City and Hackney Clinical Commissioning Forum Thursday 7

City and Hackney Clinical Commissioning Forum Thursday 7 th September 2017 St Joseph’s Hospice

1. 2. 4. Led by Welcome Clare Highton Members’ Forum: 2. 3. Agenda Items 1. CCG Chair Election / Selection options Appointment of the CCG Lay Member for Governance Homerton Update: Digital and Electronic Communication SUN Crisis Care Matthew Knell Niall Canavan Maria Lliopoulou 5. NDA Target Clare Highton 6. North East London Commissioning Arrangements Clare Highton 7. Prescribing Update incl National Consultation on Items which should not be routinely prescribed in primary care Rozalia Enti 8. 18/19 CCG Commissioning Intentions David Maher

CCG Chair Election / Selection options and appointment of the CCG Lay Member for Governance Presentation to the Thursday 7 September 2017 Members Forum FOR DECISION

Background • Clare and Haren reach the end of their terms of office in March 2018 and can not carry on as Chair and Clinical Vice Chair; • We have been asking Consortia to debate whether we should move to a “presidential system” to appoint the Chair; • At present the Chair comes via being elected as a Consortia Representative onto the Clinical Executive Committee and then elected onto the Governing Body; • The proposal is in future any GP could stand to be Chair; • Consortia have supported the presidential model in principle and we now want to debate some of the practicalities… • We will return to the October 2017 Members Forum with changes to the CCG Constitution that will outline the agreed process and enable us to run the upcoming election process towards the end of this year / early next year (depending on NHSE agreement of our Constitutional changes!).

Underlying Assumptions 1. We are discussing changing the election process for the CCG Chair only – the Consortia Lead election / selection process remains unchanged; 2. The Consortia Leads will continue to elect / select two of their number to serve on the CCG Governing Body as Clinical Vice Chair and Governing Body GP; 3. One individual cannot hold both the Consortia Lead role and CCG Chair role. Similar to the current system, should this become the case, the individual will need to stand down from their Consortia Lead role and that Consortia will need to re-run their election / selection process without the new CCG Chair in the running; 4. Any Chair of the CCG would not be able to hold corporate or governing positions with the local GP Federation or Local Medical Committee as these would constitute a major conflict of interest. Any individual in this position would be able to stand for election, but would need to step down from any competing role if elected CCG Chair; 5. That the CCG Governing Body and Members Forum will still need to vote in the new CCG Chair in a majority (2/3 rds Practices for the Members Forum) vote.

For Decision – Standing for CCG Chair 1. Several Consortia have raised that there should be a set of criteria that any candidate for the CCG Chair role should have to meet. These have included: a) b) c) 2. A set period of time working as a GP in the City of London and/or London Borough of Hackney, for instance two years. We could base this on the local performers list registration date; That any candidate should be a salaried GP or partner with a member practice of the CCG. This would exclude locums from standing for the Chair role; Any other suggested and agreed on criteria? Any potential candidate for the CCG Chair role will require at least one ‘seconder’ support to stand for election and to be included on the ballot paper: a) Is the Members Forum content with one ‘seconder’, or does this need to be a higher number (or unwanted)?

For Decision – Application Process 3. We have had some feedback that an application would be useful to be completed to stand for election as CCG Chair. This form could require the previous points be addressed and accompanied by a job role and person specification that each application can be scored against: a) b) c) 4. The job role and person specification could return to the Members Forum for agreement in October 2017; The application forms could be initially assessed and shortlisted by a panel consisting of Clare Highton, Councillor Jonathan Mc. Shane (TBC) and a CCG Governing Body Lay Member (TBC) and those scoring above a set level (60%? ) proceed in the process; The same panel could then interview each shortlisted candidate against a consistent set of questions and those scoring above a set level (80%? ) proceed to the final stage of the process. We think it would be very useful if we run a ‘hustings’ style open event to all local GPs (and associated staff? ) in which the candidates coming out of the interview process will make themselves available to answer questions from local GPs in a two hour evening event. The same questions will be posed to each candidate and the event could be chaired by Clare Highton.

