidectomy)

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• Treatment for facial atrophy • Surgery on the upper eyelid (upper lid blepharoplasty) • Surgery on the lower eyelid (lower lid blepharoplasty) • Surgery to reshape the nose (rhinoplasty) • Correction of prominent ears (pinnaplasty / otoplasty) • Correction of male pattern baldness • Hair transplantation • Correction of hair loss (alopecia) • Abdominoplasty and other similar procedures for removal of excess skin from arms, legs and all other parts of the body • Body contouring • Treatment (including laser treatment) for telangiectasia, hirsutism, keloid scarring and acne scarring, including skin resurfacing techniques for acne and other scarring conditions • Secondary care removal of benign skin lesions (including, but not limited to moles skin tags, sebaceous cysts, lipomata, warts, comedones, milia, molluscum contagiosum, seborrheic keratosis, neurofibromata, cysts, xanthelasma and benign pigmented naevi) • Tattoo removal • Surgical treatment of pigeon chest/chest wall deformity • Non acute split earlobe repair/refashioning • Any other treatments that are aimed at improving appearance

2.6. This policy applies to all service providers in secondary care and community care that carry out procedures to improve aesthetic appearance.

2.7. Prior approval must be sought from the Clinical Commissioning Group before carrying out any cosmetic procedure (unless it is following trauma, burns, destructive surgery, cancer treatment or congenital malformation), even if the policy indicates that they will normally be funded. Applications for prior approval under this policy should clearly state how the patient meets all the relevant policy criteria.

2.8. General practitioners should note the provisions of this policy before making a referral to secondary care for a cosmetic procedure. Patients who do not meet the eligibility criteria set out in this policy should not be referred. However, on occasions general practitioners may not be best placed to decide whether or not the policy criteria apply in a particular case and thus may refer to secondary care for an opinion only. In cases of doubt, prior approval should be obtained from the Clinical Commissioning Group before referral.

2.9. Although the policy does not apply to treatments that can be prescribed in primary care, or minor surgical procedures that can be carried out entirely within a general practice, GPs may wish to base their decision to treat on the principles and criteria contained within this policy.

2.10. Patients who do not meet the eligibility criteria set out in this policy will not be offered NHS funding. However, if a clinician (General Practitioner or Consultant) and/or a patient believes that the individual clinical circumstances of their case makes them an exception to the policy, and merits funding on an exceptional grounds, the clinician will need to make an application in accordance with the Clinical Commissioning Group’s policy for Individual Funding Requests. As such, applications will need to demonstrate that there are unlikely to be other ‘similar patients’ in the population for which the Clinical Commissioning Group is responsible. (i.e. demonstrate that the patient is significantly different to the general population of patients with the condition in question, and/or is likely to gain significantly more benefit from the intervention than might be expected for the average patient with the same clinical condition at the same clinical stage).

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2.11. It should be noted that the vast majority of applications for individual case funding for cosmetic procedures suggest that there are various psychological disorders and psychosocial factors associated with the physical problem (e.g. depression, anxiety, feelings of revulsion regarding the physical problem, social withdrawal, problems with sexual relationships and perceptions of teasing/bullying/ostracising by others because of the physical problem). The co-existence of these factors cannot, therefore, in itself be considered as ‘exceptional’ in these cases.

2.12. Obtaining a psychiatric opinion that the patient’s cosmetic problem is contributing to their psychological state does not necessarily indicate that the patient is exceptional and will not guarantee that individual case funding will be agreed. Therefore, psychiatric referral should not be made solely to support an application for individual case funding.

Principles

2.13. The NHS Coventry and Rugby Clinical Commissioning Group Framework for Commissioning underpins development of this policy.

2.14. All decisions will be taken in the context of the overall financial position of the Clinical Commissioning Group

3. Policy

2.15. The premise of the policy is that, NHS Coventry and Rugby Clinical Commissioning Group does not routinely fund cosmetic procedures unless the eligibility criteria in section 2.2 are met.

2.16. Also note that as explained in section 2.7 an approval for funding in each case must be sought from the Clinical Commissioning Group before carrying out the treatment. (This may be obtained before referral for the treatment if appropriate.)

2.17. The responsibility for presenting the information relevant to eligibility criteria rests with the clinician. The Clinical Commissioning Group as commissioner is ultimately responsible for assessing whether or not the eligibility criteria are in keeping with the content and the principles of the policy.

2.18. General clinical eligibility criteria

2.18.1. Aesthetic procedures for patients who are deemed to be within the normal morphological range will be considered purely cosmetic and therefore NOT funded on the NHS. However, funding may be appropriate to alleviate or improve a physical deformity that most people would recognise as being severely abnormal.

2.18.2. Referrals for the revision of treatments originally performed outside the NHS will NOT normally be supported and patients should be referred back to the practitioner who carried out the original procedure. However, in cases where there are significant complications following an aesthetic procedure (for example, infection), or circumstances that require the transfer of a patient to the NHS for appropriate management, the patient will be entitled to routine NHS treatment to treat that complication; but this may not be equivalent to revision of the original procedure. (An example is that complications due to removal of breast implants may be treated by removal of the implants, but the implants may not be replaced.)

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2.18.3. Patients previously treated within the NHS should be considered for revision surgery based on clinical need and priority.

2.18.4. Cosmetic surgery procedures will NOT be funded to alleviate psychological distress or dysfunction. Exceptions to this are unlikely (because the vast majority of applications for individual case funding for cosmetic procedures suggest that there are various psychological disorders and psychosocial factors associated with the physical problem, and therefore the co-existence of these factors cannot be considered as ‘exceptional’ in these cases).

2.18.5. When there is particular concern over psychological well-being, patients should be referred to the appropriate service for appropriate psychological assessment, treatment and/or support. (In cases where children are reported to be being bullied or teased due to variations in appearance, there is an expectation that this should also be addressed vigorously with the child’s school).

2.18.6. Surgical outcomes (e.g. wound healing, complications etc) can be adversely affected by smoking. To ensure the best outcomes, patients should have stopped smoking prior to referral for any treatments under this policy. Applications for prior approval under this policy should record smoking status. Smoking status should be validated at pre-operative appointment using an appropriate test. Support to stop smoking is available to patients through a range of NHS stop smoking services.

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TABLE 1 – INDEX OF TREATMENTS

Prior Approval Page reference reference

Female breast reduction AES/PA/001 9 (reduction mammoplasty) Correction of breast asymmetry AES/PA/002 10

Male breast reduction for gynaecomastia AES/PA/003 10

Breast enlargement 11 (augmentation mammoplasty)

AES/PA/004 Revision of breast augmentation 11

Breast surgery following cancer treatment N/A 12 relating to an unaffected breast

Mastopexy N/A 12

Face lifts N/A 12 (rhytidectomy)

Surgery on the upper eyelid AES/PA/005 13 (upper lid blepharoplasty) and brow lifts

Surgery on the lower eyelid AES/PA/006 13 (lower lid blepharoplasty)

Correction of prominent ears 13 (pinnaplasty/otoplasty)

Abdominoplasty AES/PA/007 13

Body contouring N/A 14

(Benign skin lesions including sebaceous cysts) N/A 14

Laser treatment of skin conditions AES/PA/008 15

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Tattoo removal N/A 15

Surgical treatment of pigeon chest/chest wall N/A 16 deformity

Non acute split ear lobe repair/refashioning N/A 16

2.2 Clinical eligibility criteria for specific procedures

Procedure Guidance

Female breast reduction Note: this policy does not apply to gender reassignment cases (reduction mammoplasty) Breast reduction surgery for cosmetic reasons is not funded.

AES/PA/001 Breast reduction surgery is considered to be cosmetic unless breast hypertrophy is causing significant symptoms as indicated

below.

Breast reduction surgery will be funded for non-cosmetic indications for women aged 18 or older for whom growth is complete when ALL the following criteria (1-4) are met: (1) SIGNIFICANT SYMPTOMS ARE PRESENT • These symptoms are persistent, as evidenced by a documented history of at least one year, and are sufficiently severe to affect activities of daily living (such as working or undertaking household tasks) AND • The opinion of the requesting clinician is that the symptoms are mainly attributable to the breast hypertrophy and are likely to be significantly reduced by breast reduction AND • The patient is suffering from pain in neck, shoulders or upper back (or has painful kyphosis) and this has persisted despite a 3-month trial of other therapeutic measures including: - First-line analgesic drugs - Wearing a properly fitted bra providing adequate support - Physiotherapy assessment and treatment (if considered appropriate following assessment), following postural advice and any recommended exercises. (Evidence of physiotherapy assessment and treatment must be provided). OR There is documented ulceration (not just discomfort) from bra straps cutting into shoulders, and this ulceration has persisted over a period of at least three months despite wearing a properly fitted bra (with wide straps, and providing adequate support). OR There is chronic intertrigo, dermatitis, and/or ulceration in the infra-mammary fold which has been confirmed and documented on a number of occasions over a period of six

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Procedure Guidance

months, and has been unresponsive to appropriate dermatological treatments and conservative measures (e.g., good skin hygiene) over a period of six months or longer.

(2) THE BREAST HYPERTROPHY IS SEVERE • There is a significantly abnormal ratio of breast size to torso. • The patient has a bra cup size of at least F and the proposed breast reduction surgery should be intended to result in a reduction in breast size of at least 3 cup sizes.

(3) THE PATIENT IS NOT OBESE. • The patient must have a sustained body mass index (BMI) within the range 18 kg/m2 to 29 kg/m2 • The GP is required to confirm that the patient’s has had a BMI below 30 kg/m2 for at least 6 months prior to referral and request. This must be recorded at 0, 3 and 6 months.

(4) The patient is not less than one year post delivery of a child.

Correction of breast Note: As stated above in the general introduction to the policy, this asymmetry does not apply to cases where breast reconstruction is following treatment for cancer, or cases following trauma.

AES/PA/002 Funding for breast asymmetry surgery will be funded in cases of gross asymmetry where all of the following criteria are met:

• There must be a significant degree of asymmetry of breast shape and/or volume (at least a difference of two cup sizes). • The plastic surgery team, in conjunction with the patient, will make the final clinical decision as to whether the patient should have reduction or augmentation to resolve the asymmetry. (Funding will be either for augmentation to one breast, or reduction of one breast in order to achieve a reasonable degree of symmetry.) • The plastic surgery team must confirm that they have discussed possible future complications with the patient, and have not given any assurances that NHS funding for further surgery or replacement implants will be available in the event of weight or breast changes in the future (including those following pregnancy), or in the event of complications such as capsular contracture (except for removal of implant in line with current policy). • The patient is aged 18 or over • The patient must have a stable weight, and body mass index (BMI) within the range 18 kg/m2 to 29 kg/m2 • The GP is required to confirm that the patient has had a stable weight (no more than 5% change in weight) within this BMI range over a period of 6 months prior to referral and request. This must be recorded at 0, 3 and 6 months.

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Procedure Guidance

Male breast reduction for Surgical treatment of gynaecomastia for cosmetic reasons is gynaecomastia not normally funded.

Funding will be found where the gynaecomastia is extreme AND AES/PA/003 • Considered to be Simon's classification grade 3 - Gross breast enlargement with skin redundancy that simulates a

pendulous female breast AND The patient meets the following criteria: • Patient is post-pubertal • Patient is not obese (BMI of 29 or less) • Patient has been screened (and treated if appropriate) for reversible endocrinological or drug related causes.

Breast enlargement Notes: (augmentation 1. As stated above in the general introduction to the policy, this mammoplasty) does not apply to cases where breast reconstruction is following treatment for cancer, or cases following trauma. 2. this policy does not apply to gender reassignment cases

AES/PA/004 Breast augmentation is not funded.

Revision of breast Removal of breast implants augmentation Where there are significant complications from breast implants AES/PA/005 (such as severe pain or clinical risk from leaking or otherwise damaged implants), removal of implants will be funded, irrespective of the reasons for their original insertion. This includes removal for any of the following indications:

• Extrusion of implant through skin • Implants complicated by recurrent infection. • Implants with Baker Class IV contracture associated with severe pain (or implants with severe contracture that interferes with mammography) • Intra or extra-capsular rupture of silicone gel-filled implants

If any of the above criteria for removal of a breast implant is met unilaterally, patients will be offered the choice of removing both prostheses at the same time, with the intention of ensuring symmetry.

Note that following will NOT be funded: • Insertion of a new implant (unless the criteria specified below are met)

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Procedure Guidance

• Correction of any asymmetry (other than removal of a contralateral implant, as specified above) • Mastopexy and other similar surgical procedures.

Replacement of breast implants

Replacement of breast implants will be funded if removal is required for one of the reasons specified above AND the original procedure was funded by the NHS (either as part of treatment for breast cancer, or for other reasons, provided the original indication was broadly in line with the PCT’s current policy for breast augmentation or correction of asymmetry).

The replacement of privately funded breast implants, either unilaterally or bilaterally, is not funded.

Replacement with privately purchased prostheses is not allowed alongside NHS removal of implants.

Breast surgery following Commissioned in accordance with guidelines within section 2.4 cancer treatment relating above to an unaffected breast

Mastopexy Not funded

Face lifts (rhytidectomy) Face lifts and similar surgery, and related non-surgical treatments such as Botox and line filling, are not funded.

Surgery on the upper These procedure will be funded to correct functional impairment as eyelid (upper lid demonstrated by: blepharoplasty) and • Impairment of visual fields in the relaxed, non-compensated browlifts state. Objective evidence of this will be required. • Clinical observation of poor eyelid function, discomfort e.g. headache worsening towards the end of the day and / or evidence of chronic compensation through elevation of the AES/PA/006 brow.

Further advice:

• Many people acquire excess skin in the upper eyelids and brow as part of the process of ageing and this may be considered normal. However, if this starts to interfere with vision or function of the eyelid apparatus then this can warrant treatment. Surgery on the lower eyelid This procedure will be funded for correction of ectropion or (lower lid blepharoplasty) entropion or for the removal of lesions of the eyelid skin or lid margin. AES/PA/007

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Procedure Guidance

Correction of prominent Not funded ears (pinnaplasty/otoplasty)

Abdominoplasty • Abdominoplasty and similar procedures (apronectomy, panniculectomy, liposuction) for cosmetic or psychological reasons are not normally funded.

AES/PA/009 • Funding will be found when there is a considerable abdominal apron, causing functional problems, following massive weight loss (usually through bariatric surgery and less commonly by dietary means) when the patient has the following circumstances and meets the following criteria:

• There must be documented evidence of clinical pathology (eg recurrent intertrigo which has led to ulceration requiring repeated courses of treatment for a minimum period of one year) or disability (eg ambulatory or urinary difficulties) due to the skin fold in question

• The patient’s starting BMI before weight loss must have been no less than 45kg/m2

• The patient’s current BMI must be less than 30kg/m2. (In some patients a BMI of less than 30kg/m2 may not be achievable, due the weight of excess skin. In these circumstances the patient must have lost at least 15 BMI points, and their clinician must confirm that no further reduction in BMI will be possible without removal of excess skin)

• The patient’s weight must have been stable (normally at less than a BMI of 30kg/m2) for a minimum of 12 months.

• Further advice:

It is important that patients who are considering bariatric surgery are given full information about the cosmetic consequences of the bariatric procedures prior to undergoing surgery, and advised that they will not be eligible for abdominoplasty or a similar cosmetic procedure on the NHS unless they meet these criteria Body contouring Not funded

This includes any requests for implants as well as removal of tissue • (Benign skin lesions • Any lesions suspected of malignancy (or where there is including sebaceous diagnostic uncertainty and malignancy is a possibility) should cysts) be referred with an appropriate degree of urgency. Prior approval is not required in these circumstances. • Surgical excision under NHS is available for any lesions, irrespective of size, that appear to have signs of malignancy and/or where removal is required for diagnostic purpose.

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Procedure Guidance

• Although prior approval is not required (either for referral or treatment) in these cases, the reason for referral and/or for removal of the lesion should be clearly documented in any clinical letters and in the patient’s notes.

• If, following a referral to secondary care, malignancy is no longer suspected (and if the lesion has not already been excised for diagnostic purposes), any further treatment should be in line with the policy set out below. (It is therefore important that patients understand the reason for referral, and that referral in these circumstances will not automatically lead to excision of a benign lesion.)

• Sebaceous cysts which are infected or discharging, or any other acutely infected skin lesion, may also be referred and treated without prior approval. Again, the reason for referral and/or for removal of the lesion should be clearly documented in any clinical letters and in the patient’s notes.

• Treatment of benign skin lesions, with no risk of malignancy or infection, is considered to be cosmetic and should not normally be referred or treated. This includes: • Benign naevi • Haemangiomas • Sebaceous (epidermal) cysts (asymptomatic) • Seborrhoeic warts • Skin tags and papillomas • Spider naevi • Thread veins • Warts • Xanthelasma

• Referral and treatment may be approved in certain circumstances, but prior approval should always be sought: • Lesions where the size and/or location causes significant functional problems or recurrent trauma (i.e. for functional reasons – not cosmetic)

Large lesions that cause extreme facial disfigurement may be eligible if the proposed procedure is assessed as clinically appropriate and expected to achieve significant health benefit. The risks of scarring must be balanced against the appearance of the lesion. (If laser treatment rather than surgical treatment is proposed, please see separate section on ‘laser treatment of skin conditions’.)

Laser treatment of skin Funding will be found (subject to prior approval*) for patients with conditions the following circumstances and meeting one of the following criteria:

• For port wine stains in people when lesions are located on the face and neck.

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Procedure Guidance

AES/PA/010 • For other types of haemangiomas/vascular birth marks located on the face and neck in people which, in the opinion of an

appropriate medical specialist, is unlikely to resolve without treatment and for which the long-term cosmetic benefits of treatment are considered to outweigh any long-term cosmetic risks of treatment

Funding will also be available in the following circumstances (for which prior approval should be sought before referral AND before any treatment is commenced*):

• For haemangiomas/vascular malformations in people that are located either on the face or on any other part of the body, which are causing significant functional problems (not only cosmetic concerns) for which, in the opinion of an appropriate medical specialist, laser treatment is considered to be the most suitable treatment option. (The application for prior approval must provide evidence of effectiveness of the proposed treatment.) • The treatment of pilonidal sinus is not considered cosmetic and will be funded subject to prior approval

Laser treatment of other skin conditions for cosmetic reasons is not normally funded. (This includes removal of hair from any part of the body or face, removal of spider angiomata, removal of telangiectasias, treatment of rosacea, treatment of hidradenitis suppurativa, and any other skin conditions.)

* In all cases, before final approval for treatment can be given, a treatment plan must be submitted by the provider of laser therapy to indicate the maximum number of treatment sessions (and cost) that will be required to achieve a predicted level of result which would be acceptable to the patient (or patient’s parent in the case of a young child). The treatment provider is responsible for ensuring that patient and parent expectations are realistic at the time of obtaining consent for the treatment. Once the agreed maximum number of funded treatment sessions has been reached, funding for any additional sessions required to achieve an acceptable result would be expected to be met by the treatment provider.

Tattoo removal Tattoo removal is not funded. It may be considered only if there are exceptional circumstances - any request would need to be made through the Individual Funding Request (IFR) process Surgical treatment of Not funded pigeon chest/chest wall Considered a cosmetic procedure. deformity Approval required if surgery is for a clear clinical reason such as significant impairment of cardiac or respiratory function Non acute split ear lobe Not funded repair/refashioning

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Equality Impact Assessment (EIA)

Policy/Service Treatments Designed to Person completing Kay Holland Improve Aesthetic EIA Appearance Policy

Date of EIA 12th June 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be a Protected Group Likely to be a differential differential impact? impact?

Age No Race No

Disability Yes Religion or belief No

Gender reassignment No Sex Yes

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

Sex Body dysmorphia disorder (BDD) affects females more than males (http://www.nhs.uk/conditions/body- dysmorphia/Pages/Introduction.aspx) Nearly a half of all women in the UK consider plastic surgery and in the UK, women had 90% of all cosmetic procedures.

All decisions regarding aesthetic surgery are reached on clinical grounds. Monitor IFR requests for aesthetic surgery by gender.

Disability BDD as a disability in itself causes sufferers to feel anxiety related to their appearance. Due to the nature of this disability it would be sensible to suggest that sufferers may have a higher inclination to pursue aesthetic appearance procedures to try to alleviate the cause of their condition.

In regard to other disabilities there is a lack of research surrounding those with physical disability and body image. However limited research has found that adolescents with disabilities had poorer scores on body and self image sub- scale than able-bodied adolescents. (Cromer, Enrile, McCoy, Gerhardstern, Fitzpatrick and Judis (1990).

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Body image related disabilities link to cosmetic/aesthetic surgery. Surgery will not be funded to alleviate psychological distress. All decisions regarding aesthetic surgery are reached on clinical grounds. Monitor IFR requests for aesthetic surgery.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc U

Report To: Governing Body in Common

Report Title: Rhinoplasty/Septorhinoplasty Policy

Report From: Dr S Allen, Clinical Director Chris Pycock, Secondary Care Doctor, WNCCG

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group WNCCG Executive Group, 7 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To recommend amendments to the policy to bring it in line with the Treatments designed to improve aesthetic appearance policy.

Key Points: • The policy has been amended to clarify that “where treatment is sought for situations where patients require a cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, cancer treatment or a recognised congenital malformation, reference should be made to Section 2.4 of the Treatments designed to improve Aesthetic Appearance policy.” • For information section 2.4 of the treatments designed to improve aesthetic appearance states “This policy does not apply to situations where patients require a cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, cancer treatment or a recognised congenital malformation. These cases are eligible for NHS funding as part of the treatment plan under routine commissioning arrangements and would be subject to a planned course of treatment within an agreed timescale, which may be long term in some cases. However, further revision for cosmetic improvement will not be funded” Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Objective(s) / Plans Supports supported by this • Specialist care in the right place, at the right time; report: • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Adherence to the policy may result in a reduction Recurrent Expenditure: Financial: in costs for activity in secondary care.

Is this expenditure included Yes  No N/A within the CCG’s Financial

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc U

Plan? (Delete as appropriate) Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the Performance: contract. The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to Policy) Patient and Public not applicable Engagement: Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to submission to Clinical Engagement: Clinical Executive Group and Governing Body. WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: not applicable

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Enclosure U

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Commissioning Policy: Warwickshire North CCG (WNCCG)

Treatment Rhinoplasty/Septothinoplasty Indication Nasal Deformity Treatment Prior approval from the Clinical Commissioning Group will be required before any treatment proceeds in secondary care.

These procedures should not be carried out and will not be funded for cosmetic reasons.

These procedures will only be funded for the following conditions (with indications clearly documented for audit purposes):

• Correction of nasal deformity causing significant nasal blockage • Correction of nasal deformity associated with specific recognised facial congenital disorders.

Where treatment is sought for situations where patients require a cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, cancer treatment or a recognised congenital malformation, reference should be made to Section 2.4 of the Treatments designed to improve Aesthetic Appearance policy.

Equality Impact See attached Assessment

Version Control:

Version 2.0 Ratified by Governing Body Date ratified Name of Originator/Author Joint CCG Clinical Commissioning Policy Development Group Name of Responsible Clinical Executive Group Committee Date Issued Review Date September 2020

Equality Impact Assessment (EIA)

Policy/Service Rhinoplasty/Septorhinoplasty Person completing CCG Joint Clinical EIA Commissioning Policy Development Group

Kay Holland Interim Acute Programme Lead Date of EIA 12th June 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be a Protected Group Likely to be a differential differential impact? impact?

Age No Race No

Disability No Religion or belief No

Gender reassignment No Sex No

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

This is a harmonised policy across three Clinical Commissioning Groups – Coventry and Rugby CCG; South Warwickshire CCG and Warwickshire North CCG.

The impact of this policy has been considered against all protected characteristics and Human Rights values.

The policy provides a consistent clinically based criteria for decision making, benefitting patients within the CCG area by providing consistency and equity of service provision. The policy provides an avenue through the ‘Individual Funding Requests’ policy to seek funding in exceptional clinical circumstances.

Since CCGs operate within finite budgetary constraints the policies detailed in this document make explicit the need for

the CCGs to prioritise resources and provide interventions with the greatest proven health gain.

The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc V

Report To: Governing Body in Common

Report Title: Functional Electrical Stimulation (FES) policy

Report From: Dr S Allen, Clinical Director Chris Pycock, WNCCG Secondary Care Doctor

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group WNCCG Executive Group, 7 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To recommend a formal policy for the use of FES in the community for “Drop Foot” of central neurological origin for carefully selected patients.

Key Points: • Formalisation of a currently commissioned service; • FES is not routinely commissioned by the CCG under community services for dropped foot because of limited evidence of clinical effectiveness; • In accordance with national guidelines carefully selected patients will be supported subject to meeting criteria detailed in the policy; • The Policy Development Group recommended the policy as written without the requirement for prior approval;

Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Supports Objective(s) / Plans • Care closer to home; supported by this • report: Specialist care in the right place, at the right time; • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Recurrent Expenditure: Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc V

contract. The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers.

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to Policy) Patient and Public not applicable Engagement: Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to submission to Clinical Engagement: Clinical Executive Group and Governing Body. WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: not applicable

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Enc V

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Commissioning Policy: Warwickshire North CCG (WNCCG)

Treatment Functional Electrical Stimulation (FES) Indication “Drop Foot” of central neurological origin Treatment: CRCCG does not routinely commission under community services FES for dropped foot because of the limited evidence for clinical effectiveness.

Treatments for drop foot include physiotherapy, orthotic devices, medical therapy and electrical stimulation of the affected nerves and surgery.

First-line treatment is usually physiotherapy and/or the use of an ankle foot orthosis (AFO). An AFO is a device, usually made of plastic, which is worn on the lower part of the leg and on the foot. It is used to align the lower leg correctly and control the motion of the ankle and foot, to provide stability and improve gait. Evidence will be required to demonstrate that first-line treatments have been tried.

In accordance with national guidelines carefully selected patients may be eligible to be considered for FES if certain pre-requisite criteria are fulfilled: • The individual has a upper motor neuron lesion resulting from stroke, multiple sclerosis, cerebral palsy or spinal cord injury (but has an intact peroneal nerve): • There is evidence that the dropped foot interferes significantly with the individual’s day to day living, arising from problems such as frequent falls and severe fatigue; • There is evidence that FES has been recommended for the individual after a thorough assessment of their suitability by the local physiotherapy service or MDT specialising in rehabilitation (this recommendation must specify how any benefit will be measured for the individual); • There is evidence to demonstrate that first-line treatments have been tried.

Note: If a patient meets the policy criteria it is expected that the patient will demonstrate a positive trial of FES before proceeding to a permanent stimulator. In this case the patient will proceed with a surface electrode device, but an additional individual funding request will need to be made if an implanted electrode is being considered.

NICE Interventional procedures guidance (IPG278) Functional electrical stimulation for drop foot of central neurological origin. Published date: January 2009 https://www.nice.org.uk/guidance/ipg278

Equality See EIA attached Impact

VERSION CONTROL

Version 1.0 Coventry and Rugby Clinical Commissioning Group FES policy August 2017

Ratified by Governing Body Date ratified Name of originator/author Joint Clinical Commissioning Policy Development Group

Name of responsible Clinical Executive Group committee Date issued Review date September 2017

Coventry and Rugby Clinical Commissioning Group FES policy August 2017

Equality Impact Assessment (EIA)

Policy/Service Functional Electrical Person completing Policy Development Group Stimulation (FES) EIA Kay Holland Interim Acute Programme Lead Date of EIA 26 July 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be a Protected Group Likely to be a differential differential impact? impact?

Age No Race No

Disability No Religion or belief No

Gender reassignment No Sex No

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

This is a harmonised policy across three Clinical Commissioning Groups – Coventry and Rugby CCG; South Warwickshire CCG and Warwickshire North CCG.

The impact of this policy has been discussed at length by the Policy Development group and all protected characteristics and Human Rights values given due regard and only patient demographic issues that could impact on individual risk and/or clinical effectiveness were taken into account when reaching a decision.

The policy provides a consistent clinically based criteria for decision making, benefitting patients within the CCG area by providing consistency and equity of service provision. The policy provides an avenue through the ‘Individual Funding Requests’ policy to seek funding in exceptional clinical circumstances.

No potential or known adverse impacts or barriers for protected and/or vulnerable groups were identified.

Please summarise where further action is required and when the projects/decision will be reviewed.

3

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc W

Report To: Governing Body in Common

Report Title: Female Genital Prolapse Policy

Report From: Dr S Allen, Clinical Director Chris Pycock, WNCCG Secondary Care Doctor

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group WNCCG Executive Group, 7 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To recommend a revised policy to Governing Body for ratification which provides clarification for referral of patients for specialist assessment of female genital prolapse.

Key Points: • The policy has been revised by the Joint Clinical Commissioning Policy Development Group in line with recommendations of an audit undertaken by Dr Allen and following discussion with clinicians at UHCW; • It recommends that conservative management is undertaken before referral (unless indications for early referral are present); • List of grades to define moderate/severe indications (as agreed with UHCW Lead Urogynaecologist) has been added to the policy • Prior approval requirement has been added;

Recommendation: It is recommended that the Governing Bodies APPROVE the policy for adoption.

Implications

Objective(s) / Plans Supports supported by this • Specialist care in the right place, at the right time; report: • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Adherence to the policy may result in a reduction Recurrent Expenditure: in costs for activity in secondary care. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the Performance: contract.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc W

The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to Policy) Patient and Public not applicable Engagement: CRCCG - linical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to Clinical Engagement: submission to Clinical Executive Group and Governing Body. WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: not applicable

Page 2 of 2

Enclosure W

Introduction The rationale and scope of this policy is contained within the overarching LPP policy which sets out the CCGs approach to Low Priority Procedures.

This document refers specifically to Female Genital Prolapse procedures.

Commissioning Policy: Coventry and Rugby CCG (CRCCG) Commissioning Policy: Warwickshire North CCG (WNCCG) Treatment Referral for specialist assessment Indication Female Genital Prolapse Criteria Prior approval from the Clinical Commissioning Group will be required before any treatment proceeds in secondary care.

The CCG does not fund surgical procedures for asymptomatic or mildly symptomatic pelvic organ prolapse.

Appropriate conservative management by Primary/Community providers is required before referral for specialist assessment and surgical intervention is considered (unless indication for early referral is present).

Conservative management should include: • Weight loss if BMI >30; • Treatment for constipation if present to minimise straining; • Management of causes of any cough; • Pelvic floor muscle training; • Ring or other pessary (where appropriate) *

Referral for specialist assessment is indicated for any of the following:

• Failure of primary/community management in moderate/severe prolapse **with clear documentation that a trial of ring or other pessary has failed

• Prolapse combined with urinary incontinence or faecal

incontinence;

• Failure of pessary;

• Women with symptomatic prolapse (including those

combined with urethral sphincter incompetence or faecal

incontinence);

*Please note where a GP does not have the facilities to provide

pessary insertion, referral to an appropriate provider of this service is indicated.

** Definition of “moderate” and “severe” by following grading , where Grade 2 is moderate and Grades 3 and 4 are severe:

• Grade 0 – Norma position • Grade 1 – descent into vagina not reaching introitus • Grade 2 – descent just outside the introitus

• Grade 3 – descent outside the introitus – beyond 2 cms • Grade 4 – Procidentia

Equality Impact See attached Assessment

Version Control:

Version 4.0 Ratified by Governing Body Date ratified Name of Originator/Author Joint CCG Clinical Commissioning Policy Development Group Name of Responsible Committee Clinical Development Group Date Issued Review Date

Equality Impact Assessment (EIA)

Policy/Service Female Genital Prolapse Person completing Joint CCG Clinical EIA Commissioning Policy Development Group

Date of EIA 15 June 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be a Protected Group Likely to be a differential differential impact? impact?

Age Yes Race Unknown

Disability Yes Religion or belief No

Gender reassignment No Sex Yes

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

This is a harmonised policy across three Clinical Commissioning Groups – Coventry and Rugby CCG; South Warwickshire CCG and Warwickshire North CCG.

The impact of this policy has been discussed at length by the Policy Development group and all protected characteristics and Human Rights values given due regard and only patient demographic issues that could impact on individual risk and/or clinical effectiveness were taken into account when reaching a decision.

The policy provides a consistent clinically based criteria for decision making, benefitting patients within the CCG area by providing consistency and equity of service provision. The policy provides an avenue through the ‘Individual Funding Requests’ policy to seek funding in exceptional clinical circumstances.

Sex – Female genital prolapse will only affect women, it is more common in women who have experienced pregnancy and childbirth;

Race – It is reported that the prevalence of prolapse may vary between different racial groups, but this appears to be based on a very small number of studies;

Disability – Certain conditions may predispose to prolapse (including joint hypermobility syndrome, Marfan syndrome, Ehlers-Danlos syndrome and spina bifida/spina bifida occulta). Overweight (BMI 25-30) and obesity (BMI >30) have also been implicatedas risk factors for prolapse, although not consistently identified in studies.

Age – increasing age is a risk factor for developing prolapse.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc X

Report To: Governing Body in Common

Report Title: Arthroscopy of knee joint (diagnostic/therapeutic) policy

Report From: Dr S Allen, Clinical Director Chris Pycock, WNCCG Secondary Care Doctor

Date: 14th September 2017

Previously Considered by: Policy Development Group CRCCG Clinical Executive Group WNCCG Executive Group, 7 September 2017

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To recommend a revised policy for ratification which clarifies the commissioning position of the CCG.

Key Points: • The policy has been amended by the Policy Development Group (PDG) in line with NICE guidance, and following discussion with clinicians at UHCW; • Orthopaedic consultants at UHCW advised that their P.KIP scheme focussing on conservative management has reduced arthroscopies by 50/60% and that the policy criteria was acceptable for those patients needing the procedure; • Consultants also recommended that advice for GPs on GP Gateway be updated to provide guidance on patients presenting with “locking of knee” or “knee giving way”, this will be discussed at the next GP Gateway Editorial Board; • Policy aims to avoid inappropriate MRI scans, so stipulates that any scans should be requested by secondary care; • Revised policy supported by PDG on behalf of all local CCGs;

Recommendation: The Governing Body is requested to APPROVE the policy for adoption

Implications

Objective(s) / Plans Supports supported by this • Specialist care in the right place, at the right time; report: • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable Financial: Adherence to the policy may result in a reduction Recurrent Expenditure: in costs for activity in secondary care.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc X

Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) [Outline any performance implications relating to this report/ decision. If not relevant Performance: state ‘not applicable’] The policy aims to make the limits and eligibility criteria for NHS-funded treatment fair, Quality and Safety: clear and explicit to the public, patients and providers.