For Decision – Election Process 5. Who can vote? a) b) c) 6. Should votes be allocated to individuals, or to Practices? Should voting be restricted to the same criteria as agreed earlier as applying to who can stand? (eg, salaried and partners only, working in City and Hackney for at least two years? )? Should wider GP practice staff take part in this process, eg, practice managers, nurses, receptionists etc? There are several options on how we could run the actual election process: A week long period of time in which voting is available, either through: i. Anonymous ‘one link, one vote’ internet voting system; ii. Anonymous, but individual ballot paper and boxes made available in each GP practice; iii. Internal posting of anonymous, but individual ballot papers back to the CCG. b) An instant vote at the end of the previously mentioned hustings event. a) 7. There also options for who we involve in the elections process: 1. 2. We have committed to involving the LMC in our GP election processes, to date this has meant only in terms of keeping them up to date on elections and our processes, is there any more formal role for them in terms of this election? Do we want to involve any external, independent organisations in supporting the election process to make sure it is fair?

For Decision • • We are also requesting Members Forum approval of the appointment of Sue Evans to the Lay Member for Governance role that will be vacated by Mariette Davis on 30 September 2017; Sue was appointed to the CCG Associate Lay Member for Governance role at the Thursday 2 March 2017 Members Forum and has been supporting the Governing Body on commissioned services, sitting on the Governing Body, Audit Committee, Finance and Performance Committee and Remuneration Committee in a non voting capacity since April 2017; If approved by the Member Forum, Sue will take on the full Lay Member for Governance responsibilities, including chairing the Audit and Remuneration Committees and Conflicts of Interest Guardian; The CCG is not currently planning on advertising and filling the Associate Lay Member for Governance role.

SUE EVANS Chartered Accountant with thirty years of experience in financial roles as well as experience of governance, general management, HR and IT; In addition to a career in the private sector, also worked for charities and as a public appointee in organisations of all sizes; Career experience includes: • • Lay Member of Essex Advisory Committee (Magistrates Courts); Trustee and Treasurer of Loughton Youth Project (Registered Charity); Governor, Trustee and Director of St Aubyn’s Preparatory School (Registered Charity and Company); Company Secretary for the Worshipful Company of Glass Sellers’ of London Charity Fund (Registered Charity); Group Accounting Controller, British Telecommunications PLC/Xansa PLC.

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Homerton Update: Digital and Electronic Communication Niall Canavan Verbal update

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ADVERT Annual General Meeting Wednesday 27 th September 2017, 6 pm – 8 pm Assembly Hall (Hackney Town Hall) London, E 8 1 EA Light refreshments and drinks will be provided. Places are limited, to book your place please visit: www. eventbrite. co. uk and search ‘City and Hackney CCG Annual General meeting’

SUN Crisis Care Maria Lliopoulou Verbal update

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NDA Triple Target Clare Highton

0, 0% Greenhouse Health Centre Hoxton Surgery Nightingale Practice Dr SN Prasad (Brooke Road) Wick Health Centre Queensbridge Group Practice Well Street Surgery The Lawson Practice Lower Clapton Health Centre Drs Gadhvi & Pathan De Beauvoir Shoreditch Park Surgery Barton House Health Centre Cranwich Road (Spitzer & Partne. . . Athena Medical Centre Allerton Road Surgery Stamford Hill Group Practice London Fields Medical Centre Beechwood Road Sorsby Health Centre Tollgate Lodge The Dalston Practice Somerford Grove Health Centre The Heron Practice, John Scott HC Dr Gangola, Barretts Grove Southgate Rd & Whiston Rd MC Springfield Medical Centre Abney House Elsdale Street Sandringham Road Rosewood Practice Statham Grove Surgery Trowbridge Practice Neaman Practice (Long Lane) Riverside Practice Cedar Practice, John Scott HC Latimer Health Centre Lea Surgery Healy Medical Centre Richmond Road MC Elm Practice Clapton Surgery Kingsmead Healthcare % NDA triple treatment target achievement as at 1 st April 2017 60, 0% 50, 0% 40, 0% 30, 0% 20, 0% 10, 0% Achievement Average