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to policy) Patient and Public Not applicable Engagement: CRCCG Clinical representatives sit on the Policy Development Group, the policy has also been discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to Clinical Engagement: submission to Clinical Executive Group and Governing Body. WNCCG - Chris Pycock was involved in the discussions at the Policy Development Group Risk and Assurance: not applicable

Page 2 of 2

Enclosure X

Commissioning Policy: Coventry and Rugby Clinical Commissioning Group (CRCCG)

Commissioning Policy Warwickshire North CCG (WNCCG)

Treatment Arthroscopy of knee joint (diagnostic/therapeutic) Indication Internal joint derangement Treatment: Diagnostic arthroscopy of the knee:

Not commissioned or funded for the investigation of knee pain

Therapeutic arthroscopy of the knee:

Arthroscopy of the knee can be undertaken where a competent history and clinical examination has demonstrated clear evidence of an internal joint derangement (meniscal tear, ligament rupture or loose body) and where conservative treatment has failed or where it is clear that conservative treatment will not be effective. Occasionally MRI would be required but this would normally be requested by secondary care

Knee arthroscopy can therefore be carried out for: • Removal of loose body • Meniscal surgery (repair or resection) • Ligament reconstruction/repair (including lateral • relapse) • Synovectomy • Treatment of articular defects e.g. micro-fracture Treatment of osteoarthritis (only in line with NICE guideline (CG177)1

A proportion of knee arthroscopies may not lead to the anticipated therapeutic intervention, and therefore will be coded as diagnostic arthroscopies. Surgeons are asked to ensure that coding of the arthroscopy is undertaken after the procedure has taken place.

Ref: 1 National Institute for Health and Clinical Excellence (NICE) (2014) Osteoarthritis: National clinical guideline for care and management in adults. [Available online from: https://www.nice.org.uk/guidance/cg177]

Equality See EIA attached Impact

VERSION CONTROL

Version 2.0 Ratified by Governing Body Date ratified Name of originator/author Joint CCG Clinical Commissioning Policy Development Group

Name of responsible Clinical Executive Forum

committee Date issued Review date September 2020

Equality Impact Assessment (EIA)

Policy/Service Arthroscopy of Knee Joint Person completing Policy Development EIA Group

Date of EIA 26th July 2017 Accountable CCG Andrea Green Lead NHS Coventry and Rugby Clinical Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate discrimination, advance equality of opportunity, and foster good relations with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to be Protected Group Likely to be a a differential differential impact? impact?

Age No Race No

Disability No Religion or belief No

Gender reassignment No Sex No

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

This is a harmonised policy across three Clinical Commissioning Groups – Coventry and Rugby CCG, South Warwickshire CCG and Warwickshire North CCG.

Since CCGs operate within finite budgetary constraints the policy detailed in this document make explicit the need for the CCGs to prioritise resources and provide interventions with the greatest proven health gain.

The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness.”

The impact of this policy has been considered against all protected characteristics and Human Rights values. By not being routinely commissioned it is likely to have a positive impact as the procedure is highlighted as being less effective (potential to miss significant amounts of pathology).

The policy provides a consistent clinically based criteria for decision making, benefitting patients within the CCG area by providing consistency and equity of service provision. The policy provides an avenue through the ‘Individual Funding Requests’ policy to seek funding in exceptional clinical circumstances.

No potential or known adverse impacts or barriers for protected and/or vulnerable groups were identified.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

NHS Coventry and Rugby Clinical Commissioning Group Enc Y

Report To: Governing Body in Common

Report Title: CRCCG Consultant to Consultant Referrals Policy

Report From: Dr S Allen, Clinical Director

Date: 14th September 2017

Previously Considered by: CRCCG Clinical Executive Group

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To recommend amendments to the policy following discussion with Operational Leads at University Hospitals of Coventry & Warwickshire.

Key Points: • The original policy was agreed and ratified in May 2017; • Following discussions with UHCW it has been recognised that some amendments were required to ensure the policy was operationally and contractually acceptable to the Trust; • The changes to the policy are minimal and the main change being, removal of the clause to monitor and maintain consultant to consultant referrals within agreed activity plans, as there is currently no plan agreed, activity will be monitored during 2017/18 to inform the agreement of a plan in 2018/19; • Operational and Contracting Leads at UHCW have confirmed that they support the amendments and will vary the policy into their contract once ratified; • The policy will be reviewed annually;

Recommendation: It is recommended that the Governing Body APPROVES the policy for adoption.

Implications

Supports Objective(s) / Plans • Care closer to home; supported by this • report: Specialist care in the right place, at the right time; • Care delivered within a financially sustainable system. Conflicts of Interest: None Non-Recurrent Expenditure: not applicable May result in a reduction in costs for activity in Recurrent Expenditure: secondary care. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: This policy is expected to deliver a reduction in the amount of Consultant to Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group Enc Y

Consultant referrals at the Trust and compliance with this policy will be monitored monthly. The policy • Supports consultant to consultant referrals when appropriate and in the patients best interests; • Promotes care closer to home where possible by ensuring management of patients within primary and community care where appropriate; Quality and Safety: • Ensues patients are offered choice for each episode of care where clinically appropriate. • Contributes to the management of secondary care capacity by ensuring that only those patients genuinely in need of secondary care receive it, and in a more timely way as part of 18 week pathways;

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public not applicable Engagement: Clinical representatives sit on the Policy Development Group, the policy has also been Clinical Engagement: discussed with Dr O’Brien, Dr Yadav, Dr Raistrick and Dr Allen prior to submission to Clinical Executive Group and Governing Body Risk and Assurance: not applicable

Page 2 of 2

Enclosure Y

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Title: Management of Consultant to Consultant Referrals Policy

Policy: Introduction Whilst consultant to consultant referrals are appropriate and in the patients best interests in some instances, at other times they are less appropriate and the patient should have been offered choice or their problem/condition managed within primary/community care.

Service Condition 8.5, NH Standard Contract 2016 – 19, states “Except as permitted under an applicable Prior Approval Scheme, the Provider must not carry out, nor refer to another provider to carry out, any non-immediate or routine treatment or care that is not directly related to the condition or complaint which was the subject of the Service User’s original Referral or presentation without the agreement of the Service User’s GP.”

Coventry and Rugby Clinical Commissioning Group (CRCCG) has agreed a policy which defines the conditions whereby a consultant to consultant referral would be appropriate.

Principles To facilitate the effective use of consultant to consultant referrals there must be some key guiding principles to ensure patient safety and reduce clinical risk. • Provide care closer to home where possible by ensuring management of patients within primary and community care where appropriate; • Ensure patients are offered choice for each different episode of care where clinically appropriate; • Contribute to the management of secondary care capacity by ensuring that only those patients genuinely in need of secondary care receive it, and in a more timely way as part of 18 week pathways; • Primary Care will make every effort to ensure that patients are referred to the correct consultant clinics for their condition; • Allow consultant to consultant referrals where appropriate and when part of an agreed and documented clinical pathway; • All appropriate consultant to consultant or accident and emergency to fracture clinic referrals that comply with the policy to be approved by a consultant; • Delays in urgent clinical cases to be kept to a minimum (less than 2 weeks); • GP to be informed in writing, where a consultant to consultant referral takes place; • Patients to be fully informed on the process and the role of their GP; • For the avoidance of doubt, due to UHCW’s current practice on coding of activity, Code 97 referrals are deemed as Consultant to Consultant referrals unless otherwise proven not to be.

Times when a Consultant to Consultant Referral would be appropriate: There are times when a consultant to consultant referral may be of clinical

1

necessity and/or of benefit to the patient. • For investigation, management or treatment of cancer, or suspected cancer in line with Cancer criteria for referral; • Where signs and symptoms suggest a life threatening or urgent condition that requires the patient to be seen in less than 2 weeks. An example would be where Radiology following a GP request, picks up potentially suspicious signs on investigation, and refers directly to an MDT of the relevant specialty for further clarification and discussion (as per 2 week wait); in the meantime informing the GP of their action. This referral is in the patients best interest and reduces delay; • Patients who remain under the original team referred to (e.g. Neurology) but require simultaneous input directly related with their current condition/treatment from another team (e.g. Respiratory); • For pre-operative assessment, including assessment in other specialties like cardiology; • Pregnant women who require review by other specialties as a result of their pregnancy e.g. Obstetrics to Diabetes Clinic; • If the referral is part of an agreed and documented clinical pathway e.g. Neurology to Neurosurgery, Cardiology to Cardiac Surgery – standard allowable pathways exceptions are detailed in the attached annex A; • For palliative care; • A&E referral to fracture clinic and agreed Hot Clinic pathways; • Secondary care referrals to Tertiary/Specialist Care; • Referrals within the same specialty – where the referrer has sent the patient referral to the correct specialty but to the wrong consultant (the referral letter should be redirected to the correct consultant before the patient is seen); • Referrals to the wrong specialty – where a patient is more appropriately managed in a different specialty (preferably the referral letter should be forwarded to the correct consultant before the patient is seen).

GPs should be informed in writing that a consultant to consultant referral has been made.

Times when a Consultant to Consultant Referral is not appropriate: Outpatient appointments or follow on care which results from an inappropriate consultant to consultant referral outside the agreed consultant to Consultant referral policy will be subject to normal contract challenge process, and cover the following: • Conditions that can be managed in Primary and Community Care settings, for example hypertension, diabetes, asthma, COPD etc.; • When a patient requests a second opinion, they should be referred back to their GP rather than a referral being made to another consultant, so that the patient can be offered choice; Conditions that are unrelated to the 2

presenting problem/condition, e.g. a patient being seen for an Orthopaedic complaint should not be referred to General Surgery; • Conditions that do not require an urgent (i.e. to be seen within 2 weeks) referral; • Incidental clinical findings, that are not of an urgent nature; • Accident & Emergency referrals other than those to fracture clinic or otherwise defined as clinically urgent; • When an in-patient develops a condition which is non-urgent (more than 2 weeks) and not related to their original condition; • Referrals for procedures of limited clinical effectiveness/low priority.

In the above situations, the patient should be referred back to the GP for ongoing action. The letter to the GP should contain all the relevant information and outline the clinical findings and indicate that a referral to another specialty may be appropriate. This letter should be sent in line with agreed contract timescales for clinic letters.

Consultants should advise patients that the GP will be notified regarding their condition and that the GP will reassess and make any further decisions about their management or referral based on their knowledge of the skills and services available in the community. Patients should be advised to arrange to see their GP two weeks after their attendance at the hospital clinic.

Supplementary Information

Challenge Any outpatient attendance and subsequent treatment resulting from a consultant to consultant referral made outside this policy, will be subject to discussions at the monthly contract management meetings held between the CCG and the Trust.

Monitoring This policy is expected to deliver a reduction in the amount of Consultant to Consultant referrals at the Trust and compliance with this policy will be monitored monthly, as per Schedule 2, Part 1 of the contract.

Roles Whilst the title of the policy relates to consultants, it is understood that other health care practitioners (junior doctors, specialist nurse, midwives etc.) acting under the consultants’ instructions or guidelines will also make referrals. Any such referrals should be signed off by or have evidence of being discussed with the consultant.

Note Consultant to consultant referrals should be monitored during 2017/18 to enable commissioner and provider to agree a contract activity plan for 2018/19

Equality N/A Impact

3

VERSION CONTROL

Version 1.1 Ratified by Governing Body Date ratified Name of originator/author Kay Holland, Interim Acute Programme Lead Name of responsible Clinical Development Group committee Date issued Review date Annual

4

Annex A – Allowable Exceptions Consultant to Consultant Referrals

Where Source of referral 01/02/04/05/10/11/ and 97 Please confirm subspecialty codes Primary diagnosis code of cancer to be excluded

Allowed within same main specialty, provided for same condition

Table: Other allowed exclusions, provided for same condition From To Ref Ref Spec Referral Specialty Spec Referral Specialty Code Code 315 Palliative Clinical Genetics (Spec Com ? 311 Remove) 350 Infectious Diseases 371 Medical Oncology 372 Nuclear Medicine 800 Clinical Oncology 650 Physiotherapy 651 Occupational Therapy All Any specialty 652 Speech & Language Therapy 654 Dietetics 211- 291, All Paediatic specialties 420, 421 800 - Radiology & Pathology 834 PreOp Assessment (Need logic/clinic code to identify) 100 General Surgery 102 Transplantation Surgery 103 Breast Surgery 100 General Surgery 104 Colorectal Surgery 106 Upper Gastrointestinal Surgery 107 Vascular Surgery 301 Gastroenterology 304 Clinical Physiology 101 Urology 361 Nephrology

5

100 General Surgery 103 Breast Surgery 159 Plastic Surgery 304 Clinical Physiology 100 General Surgery 104 Colorectal 300 Gastroenterology 100 General Surgery 106 Upper Gastrointestinal Surgery 300 Gastroenterology 100 General Surgery 107 Vascular Surgery 304 Clinical Physiology 653 Podiatry 110 Trauma & Orthopaedics 658 Orthotics Head & Neck 140 Oral Surgery 141 Restorative Dentistry 143 Orthodontics 120 ENT 145 Oral Maxillofacial 307 Diabetic Medicine 840 Audiology** 302 Endocrinology 655 Orthoptics 130 Opthalmology 662 Optometry Eye Casualty 108 Spinal 110 Trauma & Orthopaedics 150 Neurosurgery 145 Oral & Maxillo Facial 400 Neurology 401 Clinical Neurophysiology 161 Burns 160 Plastics 172 Cardiac Surgery 170 Cardiothoracic Surgery 327 Cardiac Rehabilitation 170 Cardiothoracic Surgery 172 Cardiac Surgery 327 Cardiac Rehabilitation 120 ENT 130 Ophthalmology 180 Accident & Emergency 320 Cardiology 110 Trauma & Orthopaedics 400 Neurology 110 Trauma & Orthopaedics 191 Pain 108 Spinal Surgery 150 Neurosurgery 300 General Medicine 314 Rehabilitation

6

100 General Surgery 104 Colorectal Surgery 301 Gastroenterology 105 Upper Gastrointestinal Surgery 304 Clinical Physiology 120 ENT 130 Ophthalmology 302 Endocrinology 307 Diabetic Medicine Weight Management Head & neck 303 Clinical Haematology 309 Haemophillia 420 Paediatrics 317 Allergy 340 Respiratory 170 Cardiothoracic Surgery 172 Cardiac Surgery 320 Cardiology Cath Lab 327 Cardiac Rehabilitation 324 Anticoagulent Service 303 Clinical Haematology 328 Stroke Medicine 314 Rehabilitation Transient Ischaemic Attacks 328 Stroke Medicine 329 (TIAs) 400 Neurology 160 Plastics 330 Dermatology 371 Medical Oncology 340 Respiratory 304 Clinical Physiology 343 Cystic Fibrosis 340 Respiratory 361 Nephrology 101 Urology 150 Neurosurgery 328 Stroke Medicine 400 Neurology 401 Clinical Neurophysiology 501 Obstetrics 560 Midwifery Services 110 Trauma & Orthopaedics 150 Neurosurgery 401 Clinical Neurophysiology 400 Neurology 410 Rheumatology 110 Trauma & Orthopaedics 410 Rheumatology 401 Clinical Neurophysiology 430 Geriatric Medicine 314 Rehabilitation 501 Obstetrics Provided in relation to complications Any 560 Midwifery Service of pregnancy 101 Urology 502 Gynaecology Fertility Services 503 Gynaecological Oncology 7

653 Podiatry 307 Diabetic Medicine 120 ENT 840 Audiology 400 Neurology 600+ Therapies All Only agreed pathways

8

Enclosure Z

Clinical, Quality and Governance (CQG) Committee Report for the Meeting held on 28th June 2017

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll Governing Body for 1. Quality, Safety and Governance Provider reports: The Committee received the reports for Coventry and Warwickshire approval, debate or further Partnership NHS Trust (CWPT), University Hospitals Coventry and consideration: Warwickshire NHS Trust (UHCW), Care Homes and other providers. The main issues included: UHCW - the CCG to advise GP Practices about the improved performance related to urgent clinic letters; Care Homes - three care homes on escalation and enhanced monitoring and two homes had No issues referred. been removed from escalation; BMI Meriden - the action plan following the Care Quality Commission (CQC) inspection in May 2016 has been shared with the CCG; and, Virgin Healthcare, City of Coventry Walk in Centre: the walk in centre will become a Child Protection Information System pilot site. Key Issues for the Governing 2. Patient Safety Reports: Body: The Committee reviewed the reports for UHCW, CWPT and other providers, noting that both UHCW and CWPT recorded approximately 20% fewer incidents in 2016/17 compared to the previous year. The Committee also No issues highlighted. noted that BMI Meriden reported no serious incidents in 2016/17 and that South Warwickshire NHS Foundation Trust (SWFT) and George Eliot Hospital NHS Trust (GEH) each reported two incidents involving CRCCG patients. 3. Infection Prevention and Control CRCCG Performance report: The Committee reviewed the report noting that during 2016/17: the CCG achieved its target of zero MRSA bacteraemia; exceeded the locally set threshold for E-coli bacteraemia; and, remained under its locally set threshold for MSSA bacteraemia. The CCG is working with local providers and South Warwickshire and North Warwickshire CCGs to develop a collaborative approach towards the reduction of E coli bacteraemia.

4. Safeguarding Assurance Report: The Committee reviewed the report, noting the findings and supporting the actions being taken to address quality concerns. 5. Update on the Health of Looked After Children in Rugby: The Committee received the report, noting the contents and that a looked after joint commissioning sub-group involving all CCG leads had been formed to identify and oversee the next steps. 6. Transforming Care Update: The Committee noted the update, including that national team feedback was positive on all of the areas of work that we are doing. 7. Primary Care update: The Committee noted the verbal update, including that the CCG’s Primary Care Commissioning Committee had been set up and work is continuing on the reporting systems. 8. Corporate Risk Register: The Committee reviewed the register and were assured that all six risks are being actively managed. 9. Emergency Preparedness Resilience and Response (EPRR) Annual Compliance Self-Assessment: The Committee noted the EPRR activity taking place at the CCG and the progress made against the annual EPRR Core Standards assessment. The Committee approved delegation of sign off to the CCG AEO for the 2017 core standards process. 10. Other: The Committee noted: the Warwickshire Safeguarding Adults Board minutes, 2 0th October 2017; CWPT Clinical Quality Review (CQR) minutes, 15th March 2017; and, UHCW CQR minutes, 6th April 2017.

Key Information: • Committee Chair: Mr Ludlow Johnson (Lay Member, Patient and Public Involvement and Health Inequalities) • CCG Lead: Mrs Glynis Washington (Director of Nursing)/Mrs Jenny Horrabin (Deputy Director of Corporate Affairs) • Date of Next Meeting: 23rd August 2017

Clinical, Quality and Governance (CQG) Committee Report for the Meeting held on 24th May 2017

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll 1. HR Report: Governing Body for The Committee received the report, noting that at the end of June 2017 approval, debate or further CRCCG had a headcount of 200. The Committee requested further information on compliance around training and appraisal s and asked the consideration: CCG to arrange a refresher update for new staff on Electronic Staff Record (ESR) procedures. 2. Workforce Race Equality Standards (WRES) update report: No issues referred. The Committee reviewed the report, noting that the next formal WRES submission date is July 2017, and a more detailed report and action plan would be presented at the July CQG meeting. The Committee noted the following specific actions: reminder to be sent to all staff annually to highlight the importance about recording ethnic data on ESR; Key Issues for the Governing 3. NHS Staff Survey 2016 - Results and CCG Action plan: Body: The Committee reviewed the contents of the NHS Staff Survey results and endorsed the supporting CCG action plan. No issues highlighted. 4. CCG Complaints Report, 2016/17, Quarter 4 (1 Jan to 31 March 2017) : The Committee reviewed the report, noting that 24 new complaints had been received of which 19 concerned Continuing Healthcare. The Committee also noted that an equality and diversity questionnaire is sent out with all complaint response letters and any feedback received will be included in the 2016/17 Annual Complaints report. 5. Corporate Risk Register - May 2017: The Committee received the Corporate Risk Register and reviewed the six risks currently on the register and endorsed the mitigating actions in place. 6. Business Continuity Update: The Committee noted the extension to the existing Business Continuity Policy to September 2017 and the plans in place to standardise the business continuity arrangements to reflect the joint working arrangements between the CCG and Warwickshire North CCG in place from April 2017. 7. Information Governance Quarter 4 Report: The Committee noted the assurance on compliance with Information Governance requirements in Quarter 4. 8. Committee Effectiveness Tool: The Committee agreed to endorse the approach to the review of committee effectiveness, noting that the review and action plan will be presented to the July CQG meeting. 9. Clinical Governance exception report: The Committee noted the exception reports relating to Coventry and Warwickshire Partnership NHS Trust (CWPT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW); noted the CWPT National Mental Health Survey 2016 - Action Plan; endorsed the commentary for the CWPT Quality Accounts; noted the contents of the Prescribing Quality Report up to February 2017 and agreed any ongoing actions; and, noted the verbal Primary Care Update about progress to date on agreeing processes and reporting flows. 10. Other: • The Committee noted: the CWPT Clinical Quality Review (CQR) th minutes, 18 January 2017; and, South Warwickshire NHS Foundation Trust (SWFT) CQR minutes, 19th January 2017. • The Com mittee agreed that an update on Early Intervention Service (EIS) waiting times should be included in the CWPT provider report at the June CQG meeting.

Key Information: • Committee Chair: Mr Ludlow Johnson (Lay Member, Patient and Public Involvement and Health Inequalities) • CCG Lead: Mrs Glynis Washington (Director of Nursing)/Mrs Jenny Horrabin (Deputy Director of Corporate Affairs) • Date of Next Meeting: 28th June 2017

Clinical, Quality and Governance (CQG) Committee Report for the Meeting held on 26th July 2017

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll Governing Body for Governance: 1. Risk Register: approval, debate or further The Committee reviewed the risk register and endorsed the mitigating consideration: actions, noting that going forward there will be changes to the way information is presented as the risk register is being aligned with Warwickshire North CCG. No issues referred. 2. HR Report: The Committee received the report, noting that at the end of June 2017 the CCG had a headcount of 192 and compliance around mandatory training continues to be an issue. 3. Information Governance (IG) Quarter 1 (including Caldicott Log) Key Issues for the Governing report : Body: The Committee noted the compliance with IG requirements in 2016/17

Quarter 1. No issues highlighted. 4. Freedom of Information (FoI) Quarter 1 report: The Committee received the report, noting that during 2016/17 Quarter 1, 42 FoI requests had been received, with all but four responses being completed within the 20 day deadline. The Committee agreed that further details should be provided in future reports about requests where the deadline for a response had been exceeded. 5. Modern Slavery Act 2015 and statutory duties: The Committee approved the statement in relation to the modern slavery act. 6. CCG Complaints Annual Report 2016/17: The Committee approved the report for publication on the CCG website.

7. CCG Complaints Report, 2017/18, Quarter 1: The Committee reviewed the report, noting that 19 new complaints had been received of which 17 concerned Continuing Healthcare. The Committee requested that consideration is given to producing a report on how the CCG tri-angulates complaints information with other information sources, including incidents and GP Feedback, to identify themes and trends. 8. Workforce Race Equality Standards (WRES) Report (approval to publish) : The Committee reviewed the report and during the discussion identified a number of actions. Subject to resolving the actions, the Committee approved the WRES for publication on the CCG website.

9. Clinical Governance exception report: The Committee noted the exception reports relating to Coventry and Warwickshire Partnership NHS Trust (CWPT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). Key points were: CWPT - the Care Quality Commission (CQC) draft report on Mental Health, Learning Disabilities and Dental Services expected in August 2017; UHCW - NHS England is currently in the process of reviewing the outcome of post infection reviews (PIRs) related to 4 cases of MRSA; GP Feedback - further information on the GP feedback reporting system to be presented at the

CQG October meeting. 10. Other: The Committee noted the minutes of the Coventry Safeguarding Adults Board, 23rd March 2017; CWPT Clinical Quality Review (CQR) minutes, 17th th May 2017; and, George Eliot Hospital NHS Trust (GEH) CQR minutes, 8 December 2016, 16th February 2017, 16th March 2017 and 20th April 2017.

Key Information: • Committee Chair: Mr Ludlow Johnson (Lay Member, Patient and Public Involvement and Health Inequalities) • CCG Lead: Mrs Glynis Washington (Director of Nursing)/Mrs Maria Maltby (Deputy Director of Corporate Affairs) • Date of Next Meeting: 23rd August 2017

Clinical Development Group (CDG) Report for the Meeting held on 25th July 2017

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll 1. Commissioning a Holistic ‘Risky Behaviours’ Early Intervention Governing Body for and Young People’s Substance Misuse Service: approval, debate or further Members received a briefing on the proposal by Coventry Public Health to bring the early intervention and substance mis-use services together consideration: as part of a retender process. Members discussed and noted the proposal, but requested the opportunity to comment on the draft specification, to include the promotion of GP Gateway. No issues referred. 2. Mental Health QIPP (Quality, Innovation, Productivity and Prevention) Ideas for 2018/19: Members received a briefing on the background to how outline QIPP

proposals have been generated and were invited to offer an initial clinical sense check. Members agreed that considerations should Key Issues for the Governing include how primary care and IAPT (Improving Access to Psychological Therapy) could better manage patients with i) medically unexplained Body: symptoms and ii) LTCs; ‘Crisis Houses’ and Dementia.

3. Elective Care QIPP Ideas for 2018/19: No issues highlighted. Members received a briefing on proposed ideas for schemes, noting that work to look at the redesign of Dermatology had made little progress and a review of the Community MSK (Musculoskeletal) service is required. Members suggested further areas for consideration around Pre-ops; Ophthalmology; and, Community Physiotherapy.

4. Stroke Business Case: Members were advised that one of the underlying principles of the

Stroke Business Case is to screen more successfully for arterial fibrillation (AF). A national expert on stroke management had been invited to attend a meeting with local GPs. Members agreed that the Stroke Business Case should be forwarded to clinical leads for comment , and that AF should be included as a potential scheme for use of PMS monies. 5. Planned Care Programme of Work and Commissioning Policy Development: Members received updates on the: • Planned Care Programme of Work with University Hospitals Coventry and Warwickshire NHS Trust (UHCW) which is linked to the key requirements of the NHS standard contract around the link between primary and secondary care. • Policy Development Group set up to develop new commissioning policies and to ensure that existing policies, as appropriate, are up- to-date and comply with NICE guidance. Following discussion on new policy development, it was agreed that more focus is required on Equality Impact Assessments and further work is required on ways of engaging more with patients and the public and other stakeholders. Also in relation to ensuring that all policy updates are made available on GP Gateway in a timely manner.

6. Items for noting: st Arden Mental Health Commissioning Group Minutes, 1 June 2017.

7. Privacy Impact Assessment (PIA) Members were requested to advise the CCG of any comments on the PIA to allow a clinical review of patients diagnosed with Clostridium difficile or E.Coli bacteraemia.

Key Information: • Committee Chair: Mrs Clare Hollingworth (Chief Finance Officer) • CCG Lead: Mrs Clare Hollingworth • Date of Next Meeting: 22nd August 2017

Clinical Development Group (CDG) Report for the Meeting held on 27th June 2017

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll 1. Matters Arising - Appointment Slot Issues (ASI) at University Governing Body for Hospitals Coventry and Warwickshire NHS Trust (UHCW) approval, debate or further Members were advised that concerns had been raised again about ASI consideration: and the impact on the way referrals are processed and the delays for people being booked into appointment slots. The present system is a frustration for GPs who are unable to close referrals. Members agreed that the CCG should carry out a review of appointment availability and No issues referred. quality implications and then meet with appropriate stakeholders with the aim of agreeing a new process for the CDG to consider from both a commissioning and operational GP perspective.

2. Draft Coventry Young Offending Service Youth Justice Plan 2017 - 2018 Key Issues for the Governing Members received a briefing and an early opportunity to comment on Body: the draft plan before finalisation in July 2017, including information about the level of resource input from the CCG into the service. No issues highlighted. Following discussion Members endorsed the level of resource currently in the draft plan for the year ahead and agreed that the CCG’s nominated Commissioning Director would sign off the final plan on behalf of the CCG. Members wishing to comment on the draft plan were invited to do so by 11th July 2017.

3. Coventry Drug and Alcohol Strategy 2017 - 2020 and Summary: Members received a briefing on the strategy as part of the final

Consultation process. An update was also provided on progress made to address alcohol and drug mis-use against previous strategies, with reference made to the Family Drug and Alcohol service, including the Alcohol Liaison Nursing services commissioned by the CCG. Members asked for a report to be prepared and circulated to provide further details around activity for patients seen by the Alcohol Liaison Nurse. Members were also informed about a new adult service starting in Coventry in November to provide treatment and support. The contract to run the service had been awarded to Change, Grow, Live (CGL). Members noted that closer to the launch date a communication package would be prepared to involve local GPs. A similar new service is planned for Warwickshire (including Rugby) with an anticipated commencement date of summer of 2018, but the tender process had not yet started. 4. Items for noting: Arden Mental Health Commissioning Group Minutes, 2nd March 2017 th and 4 May 2017. 5. Other Members noted that the CDG Terms of Reference are being revised by the CCG’s Deputy Director of Corporate Affairs.

Key Information: • Committee Chair: Mrs Clare Hollingworth (Chief Finance Officer) • CCG Lead: Mrs Clare Hollingworth • Date of Next Meeting: 25th July 2017

Finance and Performance (F&P) Committee Report for the Meeting held on 24th July 2017

Achievements / Decisions Made / To Note Matters referred to 1. CCGlllllllllllllllll Finance Report - Month 3 (June): Governing Body for The Committee reviewed the report, noting that the financial position was in approval, debate or further line with the plan agreed with NHS England (NHSE), although based on limited data. The Committee also noted that: consideration: • The CCG is working with the Commissioning Support Unit (CSU) to Procurement update, July 2017: address data quality issues for Continuing Healthcare. The Committee recommended that the • Running cost expenditure is underspent, mainly due to slippage. Governing Body approves the extension • University Hospitals Coventry and Warwickshire NHS Trust (UHCW) of the existing Any Qualified Provider position reported as breakeven whilst activity queries relating to (AQP) contracts for the provision of Age changes in IR rules are resolved. Related Macular Degeneration (ARMD) Following discussion, the Committee requested a more in depth report services, within the clinical pathways, until covering finance, QIPP (Quality, Innovation, Productivity and Prevention) 31st March 2020. and contract performance for the next F&P meeting in August.

2. QIPP Report: Based on available information, the Committee was not assured about QIPP performance with further discussion requested at the next F&P meeting. 3. Performance Report: Key Issues for the Governing The Committee reviewed the report providing information on performance Body: against the full range of national targets and, where appropriate, the recovery actions being taken. Key areas where performance continues to Procurement Update, July 2017: be below target are Referral to Treatment (RTT); A&E 4 hour waits; and, The Committee resolved to assure the Dementia Diagnosis. The Committee noted that all nine cancer wait targets Governing Body that the Transforming were met by the CCG in May, and that six cases where patients had waited Care Partnership framework contract for more than 100 days from referral to treatment at UHCW are being reviewed learning disability services is now in place, through the Clinical Quality Review Meeting. with contracts awarded through Warwickshire County Council to four 4. Procurement Update, July 2017: st providers until 31 March 2020, with the The Committee were assured on the progress of current procurements, option to extend for up to two further including: years. • Out of Hospital: CRCCG and WNCCG Governing Bodies had approved direct awards of 3 year contracts with Coventry and

Warwickshire Partnership NHS Trust (CWPT) due to start on 1st April 2018. • Rugby Town Medical Practice: the CCG’s Primary Care Commissioning Committee to consider future APMS (Alternative Provider Medical Services) contractual arrangements at their August meeting.

(Note: also see Governing Body panels).

5. Transfer of Coventry Walk in Centre Contract Management: The Committee received the report and made the following decisions: • To approve the transfer of the Coventry walk in centre and clinical responsibility from the CCG to UHCW. • To approve the direct award of a 2 year contract to Virgin Care for continuation of delivery of the Coventry walk in centre (ahead of novation to UHCW). • To recommend that the proposed UHCW service specification is submitted to the CCG’s Clinical Development Group (CDG) for validation. 6. Action, Delivery and Recovery Plans The Committee noted the progress made to date on the UHCW A&E Action Plan; UHCW RTT Delivery Plan; and, the revised dementia diagnosis recovery plan but were not assured that these were adequate to address performance issues. Deep Dive into A&E requested for August meeting and into RTT at the September F&P meeting. A more concise Dementia Diagnosis RAP was requested for September. 7. Other Members received and noted the Clinical Operation Group Minutes, 12th June 2017, and the Financial Recovery Board Minutes of 30th June and 3rd July 2017.

Key Information: • Committee Chair: Mr Peter Maddock (Lay Member, Governance) • CCG Lead: Mrs Clare Hollingworth (Chief Finance Officer) st • Date of Next Meeting: 21 August 2017 Finance and Performance Committee Report for the Meeting held on 26th June 2017

Achievements / Decisions Made / To Note Matters referred to 1. Full Yearlllllllllllllllll Primary Care Prescribing Report 2016/17: Governing Body for The Committee received the full year prescribing report for 2016/17, noting approval, debate or further that overall the cost and quality indicators suggest strong performance The Committee received assurance that under-prescribing would be consideration: appropriately managed. The Committee thanked Medicines Management Procurement update: and GP Practices for their achievements. The Committee recommended that the 2. CCG Finance Report - Month 2 (May): Governing Body approves a 24 month The Committee reviewed the new format report, noting that the financial extension to the current direct access position was reported as on plan although based on limited data. The community based Non Obstetric Committee also noted that: Ultrasound services (NOUS) contracts • Running cost expenditure is predicted to be on plan, with a slight with UHCW and Holbrooks Health Team underspend year to date due to slippage. due to expire at the end of June 2017. • Quality, Innovation, Productivity and Prevention (QIPP) delivery is currently forecast to be in line with plan, but considerable work is required to ensure QIPP targets are met. Management of QIPP will be a key task for the CCG’s Executive Team. Key Issues for the Governing (Note: also see Governing Body panel) Body: 3. Performance Report: The Committee reviewed the report providing information on performance Finance Report Month 2: the Committee against the full range of national targets and, where appropriate, the agreed to submit the report in its current recovery actions being taken. Key areas where performance by University new format to the Governing Body. Hospitals Coventry and Warwickshire NHS Trust (UHCW) is below target are: Referral to Treatment (RTT) where a new performance notice had been Performance Report: the Committee issued and a new remedial action plan requested; A&E 4 hour waits; cancer agreed that the issues and actions raised waiting times, including where five patients breached the 31 day target, and would be included in the performance one patient the 62 day target. The Committee was assured that these report to the Governing Body. issues would be escalated with UHCW. The Committee noted that for

Dementia Diagnosis the CCG is working on the development and implementation of a remedial action plan with NHSE to improve performanc e. (Note: also see Governing Body panel)

4. Procurement Update: The Committee received the report which provided an overview of the procurement work programme and a progress update for each of the current services that are in the live procurement phase. The key points were: • The CCG’s Primary Care Commissioning Committee had extended the contracts with Virgin Healthcare for the Anchor Centre and Meridian until 30 th April 2018, whilst an option appraisal is undertaken regarding service design and procurement. • Rugby Out of Hours contract to be extended to 31st March 2018. Coventry Walk-in-Centre contract is due to end on 30th September 2017 , a recommendation on how to proceed will be brought to the July F&P Committee meeting. • Members were advised that a Procurement Group is being established to co -ordinate activities across all three Coventry and Warwickshire CCGs.