50, 00% 45, 00% 40, 00% 35, 00% 30, 00% 25, 00% 20, 00% 15, 00% 10, 00% 5, 00% 0, 00% Greenhouse Health Centre Trowbridge Practice Queensbridge Group Practice Shoreditch Park Surgery Tollgate Lodge Healthcare Ce. . . Hoxton Surgery Brooke Road Surgery Riverside Practice Nightingale Practice Dalston Practice Lower Clapton Health Centre Barton House Health Centre Cranwich Road Surgery Well Street Surgery Wick Health Centre Lawson Practice Barretts Grove Surgery Neaman Practice Sorsby Health Centre Rosewood Practice Springfield Medical Centre De Beauvoir Surgery Somerford Grove Health Cent. . . Sandringham Road Practice Statham Grove Surgery Cedar Practice Abney House Medical Centre Heron Practice Beechwood Medical Centre Elsdale Street Surgery London Fields Medical Centre Healy Medical Centre Athena Medical Centre Richmond Road Medical Cent. . . Allerton Road Surgery Gadvhi Practice Latimer Health Centre Stamford Hill Group Practice Kingsmead Healthcare Southgate Rd MC & Whiston. . . Elm Practice Clapton Surgery Lea Surgery % Triple NDA Targets LTC contract dashboard end of Q 1 (31 st July 2017) % achievement average target

NDA target • Complex to achieve • Exact methodology difficult to be sure of • Legal basis has changed - Since May 2017, NHS England direct NHS Digital to collect, analyse and report the NDA data - GP practices and specialist services are required to supply the data for their practice or diabetes clinic • Data collection for NDA this year took place in July • Results will be known later in the year (? Early 2018)

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North East London Commissioning Arrangements Verbal update

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ADVERT Rheumatology Advice & Guidance Service now electronic • Rheumatology Advice & Guidance Services have moved to e-RS (formally choose and book) • Please don’t use the old email address anymore • If you have any concerns or queries, please email debbie. james@nhs. net

Prescribing Programme Board Update including Medicines of limited value to the NHS [MOLV-LIST] Rozalia Enti Assistant Director Medicines Management NHS City& Hackney CCG

Prescribing Programme Board (PPB) Discussion area CEC is asked to Slides A Update on Medicines of limited Value to the NHS review update including recommendations from national team on the 18 products and provide detailed views in the CEC meeting Slides 3 -8 B Initial proposal from NHSE-NHSCC on reviewing the availability via NHS prescriptions, of over the counter products (OTC medicines) provide initial views re: restriction of OTC products via NHS prescriptions C 2018/19 Prescribing Workplan provide suggestions for 2018/19 Prescribing Workplan & note key changes requiring overspending practices • to reduce overspend • attend meetings with Consortia Lead / GP Lead for prescribing to enable improved engagement in workplans D 2 6 2017 -18 Update on Prescribing - Budget - Prescribing indicators to note early progress in budget and prescribing indicators 9 10 -11 12 – 15

A. Medicines of limited value to the NHS What is the MOLV-LIST? a. Following on from discussion papers to Exec, CCF etc in April –May 2017 on DROP-LIST (Drugs to Review for Optimised Prescribing), we have updated the DROP-LIST name on this work stream to medicines of limited value to the NHS [MOLV-LIST] to describe the list of prescribed products considered as having limited evidence, or for which there are safer alternatives, or represent poor value for money for the NHS. It also incorporates products which could potentially be provided as self-care, with advice and support from the community pharmacists, or not within NHS provision. b. On 21/7/2017: - NHSE in conjunction with NHS Clinical Commissioners has issued a 3 month national consultation: Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, available via the following link https: //www. engage. england. nhs. uk/consultation/items-routinely-prescribed/ 2 7

A. Medicines of limited value to the NHS Why? We need to do more of the things that have good evidence of improving clinical outcomes for patients To help to do more of the things that work, we need to also do less of things that the NHS resources, that: • do not have good evidence for working well • are unsafe • are not good value for the NHS These work areas are not all new positions – most of the recommendations are within current formulary / medicines management guidelines, informed by national guidelines - This is a work stream that supports our ongoing programme of work to improve quality, safety of prescribing and can support delivery of savings that can be invested in treatments representing better value for money for NHS - As with all changes in prescribing, patients will need to be considered individually to determine whether a particular switch is suitable for them. 2

A. Medicines of limited value to the NHS What are we asking of Clinical Executive members? Please review the documents underpinning the national consultation available at: https: //www. engage. england. nhs. uk/consultation/items-routinely-prescribed/ The national list is wider than the list of products presented at the previous Clinical Exec meeting The prescribing programme board seeks to: 1. Raise awareness on the national consultation on “Items which should not be routinely prescribed in primary care” and encourage stakeholders to directly input into the national consultation 2. Listen to feedback / comments / concerns from prescribers, CCG Committees about the proposals a. feedback on any/ all of the 18 products b. feedback on initial indication by NHSE , for further proposals to review the supply on the NHS for products that are available over the counter from pharmacists & other retail outlets We are also: • Continuing discussions through Joint Prescribing Group • Discussing the recommendations in the proposals with local patient/ public groups 2 9