(Note: also see Governing Body panel) 5. Other • Members noted the Clinical Operation Group minutes, 8th May 2017 and the Financial Recovery Board minutes, 30th May 2017. • This was Mrs Sampson’s last meeting and Members thanked her for her hard work and contribution over the years in her role as Lay Member (Public and Patient Involvement).

Key Information: • Committee Chair: Mr Peter Maddock (Lay Member, Governance) • CCG Lead: Mrs Clare Hollingworth (Chief Finance Officer) th • Date of Next Meeting: 24 July 2017

Coventry City Council Minutes of the Meeting of Coventry Health and Well-being Board held at 2.00 pm on Monday, 10 April 2017

Present:

Board Members: Councillor Abbott Councillor Caan (Chair) Councillor Ruane Councillor Taylor Stephen Banbury, Voluntary Action Coventry Dr Adrian Canale-Parola, Coventry and Rugby CCG (Deputy Chair) Professor Guy Daly, Coventry University Ben Diamond, West Midlands Fire Service Liz Gaulton, Acting Director of Public Health Simon Gilby, Coventry and Warwickshire Partnership Trust Andrea Green, Coventry and Rugby CCG Andy Hardy, University Hospitals Coventry and Warwickshire Ruth Light, Coventry Healthwatch Danny Long, West Midlands Police Gail Quinton, Deputy Chief Executive (People)

Other Representatives: Councillor Ali Paula Deas, Coventry and Warwickshire Local Enterprise Partnership

Employees (by Directorate):

Place: L Knight People: R Nawaz

Apologies: Councillor Duggins John Mason, Coventry Healthwatch Martin Reeves, Coventry City Council Professor Caroline Meyer, Warwick University

Public Business

108. Declarations of Interest

There were no declarations of interest.

109. Minutes of Previous Meeting

The minutes of the meeting held on 6th February, 2017 were signed as a true record. There were no matters arising.

110. Employment , Economic Growth and Health - working with Coventry and Warwickshire Chamber of Commerce and Coventry and Warwickshire Local Enterprise Partnership

– 1 – The Board considered a joint report and received a presentation from Paula Deas, Coventry and Warwickshire Local Enterprise Partnership (LEP) which informed how partners were working together with Coventry and Warwickshire Chamber of Commerce and the LEP to create good growth and reduce health inequalities in Coventry.

The report highlighted that ensuring that people were able to get into work would reduce health inequalities, but they must be good quality sustainable jobs which provided a reasonable wage, opportunities for development and safe working conditions. The unemployment rate in the city was currently 6% compared to the national rate of 5.1%.

The Marmot Steering Group provided an effective mechanism for the LEP and Chamber of Commerce to work with other key statutory and voluntary organisations to address health inequality issues linked with growing economic prosperity in the city and to recognise and build upon the links between a healthy population, good work and economic growth. The vital role of employers was emphasised. Reference was made to the Strategic Economic Plan produced by the LEP and the Marmot Strategy which were aligned in some of their overall goals. The LEP worked across Coventry and Warwickshire in alignment with the Health and Wellbeing concordat. The report indicated that the focus of the LEP upon economic growth and development, if successful, would result in an increase of over 50,000 new jobs by 2031, improving the skills of the workforce and increasing the productivity of the area, so reducing health inequalities.

The report provided an update on Marmot to date. Since Coventry became a Marmot City in 2013 there had been progress in outcomes across health and across society including improvements in school readiness at 5, health outcomes, life satisfaction, employment and reductions in crime in priority locations. Key areas of focus for the next three years were detailed. Reference was made to the effective partnership working between members of the Marmot Steering Committee. All partners had signed up to the three year Marmot Action Plan and the priorities were outlined.

The Chamber of Commerce was a committed member of the Marmot Steering Group who worked with employers to educate them about the benefits of recruiting locally and also increase the number of apprenticeships. The Chamber was also keen to explore ways to encourage employees to maximise their use of funds to support the employment of people with physical disabilities and mental health issues. The Board were informed that the LEP was not a member of the Marmot Steering Group. Inclusion of a representative from the LEP would be beneficial to all Marmot partners and would enable practical discussions around ways of working that would bring together the aims and objectives of the Strategic Economic Plan with those of Marmot and other statutory and voluntary organisations.

The presentation set out the background to the development of the LEP; provided information on its governance arrangements; informed of the LEP’s achievements to date which included over £300m of government investment in local priorities and 2,928 jobs created; and drew attention to the assets of the area. Further information was provided on the benefits to the Coventry and Warwickshire area. The presentation concluded with the issues for the next five years including the

– 2 – Local Growth Fund; more devolution of powers and finance; the mayoral influence; and the changing political landscape.

Members expressed support for the work of the LEP and the opportunities for partnership working. Further information was requested about the funding opportunities available for local businesses and whether funding had been made available to support the health economy. A request was made for assistance for an individual company and the officer undertook to investigate.

RESOLVED that:

(1) Approval be given for the LEP to become a member of the Marmot Steering Group and contribute to the Marmot Action Plan.

(2) Approval be given that the Chamber of Commerce continue to attend the Marmot Steering Group and contribute to the Marmot Action Plan.

(3) The Health and Wellbeing Board contribute to the LEP’s Strategic Economic Plan.

111. Coventry & Warwickshire Sustainability and Transformation Plan Update

The Board considered a progress report from Andy Hardy, University Hospitals Coventry and Warwickshire (UHCW) which provided an update on progress with the Sustainability and Transformation Plan (STP), with particular reference to the content and progress with the individual work streams.

Urgent and Emergency Care

The current work stream priority was right sizing hospital urgent and emergency care systems in the context of changes driven through other work streams and the national Urgent and Emergency Care Plan. It was anticipated that the proposed model of Urgent and Emergency Care would be presented to the STP Design Authority for internal clinical agreement in the autumn of 2017.

The Board were informed that the Coventry and Warwickshire Stroke Programme was at the pre-consultation stage, with the pre-consultation Business Case within the NHS England assurance process. It was anticipated that this would go to an Assurance Panel in the early summer.

Planned Care

The report informed that the current work stream focus was on the first elective pathway review, muscular-skeletal, with emphasis being on hip and knee replacements with a view to start to change in practice during 2017. A Clinical Reference Group had been established and had met several times and a clinical workshop was planned for April/May. A revised MSK pathway was now in place in North Warwickshire and, subject to approval, was due to start in Coventry at the end of quarter 1 2017. The review/ revision of other elective pathways would follow in quarterly waves including General Surgery, ENT, Ophthalmology, Specialist Surgery and other smaller specialities. Following pathway redesign, policies would be revisited.

– 3 – In relation to cancer care, work was underway to achieve the cancer 38 day target.

Maternity and Paediatrics

Work was underway to refocus the work stream’s programme in line with the national ‘Better Births’ strategy. A work stream ‘away day’ had been arranged for April.

Proactive and Preventative Care

The Out of Hospital Programme was progressing to plan with proposals developed by providers currently undergoing commissioner moderation, prior to a decision on procurement. The scope of the programme beyond the Out of Hospital was much broader and was currently being developed. The Board noted that this offered the major interface with Health and Wellbeing Boards and Local Authority led services relating to the promotion of healthy lifestyles and the building of community capacity. These were also key features of Health and Wellbeing Strategies and emerging transformational plans for local authorities. Reference was made to the three steps to be undertaken to support prevention. To date efforts had focused on the first phase in terms of developing an understanding of the level and nature of work in the system. To succeed prevention needed to feature in every element of work and become ‘everybody’s business’.

Productivity and Efficiency

Progress in this area had been slow. Individual organisations had just received feedback from the National Benchmarking and this was currently being collated to give an STP wide picture, so organisational differences could be examined.

Andy Hardy informed the Board of the recent appointment of Brenda Howard as the Programme Director. She would be establishing a Programme Management Team and would establish systems and processes to oversee progress and delivery of the STP. The programme team would be supporting the work streams to deliver their priorities. The Board were also informed about the new guidance from NHS England concerning next steps on the Five Year Forward View and STPs.

Members of the Board raised a number of issues in response to the report including:  How the Programme Director post was funded and the actual costs involved  Clarification about the ‘Big Conversation’ phase on pre-consultation relating to maternity care that had been due to commence at the end of November (Minute 112 below refers)  Further information about the latest position relating to the proposals for stroke services which was with NHS England for assurance  Clarification about the timings and schedules of the individual work streams and whether there had been delays  Whether the STP would work in isolation or whether there would be implications for the STP if other STPs from the surrounding areas had failings

– 4 –  The links between the individual work streams  Further information about the thresholds and proposals for hip and knee replacements  Support for all the hard work involved with progressing the STP work streams  The importance of ensuring successful communication with the public when progressing the work streams including consideration of the terminology to be used.

Professor Guy Daly informed the Board about the work of the STP Design Authority and suggested that a report including the terms of reference and membership be submitted to a future meeting. He recommended that members be provided with a copy of the update on the Five Year Forward View.

RESOLVED that:

(1) The report be noted and the direction of travel for the STP be supported.

(2) A report on the STP Design Authority be submitted to a future meeting.

(3) The update on the Five Year Forward View be circulated to Members.

112. Engagement Strategy Update

Further to Minute 89/16, the Board considered a report of Andrea Green, Coventry and Rugby Clinical Commissioning Group (CCG) which detailed progress on the Sustainability and Transformation Plan (STP) Engagement Strategy.

The report indicated that the three local Clinical Commissioning Groups, the City Council and Warwickshire County Council had formed a collaborative Engagement Team who developed the Engagement Strategy.

The initial activity was to start to hold some “Big Conversations” with local Mothers and Carers, to find out what was important to them in respect of Maternity services, as a new national strategy on Better Births had been released by NHS England, and local leaders were considering the sustainability and transformation of the service, as part of the local long term direction of travel for healthcare, the STP. Conversations were held with Mothers and their Carers at the venues they were attending to receive their antenatal and postnatal care. This first phase of engagement included completing 57 conversations, at venues, mainly Children’s Centres across Coventry and Warwickshire. The participants included people who already had children, those who had past miscarriages and/or, traumatic births as well as those who were first time Mothers.

The Board were informed that the outcome of this phase of discussions found that all those asked had very similar expectations of maternity services, but these were not always met. The key themes in the discussions were around consistency of care; being listened to; personalised care; family friendly care; professional attitude of staff; feeling reassured; support with aspects of caring for a new baby; access to information, antenatal and postnatal support.

– 5 – The engagement identified some inequalities in the services available in antenatal and postnatal groups; breastfeeding support and continuity of care.

Andrea Green emphasised that this was the start of the process. The Board noted that the views and themes would be bought together with information from the 0 to 5s work undertaken by Coventry and Warwickshire Councils; data on local inequalities and access; and the national engagement work on maternity care currently underway, to inform the next stages of co-design which would produce a set of local views of critical success factors that the future services would need to address.

Members raised a number of questions about the work to date including:

 Did the 57 contacts reflect the diverse population of Coventry  Whether 57 conversations was a sufficient number considering the size of the locality and the potential for significant service change  A concern about the implications of Strep B infections in babies and if this was an issue for the city.

RESOLVED that:

(1) The progress to date on the Engagement Strategy be noted.

(2) Details about the arrangements for screening for Strep B be circulated.

113. Coventry and Warwickshire System Wide Care and Health Peer Challenge Feedback

Further to Minute 104, Liz Gaulton, Acting Director of Public Health introduced the Coventry and Warwickshire System Wide Care and Health Peer Challenge feedback presentation following on from the review which took place between 14th to 16th March, 2017. The focus of the review had been: ‘To provide a constructive assessment of the current and potential value to the HWB system of the HWBBs of Coventry and Warwickshire, independently and together. To consider how the Boards can bring the spirit and commitment of the Coventry and Warwickshire Alliance Concordat to life’.

The presentation set out the brief and the products of the challenge. Membership of the Peer Challenge Team was detailed along with the process that was followed. The key messages for Coventry were highlighted which including the positive strengths of the Board; ‘Marmot City’ being a good brand with further potential; the development for joint working between the Boards without Coventry losing its identity; and the importance of working beyond different boundaries including the West Midlands Combined Authority. There was an acknowledgement that the STP had not ‘landed well’ but a line needed to be drawn under it and a coherent health and social care plan for Coventry and Warwickshire needed to be developed. The suggested next steps for Coventry were set out.

The presentation also referred to the key messages for both Coventry and Warwickshire with the Concordat being viewed as a huge asset. Members noted

– 6 – both the barriers and enablers for implementing the next steps in Coventry and Warwickshire.

It was clarified that, from the feedback provided, the Board was operating well and areas for development were clear. The Board acknowledged the success of their joint working with Warwickshire.

RESOLVED that:

(1) The feedback from the Peer Challenge be noted.

(2) Approval be given to progress the proposed next steps, continuing the joint working with Warwickshire.

114. Health and Wellbeing Strategy Update - Improving the Health and Wellbeing of People with Multiple Complex Needs

The Board received a presentation from Chief Inspector Danny Long, West Midlands Police which provided an update on the Health and Wellbeing strategy priority ‘Improving the Health and Wellbeing of People with Multiple Complex Needs’. A copy of the Project Initiation Document had been circulated as background information.

The Board were reminded of the purpose of the project, to improve the health and wellbeing of people facing Multiple Complex Needs (MCN), to make it as easy as possible so that they:  Feel more resilient and connected  Are empowered to lead productive lives, free from harm  Reduce their dependency on intensive public services. It aimed to enable people with MCN to manage their lives better through access to more person centred and co-ordinated services.

The project involved a five stage plan as follows: i) Baseline data – characteristics of people facing MCN and service provision ii) Future mode – identifying options for improving services iii) Define changes needed – detailed definition of what changes were needed iv) Plan and organise – implementation plan v) Evaluation framework – understand the impact of proposed interventions.

Detailed information was provided on the research programme which had been split into two phases: Phase I – to identify the extent and nature of MCN within the city Phase II – to demonstrate how transforming the experience of people facing MCN could improve outcomes and reduce costs to the system.

The Board were informed of the various partner organisations used to gather baseline data and the key factors obtained. Findings taken from the baseline data, lived experiences and frontline professionals were outlined with detailed statistics from the Probation Service, Staffordshire and West Midlands Community Rehabilitation Company and West Midlands Police. In addition, individual case studies had been provided by West Midlands Fire Service, Aquarius, Citizens Advice Bureau, Ignite, Troubled Families, Swanswell and Whitefriars Housing.

– 7 – The Board’s attention was drawn to the combination maps which allowed comparing and contrasting different data sets. As expected most deprived areas saw more problems.

The Board were informed that there was now lots of data including evidence of local services and contract spend and much detailed local intelligence providing a comprehensive understanding of what it meant to experience MCN in Coventry and how factors related to one another. Examples of service scoping were also highlighted.

The presentation concluded with the next stage in the process, stage 3, and to become involved with:  The opportunity to work with West Midlands Mental Health Commission and develop nationally funded pilots in Coventry  Trial the MEAM approach by identifying a cohort of users who could be supported using a whole system  An Operational Group being set up to develop these opportunities and implement.

The Board asked about ‘wet’ houses in the city and where people could access support to help them ‘dry out’. It was determined that further work was required in this area.

RESOLVED that:

(1) The work to date on the strategy to improve the health and wellbeing of people with multiple complex needs be noted.

(2) The Multiple Complex Needs Board, as part of their existing work, to look at those affected by alcohol misuses and to make suggestions as to how they can be supported.

115. Coventry Female Genital Mutilation (FGM) Programme

The Board considered a report of Liz Gaulton, Acting Director of Public Health which provided an update on the progress made to tackle Female Genital Mutilation (FGM) in Coventry. The report also provided an update on the prevalence of FGM in the city and detailed progress against the recommendations endorsed by the City Council’s Scrutiny Co-ordination Committee at their meeting on 9th September, 2015.

The report provided an explanation of FGM, detailed the reasons given for practising FGM and set out the background to the work being undertaken in Coventry to eradicate the practice.

Information was provided on the current position. The Board noted that data for FGM was limited both locally and nationally but the issue was being tackled nationally with the introduction of mandatory requirements for Healthcare Professionals to record FGM. It was estimated that 137,000 women and girls were living with FGM in the UK and that 60,000 girls aged 13 and under were at risk of FGM. A recent report by City University London and Equity now concerning FGM

– 8 – in England and Wales estimated Coventry had a rate of more than seven per 1,000. Between April 2015 and March 2016 there had been 65 women accessing UHCW midwifery services who had been affected by FGM.

The report provided police data showing FGM referrals for West Midlands which showed a high percentage of referrals for Coventry during 2014-16 which was probably due to the well-established referral processes and reporting procedures in the city.

The Board noted that in June 2015 the City Council’s Public Health team commissioned Coventry Haven (in partnership with CRASAC and Birmingham and Solihull Women’s Aid (BSWA)) to provide a specialist FGM service to tackle FGM in Coventry. This service was the main vehicle through which the Scrutiny Co- ordination Committee’s recommendations were being delivered. The report provided a progress report on the actions undertaken in respect of these recommendations:  Preventing FGM from taking place by raising awareness and engaging with communities  Supporting professionals to identify and support girls and women at risk of or affected by FGM  Supporting victims of FGM throughout their lives  Building knowledge and intelligence.

The report indicated that a significant amount of the work to tackle FGM had been provided by Coventry Haven in partnership. The contract for this work was due to end on 31st May, 2017 and there was no resource available to extend the contract beyond this date. However the service was designed to be self-sustaining through the recruitment of community champions.