A. National Consultation on items not to be prescribed in primary care – Part 1 Product Co-proxamol Doxazosin modified release Category for inclusion on National Spend national list* £ 9, 002, 824 A Was this part of original C&H Formulary Position & CCG MOLV-List [annual spend to May 2017] Y Non Formulary [£ 15, 541] £ 7, 769, 931 B Y Fentanyl - immediate release Glucosamine & Chondroitin Herbal Treatments Homeopathy £ 10, 952, 130 £ 444, 535 £ 100, 009 £ 92, 412 B A A A Y Y Y (already in POLC-V) Liothyronine Lutein & Antioxidants £ 34, 802, 312 £ 1, 500, 000 B A Y Y Some products are within Formulary [£ 74, 287] Non Formulary [£ 7, 476] Non Formulary [£ 2, 543] Non Formulary [£ 392] Restricted Formulary position & specialist initiation [£ 69, 713] No change to current position [£ 6, 005] £ 5, 062, 928 B Y Restricted Formulary position [£ 33, 748] Oxycodone+Naloxone combination Perindopril arginine Travel vaccines Dosulepin Lidocaine plasters £ 529, 403 £ 4, 540, 351 £ 2, 651, 544 £ 19, 295, 030 B C A A Omega-3 fatty acids Rubefacients £ 6, 317, 927 £ 4, 301, 527 A A Tadalafil Once Daily £ 11, 474, 221 B Tramadol+Paracetamol combination Trimipramine £ 1, 980, 000 £ 19, 835, 783 B B 3 Formulary [£ 45, 660] Y - but did not produce supporting info as most prescribing from C&H is from 1 practice Non Formulary [£ 9, 166] Y No change to current position [£ 59, 961] N Non-formulary ELFT [£ 5, 537] N Hospital Only prescribing [£ 33, 112] N - but this area reviewed years Limited formulary recommendation; initiation by ago hospital specialist [£ 20, 190] N Not currently included in Formulary [£ 47, 756] Formulary restricts to post prostatectomy N patients only [£ 35, 161] N N Non formulary [£ 8, 733] Formulary ELFT [£ 58, 405] * Categories A: Products of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns B: Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation C: Items which are clinically effective but due to nature of the product are deemed a low priority for NHS funding

A. Medicines of Lower Value to the NHS Earlier this year, before the national consultation was announced we in City&Hackney (& in the other NEL CCGs) had prioritised 15 products on our local proposed MOLV-LIST The differences in the local and national lists are as below A. Differences summarised from 1 st part of NHSE proposal Items included in the NHSE List which were not originally included in the local MOLV-LIST Dosulepin Lidocaine plasters Omega-3 fatty acids Rubefacients Tadalafil Once daily Tramadol+Paracetamol combination Trimipramine 3 1 Items included in the C&H MOLV List which are not in the current NHSE proposal Dental products from general practice Eflornithine Probiotics where no ACBS approval Vitamins & Minerals where no clinical deficiency diagnosed

A. Medicines of Lower Value to the NHS Expected outcomes from review of MOLV-LIST work • Treatments of limited clinical value are not routinely used • Optimal patient outcomes are obtained from choosing a medicine using best evidence (e. g. following NICE guidance, local formularies etc. ) • Medicines wastage is reduced • The NHS achieves greater value for money invested in medicines. • Patients are more engaged, understand more about their medicines and are able to make choices, including choices about prevention and healthy living. • It becomes routine practice to signpost patients to further help with their medicines • Incidents of avoidable harm from medicines are reduced. 32

B. Over the Counter Products- Part 2 of national consultation The national proposal includes a 2 nd part – detailed recommendations will be released in the next phase, but NHSE plans to recommend to CCGs that certain products available over the counter may be considered appropriate for restriction These include products that: • can be purchased OTC, sometimes at a lower cost than that which would have been incurred by the NHS • treat a condition that is considered self-limiting & so does not need treatment as it will heal of its own accord &/ or • treat a condition which lends itself to self-care i. e. person presenting does not normally need to seek medical care/ treatment for the condition. The areas to be included are listed below 3 3