Coventry’s work to tackle FGM had been highlighted regionally and nationally as an example of good practice and the evidence from the work was being incorporated into national policy.

The report detailed the measures to be implemented over the coming months to ensure the service’s work to engage with communities, train professionals and support women who have undergone FGM could be sustained beyond May 2017.

Members asked if there had been any convictions for FGM and expressed support for the new webapp ‘Petals’ developed by researchers at Coventry University to help protect young girls and women from FGM and their subsequent webapp ‘Petals for Professionals’.

RESOLVED that the progress update set out in section 5 of the report be noted.

116. Joint Pharmaceutical Needs Assessment (PNA) and Applications for Pharmacies Update

The Board considered a report of Liz Gaulton, Acting Director of Public Health which sought approval for the plans to produce a revised Pharmaceutical Needs Assessment (PNA) for 2018.

– 9 – The report indicated that as a result of the Health and Social Care Act 2012 the responsibility to develop and update PNAs passed to local Health and Wellbeing Boards. The PNA would be used to inform NHS England in its determination as to whether to approve applications to join the pharmaceutical list. It also considers whether the number of pharmacies would still be adequate in the next four years.

Coventry’s first assessment was published in 2015. It was produced by evaluating the health needs of the local population with consideration of the existing services provided by pharmacies. It was a statutory requirement that the PNA be updated every 3 years.

The report provided detailed information on the purpose of the PNA along with information about what NHS Pharmaceutical services include.

The process of producing a PNA took around 12 months and involved a period of consultation concluding with the Board sign off. The Board were informed that to maximise the resources available and align with local planning footprints, officers were exploring a Coventry and Warwickshire PNA for 2018. This would also align with the Coventry and Warwickshire Alliance Concordat. The work was to be led by the Directors of Public Health and their teams from Coventry and Warwickshire. A small Steering Group was to be established. It was the intention to submit an update report to a future Board meeting with final approval being sought by February 2018.

Ruth Light informed of the recent work undertaken by Coventry Healthwatch about the public’s use of pharmacies. Healthwatch has produced 9 recommendations arising from discussions with residents. The importance of publicising pharmacies to the Coventry public was emphasised.

RESOLVED that:

(1) The update and progress on the Pharmaceutical Needs Assessment be noted.

(2) Approval be given for Coventry to conduct its revised PNA in partnership with Warwickshire County Council.

117. Coventry, Warwickshire and Solihull's Transforming Care Partnership

Further to Minute 56/16, the Board noted a joint report, submitted to Members for information, which provided an update on Coventry, Warwickshire and Solihull’s Transforming Care Programme. Details of progress made was set out in an appendix to the report.

The report indicated that partners had worked collaboratively to develop and implement a new model of care for adults to support the delivery of the Transforming Care programme locally. Work was currently taking place to ensure this effectively met the needs of adults with autistic spectrum disorders. Work was also taking place with stakeholders to develop a new model of care to support children and young people in the community preventing admissions to hospital and residential settings where appropriate.

– 10 – Progress had been made regarding the financial arrangements to deliver the programme and work was ongoing to clarify the amount and mechanism for funds to be distributed to local areas from NHS England.

During 2016/17 the Transforming Care Programme had not met planned trajectories. It was anticipated that the programme would be back on track with trajectories in quarter two of 2017/18.

RESOLVED that the content of the update report set out at the appendix and the key points relating to progress and local issues be noted and the Board continue to receive periodic briefings on progress relating to the delivery of the Transforming Care programme.

118. Any other items of public business - Social Care Summit

Professor Guy Daly, Coventry University informed of the intention to hold a Social Care Summit, organised by Coventry and Warwick Universities. A provision date of 26th June had been agreed and a number of early invitations had been circulated. It was the intention to invite members of the Health and Wellbeing Board once more details had been finalised.

(Meeting closed at 3.55 pm)

– 11 – Coventry City Council Minutes of the Meeting of Coventry Health and Well-being Board held at 2.00 pm on Monday, 10 July 2017

Present:

Board Members: Councillor Abbott Councillor Caan (Chair) Councillor Taylor Rob Allison, Voluntary Action Coventry Sarah Baxter, Coventry University Dr Adrian Canale-Parola, Coventry and Rugby CCG (Deputy Chair) Ben Diamond, West Midlands Fire Service Andrea Green, Coventry and Rugby CCG Ruth Light, Coventry Healthwatch John Mason, Coventry Healthwatch Gail Quinton, Deputy Chief Executive (People) Justine Richards, Coventry and Warwickshire Partnership Trust Rebecca Southall, University Hospitals Coventry and Warwickshire

Other Representatives: Councillor Gannon Brenda Howard, University Hospitals Coventry and Warwickshire

Employees (by Directorate):

Place: L Knight People: P Fahy J Fowles R Nawaz

Apologies: Councillor Duggins Guy Daly, Coventry University Liz Gaulton, Acting Director of Public Health Simon Gilby, Coventry and Warwickshire Partnership Trust Sharon Goosen, West Midlands Police Andy Hardy, University Hospitals Coventry and Warwickshire Danny Long, West Midlands Police David Williams, NHS Area Team

Public Business

1. Declarations of Interest

There were no declarations of interest.

2. Minutes of Previous Meeting

The minutes of the meeting held on 10th April, 2017 were signed as a true record. Further to Minute 118 headed ‘Any other items of public business – Social Care

– 1 – Summit’ it was reported that the Social Care Summit organised by Coventry and Warwick Universities had taken place on 26th June.

There were no other matters arising.

3. Appointment of Deputy Chair of the Health and Wellbeing Board

RESOLVED that Dr Adrian Canale-Parola be appointed as Deputy Chair of the Health and Wellbeing Board for 2017/18.

4. Progress Update on Coventry's Marmot City Strategy 2016-2019

The Board considered a report and received a presentation by Ben Diamond, West Midlands Fire Service and Co-Chair of the Marmot Steering Group which provided a progress update on the Coventry Health and Wellbeing Strategy priority ‘Working together as a Marmot City to reduce health and wellbeing inequalities’.

The report set out the background to Coventry’s position as a Marmot City from 2013 to 2015 and the involvement in the initial Marmot Programme to reduce health inequalities. In 2016 Sir Michael Marmot and his team committed to working with Coventry for a further three years to progress the health inequalities work. Partners were continuing to work together on a number of projects initiated in the first two years. In addition the Marmot City priorities now were to tackle inequalities disproportionately affecting young people and ensuring all Coventry people, including vulnerable residents, could benefit from good growth which would bring jobs, housing and other benefits to the city.

The Board were informed that there remained a strong commitment to the Marmot programme from all the partners on the Steering Group. The Marmot Action Plan set out ways in which partners and stakeholders would work to achieve the key priorities. Progress against the programme indicators included:

 92% of children and young people reporting an increased awareness of the risks of sexual violence and support services available following the delivery of the sexual violence prevention programme.  Employment and training support to over 500 young people not in education, training and employment as part of the Ambition Coventry programme.  All key policy decisions taken by the City Council now consider the potential implications on inequalities across the city  Voluntary Action Coventry and the West Midlands Fire Service had both signed up to the Workplace Wellbeing Charter.

Progress against the Action Plan and indicators was set out in an appendix attached to the report under the following two headings: young people and good growth. Indicators were split into programme indicators (output focused) and overarching indicators (outcome focused). The Marmot Steering Group met on a quarterly basis to receive updates from partners, discuss progress and identify areas for development and partnership working.

The presentation informed of the continuing national recognition of the work in Coventry and gave detailed information on the supporting young people and good

– 2 – growth priorities highlighting achievements to date against targets. Comparisons of outcomes from 2015/16 to 2016/17 for both priorities clearly demonstrated positive progress. The presentation concluded with a summary of the next steps for the current year.

Members raised a number of issues arising from the presentation including:

 Clarification regarding some of the indicator statistics in the report  Further information about the reasons for the positive increase in the number of new young clients accessing the CRASAC Counselling Service  A request for further updates on progress with the indicators in due course  What Members could do to support organisations to sign up to the Workplace Wellbeing Charter and the need to market the Charter to employers  The suggestion that contact be made with the Welfare Reform Group and the Group supporting the Feeding Coventry Initiative to provide access for good guidance concerning health inequalities  An acknowledgement of the links to the Better Health, Better Care, Better Value programme  The role of the Voluntary Sector in supporting young people into work  A suggestion that contact be made with individual trade unions to gain their support for the Workplace Wellbeing Charter

Ben Diamond indicated that he would make contact with the links suggested by Members.

RESOLVED that:

(1) The progress made to date against the Marmot Action Plan be endorsed.

(2) Further progress updates from the Marmot Steering Group be submitted to future meetings of the Board every six months.

5. Coventry and Warwickshire Sustainability and Transformation Plan Update

The Board considered a report of Professor Andy Hardy, University Hospitals Coventry and Warwickshire (UHCW) and received a presentation from Brenda Howard, UHCW which provided an update on the Better Health, Better Care, Better Value programme and work streams.

The report highlighted that the Sustainability and Transformation Plan had recently been renamed ‘Better Health, Better Care, Better Value’ reflecting the triple challenges facing health and social care as set out in the ‘Five Year Forward View’ report.

On 25th May, 2017 Board Members met NHS England and NHS Improvement for a quarter one review of progress. The meeting was positive with the strength of the collaboration being commended. The well-defined governance and executive leadership structures were acknowledged. A copy of the formal response received was set out at an appendix to the report.

– 3 – The Board had agreed its support structure to enable the transformational and enabling work streams to deliver their priorities and objectives. Recruitment was underway and the aim was, as far as possible, to attract internal partner organisation applicants as secondments. It was intended to establish a ‘System Leadership Academy’ enabling participants to experience working in the different organisations within the system.

A second appendix set out the reinforced governance arrangements for the programme. The Design Authority had been reframed with greater representation from local clinical leaders and a Programme Delivery Group had been established. The Board were informed that it had recently been decided that mental health services should be designated as a transformational work stream and arrangements were now progressing to establish this. In addition it had also been decided to establish a cancer work stream as part of the approach to planned care.

The report provided detailed information on progress, including individual priorities, with the following transformation work streams: maternity and paediatrics; urgent and emergency care; mental health; proactive and preventative; productivity and efficiency; planned care and cancer.

The report also referred to the enabling work streams. Work force challenges would be an issue for all work streams and the workforce group had established three key areas of focus: career pathways, leadership, and new roles and new ways of working.

In relation to Estates, the Estates Group provided a report to the Board outlining its key priorities relating to a premises stocktake, resources required to deliver the future model and the efficiency delivery of infrastructure functions. The group was progressing discussions on a Health and Wellbeing Campus model for George Elliot Hospital and a workshop for partners across the system was planned for 11th July. An updated briefing on the Estates Strategy was tabled at the meeting which included background information on the Naylor Report and referred to local plans and key priorities The report also highlighted the communication and engagement sessions which had taken place since the last report to the Health and Wellbeing Board.

The presentation highlighted the programme governance, structure and work streams; reviewed progress with the regulators; referred to the estates strategy; and concluded with the next steps.

Members raised a number of issues in response to the presentation including:  Clarification about the estate premises under consideration and whether it included buildings owned by other organisations  The complexities associated with the mental health work stream community capacity and resilience  Examples of how voluntary organisations can support and help people suffering from mental health issues and the importance of using these community assets  The importance of including patients and the public in the structures and ensuring their views are taken into account as work progresses on the work streams

– 4 –  The importance of using Elected Members who can engage with local residents helping to get the right messages out  An acknowledgement of the need for organisations to continue to work together putting patients at heart of any new system.

RESOLVED that the contents of the report and presentation be noted. .

6. Proactive and Preventative Work Stream - Public Health Preventative Framework

The Board received a presentation from Gail Quinton, Deputy Chief Executive (People) on the Proactive and Preventative work stream of the Better Health, Better Care, Better Value programme. Jane Fowles, Public Health Consultant, also attended for the consideration of this item.

The presentation set out the benefits of a targeted proactive and preventative approach. It was important for this to be undertaken at the current time as there was a greater level of need, conditions for success were stronger and the work stream enabled partners to build on the work already underway. The presentation set out the foundation already in place and highlighted the partnership principles to drive change.

Prevention was to be being integrated into all aspects of the health and care model with agreed prevention priorities being smoking prevention; obesity; falls prevention; and the Thrive Mental Health Commission report. Reference was made to the work programme in a three stage model:  80% - community based self-help for the general population  10% - at risk or early intervention  10% - specialist care Additional information including the links to the partner organisations and the features for each of these stages were provided.

The presentation concluded with attention being drawn to the need for partner organisations to adopt the model and partnership principles and to provide a clear statement of commitment to be a public organisation which prioritises prevention and supports people to help themselves.

Jane Fowles detailed the support to be provided by Public Health to the Proactive and Preventative programme and the Chair, Councillor Caan expressed support for the Public Health initiatives including fitness in the parks and the recent event in Broadgate. Dr Canale–Parola, Deputy Chair highlighted the importance of the role of the community.

RESOLVED that the progress with the Proactive and Preventative work stream be noted.

7. Redesign and Improvement of Stroke Services

The Board received a report from Andrea Green, Coventry and Rugby Clinical Commissioning Group (CCG) on the proposals for the redesign and improvement of stroke services.

– 5 – The report referred to the establishment of a project in April, 2014 by Coventry and Warwickshire CCGs to improve local stroke services for those who have had a stroke or a transient ischemic attack (mini stroke). In due course the proposals were expanded to include improvements to acute services, specialist rehabilitation and primary prevention of strokes. Reference was made to the project governance structure including the Project Stakeholder Board and an expert Patient and Public Advisory Group.

The report set out the case for change as follows: Access to Service is time critical both to saving lives and reducing disability Local gaps in timelines for people who stroke Local TIA (mini stroke) service variation Workforce gaps – Stroke Specialist Consultants Unwarranted variation and inequality in stroke specialist rehabilitation services.

The Board were informed of the engagement with patients, carers and key stakeholders. A pre-consultation engagement programme was undertaken in the initial stage of the project to understand the views of key stakeholders and local people about the potential scenarios for a new stroke pathway in order to shape the future of stroke services in Coventry and Warwickshire. The aims of the discussions were to ensure everyone had a clear understanding of the services delivered currently, the evidence base and rationale for change and what scenarios were being discussed. Four possible scenarios for the future of acute stroke care were put forward. Key themes received from the early engagement with stroke survivors, carers and the public were related to transport issues, communication difficulties, compassion and dignity, staffing and discharge support. Following engagement, the following proposals were developed:  Having one specialist stroke team based at UHCW, made up of experts in stroke services. They will treat people in the important first few days after a stroke  A community support service for people who are recovering at home  Closure of the specialist stroke services at Warwick Hospital and George Eliot Hospital  The provision of hospital beds for people who need to be in hospital while they recover at Leamington Hospital and George Eliot Hospital.

Following treatment at Hyper Acute and the Acute Stroke Unit on the UHCW site, patients would be referred to one of five settings to meet their rehabilitation or ongoing needs:

 Home with Early Supported Discharge Service  Cared for in a nurse led stroke ‘bedded’ rehabilitation service at a local hospital  Home with the Stroke Community Rehabilitation Service  Home with a package of care  Nursing or residential care for those with more complex needs.

Attention was drawn to the support from the West Midlands Clinical Senate of national experts on Stroke Care for the model.

– 6 – It was anticipated that improvements would be a reduced number of people who stroke; a reduction in deaths from stroke; a reduced disability from those who suffer a stroke; and improved cognitive function for people after a stroke.

Further information was provided on the four week public and patient engagement on the proposals. Appendices to the report detailed the consultation questionnaire and the four engagement events to be held during July. NHS England would then need to complete their assurance process before any consultation commenced.

Members raised a number of questions in response to the report, matters raised included:

 The anticipated average length of stay at Leamington or George Eliot hospitals  The importance of providing the public with a consistent message being clear on the benefits of the proposals during the engagement and consultation stages  The requirement to tighten up on communications ensuring the message was all about better patient outcomes as oppose to saving money  The importance of all the partners supporting the redesigned and improved stroke services.

RESOLVED that, having reviewed the proposals to improve stroke services, it be noted that the CCGs are: a) Completing a further phase of engagement as the scenarios for improvement have now been translated from the feedback from patients, the public and clinicians into proposals attached at Appendix A b) Have commissioned another integrated impact assessment of the proposals c) About to enter the final stage of assurance with NHS England.

8. Improved Better Care Fund

The Board considered a report of the Deputy Chief Executive (People) which sought approval for the use of additional Better Care Fund resource to support three intended purposes. The report was also to be considered by Cabinet on 1st August and Council at their meeting on 5th September.

The report indicated that whilst the Sustainability and Transformation Programme (STP) was the primary planning tool for health and care, the Better Care Fund was the only mandatory policy to facilitate integration of health and care. The programme spanned both the NHS and local government and sought to join up health and care services so that people could manage their own health and wellbeing, and live independently in their communities for as long as possible.

In March 2017 a new policy framework for the Better Care Fund covering the period 2017 to 2019 was issued at the same time as significant additional funding being made available to Councils in order to protect adult social care. These sums came from the 2015 spending review and the 2017 spring budget and taken together comprised the Improved Better Care Fund. The additional funding element over and above the budget for Coventry was £18.6m as follows: 2017/18 - £7.1m, 2018/19 - £4.4m and 2019/10 - £7.1m (although the 2019/20 figure was

– 7 – outside the scope of the current planning). This additional funding was provided direct to Councils for the following three purposes:  To meet adult social care need  To provide support to the NHS – especially through the application of 8 high impact changes  To sustain the social care provider market

The Board were informed that plans for the use of the grant needed to be approved by the City Council, Coventry and Rugby CCG and the Health and Wellbeing Board. Resources could then start to be spent through a pooled budget arrangement.

The Board noted that a new Better Care Plan was being developed for the period up to 31st March, 2019 with a supporting section 75 partnership agreement identifying how the additional resources were to be used.

An appendix to the report set out the programme plan which contained a series of project areas which would deliver against the three purposes of the funding.

Members raised a number of issues including transparency of the funding and proposals; the positive aspects of receiving additional resource; and clarification about the current reasons for delayed discharges from hospital.

RESOLVED that:

(1) The programme plan for the resources made available through the improved Better Care Fund against the areas identified be supported.

(2) A further report on the Better Care Fund plan be submitted to a future meeting once the planning tools have been provided and completed.

9. Coventry Drug and Alcohol Strategy 2017 - 2020

The Board considered a report of Liz Gaulton, Acting Director of Public Health on the Coventry Drug and Alcohol Strategy 2017-2020, a copy of which was set out at an appendix to the report. An update was provided on the progress to address alcohol and drug misuse against the previous strategies was detailed in a further appendix.

The report indicated that Coventry’s vision was to reduce the harms caused by alcohol and drug misuse making Coventry a healthier, wealthier and happier place to live, where less alcohol and fewer drugs were consumed and where professionals were confident and well-equipped to challenge behaviour and support change. This linked to all three of the priorities in the 2016-2019 Health and Wellbeing Strategy. Reference was made to the finding in the 2016 Coventry Drug and Alcohol Needs Assessment which indicated that drug use was falling and that Coventry had a considerably larger alcohol abstinent population than many other areas although there were still sections of the population drinking at harmful levels with approximately 14,000 people in the city being high risk drinkers.

– 8 – The development of the new Drug and Alcohol Strategy coincided with the re- commissioning of drug and alcohol recovery services in the city. As drug and alcohol misuse was a cross-cutting issue, it required a multi-agency response. The strategy involved partners and covered a wide range of issues such as multiple complex needs, prevention, early intervention, education, training, employment, housing, finance, crime, recovery and support.

The strategy had been developed by, and was being implemented by, a wide range of partners including the City Council, Coventry and Rugby CCG, West Midlands Police, Probation, Youth Offending Service, drug and alcohol treatment providers and the Coventry Recovery Community. It was a three year citywide strategy for both drug and alcohol use covering both young people and adults.

The three strategic priorities were to: (i) Prevent people from taking drugs or drinking harmful levels of alcohol and intervene early to minimise harm (ii) Support those with drug and/or alcohol problems and those with multiple complex needs (iii) Promote sustainable recovery and enable people to live healthy, safe and meaningful lives. The report highlighted the main actions to be undertaken in the first twelve months.

The strategy was to be reviewed on a quarterly basis by the Drug and Alcohol Strategy Steering Group and would have an action plan detailing the specific actions. The Steering Group reported to this Board and to the Police and Crime Board.

RESOLVED that:

(1) The report summarising actions to date on the current Coventry Drug Strategy and Coventry Alcohol Strategy be noted.

(2) The Coventry Drug and Alcohol Strategy 2017-2020 be endorsed.

10. Forward Plan Agenda Items and Health and Wellbeing Board Development Day

The Chair, Councillor Caan informed the Board that arrangements were being put in place for a half day development session prior to the Board’s next formal meeting on 4th September, 2017.

11. Re-inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers

The Board considered a report of John Gregg, Director of Children’s Services which informed of the re-inspection of services for children in need of help and protection, children looked after and care leavers specifically in relation to partners by Ofsted between 6th and 30th March, 2017. A copy of the Inspection Report was set out at an appendix to the report.

– 9 – The report indicated that the Ofsted re-inspection of services report published on 13th June, 2017 judged overall Children’s Services in Coventry ‘requires improvement to be good’. Services were no longer inadequate which marked a key point in the improvement journey and demonstrated the improvements made. The Ofsted judgements were: Children who need help and protection – requires improvement Children looked after and achieving permanence – requires improvement - Adoption performance – requires improvement - Experience and progress of care leavers – good Leadership, management and governance – requires improvement.

The Department for Education removed Children’s Services from intervention on 13th June, 2017 and the service was no longer subject to an improvement notice.

The inspection report identified nine recommendations, two of which specifically related two partners: Recommendation 2 – Ensure that the Local Safeguarding Children Board supports partners to understand and consistently apply appropriate thresholds to levels of need at every stage of the child’s journey, including the early help pathway. Recommendation 3 – Ensure that the introduction of risk management methodology across the authority includes partners and the authority at all stages.

The report highlighted the areas of partnership strength detailed in the Ofsted report.

A Children’s Services Improvement Plan had been developed in response to the Ofsted recommendations and areas for development. Information was provided on the areas for partners which included a risk averse approach across partners.

RESOLVED that, having considered the recommendations highlighted in the inspection report, the agreed approach of multi-agency engagement and support to improve outcomes for children be endorsed.

12. Any other items of public business

There were no additional items of public business.

(Meeting closed at 3.55 pm)

– 10 –

Minutes of the Meeting of the Warwickshire Health and Wellbeing Board held on 26 July 2017

Present :-

Warwickshire County Councillors Councillor Izzi Seccombe (Chair) Councillor Les Caborn Councillor John Holland Councillor Jeff Morgan

Warwickshire County Council (WCC) Officers John Dixon (Interim Strategic Director for People Group) Helen King (Deputy Director of Public Health)

Clinical Commissioning Groups (CCG) Dr Adrian Canale-Parola (Coventry and Rugby CCG) Dr Deryth Stevens (Warwickshire North CCG) Dr David Spraggett (Vice Chair, South Warwickshire CCG)

Provider Representatives Mike Williams (Coventry & Warwickshire Partnership Trust)

Healthwatch Warwickshire Robin Wensley

Borough/District Councillors Councillor Margaret Bell (North Warwickshire Borough Council) Councillor Tony Jefferson (Stratford District Council) Councillor Andrew Thompson (Warwick District Council) Councillor Barry Longden (Nuneaton and Bedworth Borough Council)

1. General

(1) Apologies for Absence

Dr John Linnane (Director of Public Health), Stuart Annan (George Eliot Hospital), Andy Meehan (University Hospitals Coventry & Warwickshire), Jagtar Singh (Coventry & Warwickshire Partnership Trust), David Williams (NHS England), Philip Seccombe (Police and Crime Commissioner), Helen Earp (Office of the Police and Crime Commissioner) and Councillor Emma Crane (Rugby Borough Council).

(2) Members’ Declarations of Pecuniary and Non-Pecuniary Interests

Councillor Margaret Bell declared a non-pecuniary interest, as a member of the County Council’s Adult Social Care and Health Overview and Scrutiny Committee.

(3) Chair’s Announcements

The Chair welcomed new Board members, Councillors Jeff Morgan, John Holland and Andrew Thompson. She introduced Brenda Howard, the STP programme director and other attendees, who would be presenting to the meeting. The Chair also spoke of her

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attendance at the recent launch of Creative Health: the arts for health and wellbeing and circulated a pack of information to the Board.

(4) Minutes of the meeting held on 22 March 2017 and matters arising.

The Minutes were agreed as a true record.

2. Draft Health and Wellbeing Board Annual Review 2016/17 and Delivery Plan 2017/18

John Dixon, Interim Strategic Director for People Group at WCC presented a report which set out the achievements made by the Health and Wellbeing Board’s (HWBB) partners over the past year, together with the activity programme for 2017/18. This demonstrated the breadth of achievements made to date, also looking to the next phase of activity. The document was the product of three workshops where progress against the current strategy had been reviewed and priorities for future work identified. This working document would focus the Board’s activity in 2017/18. Sections of the report focussed on:

• Examples of success • Roles and remit of the Board • Partnership principles • A common model of working • Delivery programme for 2017/18 • Development programme

Feedback on the draft document was invited in time for the final version to be considered at the September Board meeting, alongside the Director of Public Health’s Annual report. John Dixon took the Board through the document, highlighting the key additions to work streams including children’s services, housing and the focus on the proactive and preventative work stream.

Several Board members complimented the easy read format of the document. It was suggested that the document was too inwardly focussed and that links to Coventry should be emphasised, including the Concordat. A number of sections of the document were suggested where reference could be made to the close working with Coventry. Similarly, there should be recognition that residents close to the county boundaries looked to health services in neighbouring areas.

Comments were made about the ‘Hub’ approach to providing health services and the need to ensure that local communities were able to access those services. Andrea Green, Chief Officer of Warwickshire North and Coventry and Rugby CCGs explained how the Hub model would work, connecting to other local services. There was a need to make the arrangements for service provision more visible to communities. Further information was sought about the Planned and Preventative (P&P) work stream, which was seen as key to reducing pressures on acute services. It was suggested that targets were needed for the P&P work stream to show a reducing demand for hospital interventions. Andrea Green suggested these areas could be discussed further through the health partnership for the north of the county. For out of hospital services, clarification was provided on how these would be delivered in each area of the county.

There was discussion about life expectancy, closing the gap in life expectancy between men and women, and between those in the north and south of the county. A related

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aspect was about healthy life expectancy, as people were living longer, but with significant illnesses.

The section of the report on the Board’s role and remit was discussed, with reference made to the Board’s structure. A proposal was to increase the HWBB membership to include the chief executives health organisations as board members, in addition to their Trust Chairs. Furthermore reciprocal arrangements could be sought to involve a representative of the Coventry HWBB. Following discussion, it was agreed that a report be submitted to the September Board meeting to provide a light touch review of governance.

Resolved

That the Health and Wellbeing Board:

1. Notes the achievements made to date as set out in the Annual Review.

2. Approves the proposed role of the Board, its partnership principles and common model of working.

3. Endorses the Delivery and Development Plan for 2017/18.

4. Receives a report at its September meeting to provide a light touch review of governance.

3. Place-based Joint Strategic Needs Assessment

In March 2017, the Board received a report on the Joint Strategic Needs Assessment (JSNA). An update was provided by Spencer Payne, WCC’s Business and Commissioning Intelligence Service Manager. This explained the progress made to date and particularly the development of 22 geographical boundaries that would be used to profile Warwickshire communities and create a common evidence base.

The WCC Insight Service had led a programme of work to define these boundaries for use across all partner organisations, to understand and respond to the health and wellbeing needs of communities. The task was to create a set of areas that met the following criteria:

• Approximately 30,000 to 50,000 each in terms of population • Aligned to district/borough and CCG boundaries • Aligned to super output areas (the small geographical units used when official statistics were published)

The geographies had been developed in consultation with a wide range of partners and approved by the JSNA Strategic Group. The next stage was production of a profiling tool. This would enable partners to view statistical profiles and a common set of localities and data, to inform strategic planning. The Board was asked to reaffirm its commitment to these areas being applied to strategic planning activity. The report updated on other key JSNA activity, with appendices providing further information on the JSNA Annual Review document and the results of the Living in Warwickshire Survey.

On the Living in Warwickshire Survey, the Chair felt more detail should be provided about children’s services and mental health. Comments were made on the proposed

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geographies. For area four, Councillor Bell asked officers to review the decision to include Mancetter in this area with Hartshill and Atherstone as it had not been part of the pilot area. The renaming of area five, ‘Nuneaton Common’ was suggested, as this was not recognised by the residents of that area.

Resolved

That the Health and Wellbeing Board:

1. Thanks officers for the recent activity completed, including the development of a new set of geographical areas to be used for understanding the health and wellbeing needs of our communities.

2. Reaffirms the Board’s commitment to using a common evidence base across all partners to inform strategic planning and commissioning activity. The provision of a community profiling tool will enable partners to use consistent data for commissioning plans in 2018.

4. Warwickshire Better Together Programme and HEART project

The Health and Wellbeing Board (HWBB) received an update from Chris Lewington, Head of Strategic Commissioning at WCC and Paul Coopey of Nuneaton and Bedworth Borough Council. A summary of the position of the Warwickshire Better Together programme was provided, together with a focused presentation on the Home Environment Assessment Response Team (HEART) project.

At a recent HWBB workshop it was agreed that Housing would be one of the Board’s four priorities. This aligned to the ‘Warwickshire Cares Better Together Programme’ (WCBT), emergent housing issues impacting on the health and care system and the need for greater synergies to be forged with district and borough colleagues. A Housing Partnership was formed, which met the requirements of the Better Care Fund (BCF) guidance and in particular those relating to Disabled Facilities Grants. The new HEART service was funded via the Disabled Facilities Grant and reported into the WCBT Housing Board. The achievements of the HEART project were the main focus of this report and an accompanying presentation. A launch of the project would take place on 18 August 2017.

Areas discussed included the ability of the project to meet demand within the funding available, which was confirmed, how the project worked with housing associations and linking into the work of the Warwickshire Fire and Rescue Service. There were requirements attached to the additional funding from the BCF, so robust targets and performance measures would be put in place to evidence how this additional funding was making a difference.

Resolved

That the Health and Wellbeing Board:

1. Notes that Housing is a work stream of the Warwickshire Cares Better Together Programme, given the changes to the funding allocation of the Disabled Facilities Grant, now through top tier authorities and its importance to the health and care system and;

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2. Acknowledges the achievements of the Home Environment Assessment Response Team project, as part of the wider work of the Warwickshire Cares Better Together programme.

5. Improving Stroke Services in Coventry and Warwickshire

Andrea Green and the clinical commissioning group (CCG) Board members introduced this report. In April 2014, Warwickshire and Coventry CCGs initiated a project to improve local services for those who had suffered a Stroke, or a Transient Ischemic Attack (TIA – known as a mini stroke). The report gave an overview of the project, the wide engagement of stakeholders, use of an expert Patient and Public Advisory Group and an Expert Clinical Advisory Panel. Based on earlier feedback received from the public and patients, the CCGs had expanded the scope of the project from hospital service improvements, to include improvements to acute services, specialist rehabilitation and primary prevention of strokes. Further detail was provided on:

• The background to the review • Key facts about stroke • The prevalence of stroke and the configuration of local services • The case for change – key issues for service delivery and current gaps • Engagement with patients, carers and key stakeholders • Options for service configuration/ redesign, for improvement in stroke outcomes • The next phase of testing the proposals - public and patient engagement.

In essence, the review sought to deliver a better service and better patient outcomes. The proposal was for a specialist centre at University Hospitals Coventry and Warwickshire (UHCW), with intensive support for rehabilitation at home rather than in hospital for the majority. It was recognised that some patients might require rehabilitation in hospital. The revised service would cost more, as there would be increased rehabilitation costs and primary care costs. It was important that the public did not view this as a service cut, or as a result of Sustainability and Transformation Plan (STP), as the review was already planned ahead of the STP. Its aims were to reduce mortality and levels of disability following a stroke. The approach was similar to that successfully introduced in London.

The Board was supportive of the proposals, with a number of comments and questions being submitted. In particular, it was questioned whether there were enough specialist staff at UHCW and concerns about travel times to UHCW from some parts of the county, given the target for treatment within 30 minutes of the stroke occurring. Getting a referral for preventative treatment due to GP waiting times was raised. It was suggested that the new measures be implemented and evidence of reductions in demand provided, before withdrawing the existing services at other Warwickshire hospitals. Lifestyle choices and identifying those most at risk of a stroke were further aspects discussed.

Andrea Green gave an update on feedback to the engagement, with 300 comments being received to date. It was requested that the feedback be provided to the Board and this was agreed. In terms of staffing, she acknowledged there was a shortage of specialist consultants, nurses and therapists. The proposals sought to make best use of existing staff, but some additional recruitment would be required. The delivery and implementation plan would be formulated once the engagement had concluded and the way forward had been agreed. The points on travel to treatment time were also acknowledged. This aspect of the proposals had been scrutinised closely by the clinical senate. A few Warwickshire residents might need to travel to specialist centres in

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neighbouring areas, but the majority could reach UHCW within 30 minutes. Use of a ‘pull through’ system meant staff were notified and assembled in readiness for the patient’s arrival at hospital. Rehabilitation at home was a key element of the proposals.

A councillor drew comparison to the previous review of maternity services and retention of the existing service following significant public opposition to proposals. Encouraging people to visit their GP surgery for an assessment of risk of a stroke and preventative treatment were also discussed.

Resolved

That the Health and Wellbeing Board notes the proposals to improve stroke services from NHS Coventry and Rugby, NHS Warwickshire North, and NHS South Warwickshire CCGs, noting that the CCGs are:

• Completing a further phase of engagement as the scenarios for improvement have now been translated from the feedback from patients, the public and clinicians into the proposals submitted • Commissioning another integrated impact assessment of the proposals • About to enter the final stage of assurance with NHS England.

6. 0-5 Redesign and Consultation

Beate Wagner, WCC Head of Children and Families introduced this item. On 2nd February 2017, the County Council approved its One Organisational Plan, which set out the corporate direction over the next 3 years. At the same time WCC’s budget was agreed which required a saving of £1,120,000 to be made to the Children’s Centres budget from 1st April 2018. A proposal was being consulted upon, to address this challenge within the context of wider transformation activity by WCC and which also had regard to the national context in relation to Children Centres.

Beate Wagner reminded of the focus on services for 0-5 year olds as part of the Children’s Transformation Plan. The Chair confirmed that WCC was seeking the Board’s input as part of the current consultation.

There were 5 key areas proposed in relation to the 39 children centres:

• Conversion of 12 Centres into Family Hubs that would extend the range of multi- agency services from the current 0-5 to 0-19 (or 25 in the case of disabilities) • Reassessing the use of the remaining 27 Centres with a view to the building being maintained by the community, partners or providers from where services coould be delivered or where this was not feasible to consider potential closure • A universal provision delivered in hubs, libraries, community centres that facilitated access, signposting and self-help and promoted school readiness • An Integrated Family Support Worker Service • Developing community capacity through building resilience in parents, carers and children.

The report confirmed the priority areas identified at the workshop in relation children and families:

• Improved commitment, visibility and engagement in Children and Families within the HWBB

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• Secured assurance of alignment with development of a hub model and 0-5 redesign • Progression of the Multi Agency Children and Families Champions to engage, influence and ensure a partnership approach to safeguarding and services to children and families • Progress of integration, commissioning, delivery and outcome models for children and families

Adrian Canale-Parola noted that one of the centres in Hilmorton, to the east of Rugby could be closed under the proposals. With the anticipated population growth for this area, due to significant housing development, the strategic reasoning for this was questioned. The point was noted and would be included in the consultation feedback. Councillor Barry Longden raised concerns that the revised services would cover the 0- 19 year age range and there was a potential for conflict if antisocial behaviour occurred when very young children were present at the same venue. He added that the benefits of children’s centres had been evidenced and he was also concerned about the way the consultation document was structured. Beate Wagner acknowledged the points raised, explaining the rationale for the review and the aim to provide an equitable service. Some centres were only open for a few hours each week, so the buildings were under-utilised. Councillor Morgan as the Cabinet member for Children assured that safeguarding was of prime importance. John Dixon added that this was a thorough consultation process seeking feedback through public meetings and drop in sessions, meetings at children’s centres and through on line responses.

The consultation period closed on 11 September 2017. Thereafter the results would be analysed with a view to final recommendations being submitted to the WCC Cabinet in the autumn and then implementation of the new arrangements from April 2018.

Resolved

1. That the comments made by the Board be included in the consultation responses.

2. That Board Members disseminate the consultation document within their own organisations, with a view to encouraging individual and collective responses.

3. That the priority areas identified above be used as the basis for developing actions during 2017/18.

7. Report from District and Borough Council Portfolio Group

Councillor Les Caborn gave a verbal update on the areas discussed at the June meeting with the portfolio holders of each district and borough council. It had been agreed to provide an activity update to the Board twice each year and to extend this to be a place-based update that included partner updates as well.

Resolved

That the Health and Wellbeing Board notes the update.

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8. Health and Wellbeing Executive Team Report

John Dixon provided a verbal update. As shown in the earlier agenda item, the main focus of the Executive Group’s recent activity had been the Annual Review and Delivery Plan.

Resolved

That the Board notes the update.

9. Coventry and Warwickshire Better Health, Better Care, Better Value (formerly STP) Programme

The Board received an update from Andy Hardy and Brenda Howard. Mr Hardy confirmed that the Sustainability and Transformation Plan (STP) was recently renamed “Better Health, Better Care, Better Value”. He reported the joint vision: “To work together to deliver high quality care which supports our communities to live well, stay independent and enjoy life”.

The report set out the progress since the last update to the HWBB, which comprised:

• A positive meeting between Board members, NHS England and NHS Improvement to provide a stocktake on progress. • The Board had agreed its support structure and recruitment was underway. The ambition was to attract applicants internal to partner organisations as secondments, with external applications also being invited. A “System Leadership Academy” was proposed, enabling participants to experience working in different organisations within the system. • The governance arrangements for the programme had been reinforced and the design authority reframed, with greater representation from local clinical leaders. Also, a Programme Delivery Group supporting the Board had been established with all work streams having executive leads. • It had been concluded that mental health services should be designated as a transformational work stream and arrangements were progressing to establish this. Also agreed to establish a cancer work stream, as part of the approach to planned care. Progress in this area would be overseen by the regional Cancer Alliance. • Participation in a developmental process led by Health Education England and to work with well-respected facilitator John Berwick.

Transformation and Enabling work stream updates were provided in relation to: • Maternity and Paediatrics • Urgent and Emergency Care • Mental Health • Proactive and Preventative • Productivity and Efficiency • Planned Care • Cancer • Workforce • Estates • Information management and technology • Communications and engagement • Primary care development

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A number of questions were submitted on the work streams. On the proactive and preventative work stream, Andy Hardy acknowledged that more funding should be spent on prevention, an example being a focus on reducing the risk of strokes. The impact of additional development and associated population increases for primary care services was raised. Population growth was modelled and funding sought for additional surgeries through Section 106 (planning) agreements. A move to primary care hubs, also involving social care was seen as the way forward. The removal of, or a reduction in funding for low priority procedures would attract public concern, when the detail became known. On maternity services, reference was made to the Better Births Strategy, the aims of that strategy, assessing the gap between its vision and current provision and the options for achievement of the strategy.

Councillor Longden felt that local councillors and the public were not informed on this process and found out about decisions after they had been taken. Andy Hardy responded that no decisions had been taken on service reconfigurations as shown by the report on stroke services, earlier on this agenda.

The Chair commented that the former STP process had been very health centric, with numerous restrictions placed on those involved. However, good progress was now being made and WCC was significantly involved in the proactive and preventative work stream. She also spoke about the joint work with Coventry’s HWBB, the unity and strength this brought and there was a need for an equal value to health in working together.

Public engagement was discussed. This work stream was led by Andrea Green, who explained the difficulties in engaging the public in the high level plans, as evidenced by the reaction to the STP process. Many of the detailed plans were not yet sufficiently formulated to enable public consultation. Robyn Wensley of Healthwatch added that learning could come from each consultation process to improve subsequent ones.

There was a public perception that changes reduced services or made them less easy to access. The Chair responded that there could also be opportunities from change and a role of the Board was to shape such changes, within the finances available. Mr Hardy added that unlike some public sectors, health spending was still increasing. He also referred to the recent worldwide assessment of health services, ranking the NHS highest in several categories. It was requested that a briefing be provided for the Board, following the next quarterly stocktake meeting with NHS England and NHS Improvement on progress.

Resolved

That the Health and Wellbeing Board notes the report.

10. Forward Plan

The Chair referred to the circulated report, which detailed the agenda items for formal meetings and the focus of the agreed workshop sessions. Board member input was sought to the future programme.

Resolved

That the Board members note the Forward Plan.

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11. Any Other Business

It was noted that immediately following the Board there would be an interactive session on Communication Strategy Development.

The meeting rose at 12.55pm

.... Chair

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Enclosure AA

Audit Committee Report for the Meeting held on 24 April 2017

Achievements / Decisions Made / To Note Matters referred to Governing Body lllllllllllllllll for approval, debate or further Internal Audit: The Committee noted the following: consideration: • Internal Audit Review of Financial Reporting: Internal Audit (IA) were significantly assured that the CCG was recording its • None.

current position accurately. • Internal Audit Review of Procurement – Lead Provider

Framework: IA were moderately assured in relation to the CCG’s procurement process. • Internal Audit Review of Contracts Management: IA were significantly assured that the monitoring and management of the contracts in place was in accordance with contractual conditions. • Internal Audit Review of IT Equipment: IA were moderately assured for handling of IT Equipment, however there were a few concerns relating to lack of verification exercises, missing or misplaced equipment and transparency of disposal.

Annual Head of Internal Audit Opinion 2016/17: The Committee noted that IA were significantly assured that there was a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls were generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk.

CCG Delegated Financial Limits: As the updated document required sign off by the Chief Officer’s meeting, the Committee agreed for it to be circulated to Members via email to enable timely approval by Governing Body and brought back to the next meeting. Key Issues for the Governing Body

• None.

Key Information: • Committee Chair: David Allcock, Lay Member for Audit and Governance • CCG Lead: Chris Lonsdale, Director of Finance • Date of Next Meeting: 26 May 2017

Audit Committee Report for the Meeting held on 26 May 2017

Achievements / Decisions Made / To Note Matters referred to Governing Body lllllllllllllllll for approval, debate or further Annual Report and Accounts: consideration:

• Report to those Charged with Governance (ISA260): The • None. Committee noted that an unqualified opinion had been made on the financial statements, there were no unadjusted audit differences to report, and the Value For Money conclusion was qualified ‘except-for’ on the grounds of financial resilience.

• Section 30 Report: The Committee received the report, noting that this was due to a breach in the statutory financial duty.

• Head of Internal Audit Opinion 2016/17 – Revised: The Committee noted that the Head of Internal Audit Opinion for 2016/17 had been revised to reflect that the Service Auditor reports had been received.

• Annual Report 2016/17: The Committee approved the Annual Report for formal adoption and submission to NHS England by 31 March 2017, noting that the document may be subject to minor amendments that do not materially change the document and insertion of additional images. The Governing Body had delegated authority to the Audit Committee to approve the Annual Report.

• Annual Accounts 2016/17: The Committee approved the Annual Accounts 2016/17 subject to final non- substantive amendments being made as agreed with the external auditors. Key Issues for the Governing Body • Letter of Representation: The Committee noted the Letter of Representation and authorised the Interim Chief Finance Officer • None. and the Chair of the Committee to sign it.

• Service Auditor Reports: The Committee noted the reports and agreed for them to be presented at the July 2017 Committee meeting.

Key Information: • Committee Chair: David Allcock, Lay Member for Audit and Governance • CCG Lead: Chris Lonsdale, Director of Finance • Date of Next Meeting: 3 August 2017

Commissioning Finance and Performance Committee (CF&P) Report for the Meeting held on 22nd June 2017

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body Financial Report - Month 2: The CCG was Financial Report - Month 2: forecasting an overspend of £4.3m against its in-year • The challenging plan and the improving underlying notified allocation and an overall overspend of position. £18.6m against its confirmed allocation which • The escalating concerns regarding the Continuing included a brought forward deficit of £14.3m. Initial Healthcare service and the mitigating actions. data from GEH indicated performance was on plan. Runninglllllllllllllllll costs expenditure was predicted to be on Performance Report - Month 01: The key issues plan with slight underspend year to date due to were continued achievement of RTT, A&E and slippage. The CCG was reporting a mitigated risk Dementia diagnosis. SWFT failed for the fourth position. The Committee noted the report, consecutive month the occupational therapy- recognising the paucity of data currently available. paediatric performance.

QIPP Report: The Committee noted the report, recognising the paucity of data currently available, and supported the projects to be brought for Delivery Assurance reporting in July.

Key QIPP Scheme Highlight Reports: The Committee noted the Primary Care Prescribing report, agreeing that progress and recommendations should be received in 2 months. Members also noted the Prescription Ordering Direct report and supported the recommendation of accommodation option 1 (build in-house at Heron House).

Personal Health Budgets Business Case: The Committee approved the report contents subject to capacity review within current teams for the two staff members required to oversee the pilot period.

Primary Care General Prescribing Incentive Schemes 2017/18: The Committee agreed the areas recommended for inclusion in the scheme; and agreed that practice representatives needed to attend the March 2018 Protect Learning Time. Practices not attending would be deducted 20% from their incentive scheme payment.

Performance Report - Month 01: The Committee scrutinised and challenged the position. The key issues were continued achievement of RTT, A&E and

Dementia diagnosis. SWFT failed for the fourth consecutive month the occupational therapy- paediatric performance. CWPT were achieving targets with the exception of two. Indicative April activity showed achievement of 8 of the 9 cancer performance indicators with non-achievement of

Cancer two week wait for first outpatient appointment for patients referred urgently with suspected cancer.

Matters referred to the Governing Body for approval, debate or further consideration:

Key Information: • Committee Chair: David Allcock (Lay Member Audit and Governance) • CCG Lead: Chris Lonsdale (Director of Finance) th • Date of Next Meeting: 27 July 2017 Commissioning Finance and Performance Committee (CF&P) Report for the Meeting held on 27th July 2017

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body Financial Report - Month 3: The CCG was Financial Report - Month 3: forecasting an in-year deficit of £4.3m against its • The limited flexibility within the plan and the need notified allocation. This was increased by the brought to deliver 100% of the QIPP savings. forward combined deficit of £14.2m to reach a • The over performance within the Acute sector. cumulative deficit of £18.5m. Running costs were in balance, with a slight underspend year to date. The Performance Report - Month 02: The key issues CCG waslllllllllllllllll forecasting a net risk / headroom position were continued achievement of RTT, cancer 62 days of zero. There was a forecast level of over target and dementia diagnosis. performance across the acute portfolio of almost £800k.

QIPP Report: The Committee discussed the current reporting at month 3, recognising the paucity of available data, the slippage of delivery for Prescribing and Procedures of Low Clinical Value (PLCV), and risk of slippage for Outpatient Redesign and Falls. The Committee agreed for further deep dive reports to be deferred until September.

Key QIPP Scheme Highlight Reports: The Committee noted the Making Quality Referrals report, agreeing for a deep dive report to be provided at an appropriate point. The Committee received the PLCV report, noting the external audits, the clinical audit specification, the risk to delivery of the full £620k until the audits were completed, and the further mitigation to be sought in relation to delivery of the total in year QIPP. Lastly, the Committee noted the key points and recommended approach, and endorsed the principles and next step actions within the Acute Efficiencies (Schemes 11 and 12) report.

Business Case and Commissioning Intentions for End of Life Care in Warwickshire North: The Committee noted the report and approved the recommended commissioning options, subject to a financial modelling paper to be presented to the next Committee meeting.

Performance Report - Month 02: The Committee scrutinised and challenged the position. The key issues were continued achievement of RTT, cancer 62 days target and dementia diagnosis. General and Acute referrals year to date were 25% above plan. Matters referred to the Governing Body for The CCG was 24.3% above plan for GP referrals and approval, debate or further consideration: 25.9% above plan for ‘other’ referrals. Elective • Approval for the Age Related Macular Inpatients were 8.5% above plan. Degeneration (ARMD) contract extension from 1 April 2018 until 31 March 2020. Contract Update: The Committee noted that the • Approval for Policy for Diagnosis and CCG was actively managing its contracts, and had Management of Chronic Fatigue Syndrome (CFS) made sizable challenges to its host Trust George and Myalgic Encephalomyelitis (ME), subject to Eliot Hospital at Month 1 and Month 2. confirmation that a Committee clinical lead had reviewed the policy.

Key Information: • Committee Chair: David Allcock (Lay Member Audit and Governance) • CCG Lead: Chris Lonsdale (Director of Finance) • Date of Next Meeting: 24th August 2017 Clinical Quality, Safety and Governance Committee (CQSG) Report for the Meeting held on 22 June 2017 (Main)

Achievements / Decisions Made / To Note Matters referred to Governing lllllllllllllllll Body for approval, debate or Quality, Safety and Patient Experience Report: The Committee further consideration: noted improvements in falls with harm, Friends and Family Test Inpatient score, statutory training compliance and the Summary • Emergency Preparedness Hospital Mortality Indicator (SHMI). One never event had been Resilience and Response reported during May. The Committee also noted the areas of (EPRR) Update: Delegation concern following an announced visit to George Eliot Hospital. request via the Chief Officer’s Report for the Accountable Safeguarding: The Committee received a monthly safeguarding Emergency Officer to sign off the update noting that the Local Authority’s Ofsted report was expected 2017 Annual EPRR Core to be published on 23 June 2017, and a report on Looked After Standards Submission. Children with a specific focus on Warwickshire North was to be presented to the next meeting.

Patient and Public Intelligence Reports – Q4: The Committee noted reports on Patient and Public Intelligence, Complaints, Comments, Concerns and Enquiries, Patient Engagement and the GP Feedback System.

Primary Care Quality Update: The Committee noted that no Warwickshire North Practices had been escalated to the Professional and Practice Information Gathering Group (PPIGG).

Emergency Preparedness Resilience and Response (EPRR) Update: The Committee noted updates on the Director On-Call System and staff training.

Primary Care General Prescribing Incentive Schemes 2017/18: Key Issues for the Governing The Committee approved the Prescribing Incentive Scheme for 2017/18 from a quality perspective, noting that the financial element Body of the scheme would be considered by the Commissioning, Finance and Performance Committee. • None

Any Other Business: The Committee heard that the Quality Account for 2016/17 had been signed off.

Key Information: • Committee Chair: Dr Deryth Stevens • CCG Lead: Rebecca Bartholomew (Director of Nursing)/ Maria Maltby (Head of Corporate Affairs) • Date of Next Meeting: 27 July 2017 (Themed)

Clinical Quality, Safety and Governance Committee (CQSG) Report for the Meeting held on 27 July 2017 (Themed)

Achievements / Decisions Made / To Note Matters referred to Governing lllllllllllllllll Body for approval, debate or Mortality Assurance Update: The Committee noted that George further consideration: Eliot Hospital (GEH) was no longer an outlier, and no issues had been revealed by recent audits at GEH. The Committee agreed for • Draft CCG Response to the the CCG’s plans for End of Life care to be presented to the Modern Slavery Act 2015: September meeting. Recommendation to Governing Body for adoption, signing by the Safeguarding Update: The Committee received the verbal update, Accountable Officer and noting that a named GP for Safeguarding and an IRIS (Identification publication. and Referral to Improve Safety) advocate educator for North Warwickshire had both been appointed. The Committee also noted that the CCG was required to complete a Safeguarding Assurance Tool (SAT) by the end of October 2017, and an update would be received at the September meeting.

GEH Submission of Assurance Tool for Children and Adults: The Committee noted that GEH had identified weaknesses for training and supervision however an action plan was in place to address these.

Any Other Business: The Committee heard that the results of the Local Authority’s Inspection of Safeguarding Services to Children Ofsted inspection.

Key Issues for the Governing Body

• None

Key Information: • Committee Chair: Dr Deryth Stevens • CCG Lead: Rebecca Bartholomew (Director of Nursing)/ Maria Maltby (Head of Corporate Affairs) • Date of Next Meeting: 24 August 2017 (Main)