C. 2018/19 Prescribing Work plans The Prescribing Programme Board is asking practices/prescribers/ boards & the Exec to provide ideas for 2018/19 Workplan Ideas to date for next year’s work plan include Reviews of: • drugs of potential abuse • women of child bearing age prescribed valproate • quantities ordered – of repeat prescriptions • blister pack provision & documentation • Respiratory prescribing- (Respiratory is 1 of CCG’s priority areas for Right. Care) • MOLV-LIST, OTC products Meetings: • GP Practice-Community pharmacy interface meetings Training: • Polypharmacy Please send further ideas for prescribing workplan to: CAHCCG. Cityand. Hackney. Medicines@nhs. net 3 4

C. Improving practice engagement in Qi. PP Feedback earlier this year from the CCG’s Finance & Performance Committee and the Contracts Committee requested that the Prescribing Programme Board: reviews and takes greater steps to improve practices’ implementation of Qi. PP • • incorporates a requirement for practices to reduce overspend / to come in on budget (prescribing) – into the annual prescribing incentive scheme To this end the PPB have agreed to: a. Have a requirement for reducing overspend / remain within prescribing budget allocation for prescribing schemes for 2018/19 onwards b. Implement a system by which practices - forecasting significant overspend are provided with additional support, escalated through following structure: • • 3 5 Practice Support Pharmacist meetings with the practice underpinned by progress reports on Qi. PP implementation for the practice PPB request to PSP + Practice for progress with Qi. PP Consortia lead meeting with the Practice Prescribing Programme Board GP Lead & Head of Medicines Management meeting with the practice

D. PPB – Variation in practice level forecast spend (based on June 2017 data) %ASTRO PU Change from Q 4 2016 -2017 (when budgets were set) June Epact data Prescriber Name The Lawson Practice Athena Medical Centre The Surgery (Cranwich Road) Beechwood Medical Centre Somerford Grove Practice Southgate Road Medical Centre Sandringham Practice The Greenhouse Walk-In Fountayne Road Health Centre The Allerton Road Surgery The Springfield Health Centre Rosewood Practice The Wick Health Centre The Nightingale Practice The Sorsby Health Centre Abney House Medical Centre Kingsmead Healthcare Well Street Surgery The Surgery (Barretts Grove) Healy Medical Centre London Fields Medical Centre The Neaman Practice Queensbridge Group Practice The Heron Practice The Elm Practice Stamford Hill Group Practice Richmond Road Medical Centre Elsdale Street Surgery The Statham Grove Surgery The Riverside Practice The Hoxton Surgery The Cedar Practice The Surgery (Brooke Road) The Dalston Practice Lower Clapton Group Practice Tollgate Lodge Practice The Lea Surgery Trowbridge Practice Shoreditch Park Surgery The Clapton Surgery De Beauvoir Surgery Barton House Group Practice Latimer Health Centre 3 Forecast Outturn of the Prescribing Budget Allocated for 2017 -2018 £ £ £ £ £ £ £ £ £ £ £ 1, 282, 886. 30 486, 167. 85 484, 081. 92 368, 843. 16 1, 094, 826. 75 744, 263. 52 404, 376. 50 106, 590. 54 521, 324. 12 415, 404. 10 564, 685. 98 203, 599. 88 654, 714. 03 1, 034, 116. 82 514, 086. 01 281, 954. 08 598, 960. 47 1, 370, 801. 24 321, 761. 85 537, 385. 96 872, 381. 91 858, 371. 20 921, 979. 24 1, 038, 675. 34 277, 602. 47 1, 102, 419. 87 374, 148. 97 556, 485. 83 738, 622. 65 376, 538. 82 535, 307. 45 640, 993. 38 259, 093. 54 596, 955. 79 1, 270, 863. 51 680, 208. 84 1, 032, 306. 75 453, 208. 05 687, 095. 29 509, 446. 32 722, 464. 69 1, 248, 817. 13 621, 181. 91 £ £ £ £ £ £ £ £ £ £ £ 1, 540, 071. 00 648, 064. 00 544, 180. 00 432, 518. 00 1, 151, 539. 00 808, 728. 00 463, 370. 00 130, 571. 00 539, 004. 00 438, 243. 00 575, 846. 00 203, 797. 00 666, 017. 00 1, 077, 821. 00 511, 860. 00 268, 575. 00 574, 102. 00 1, 353, 993. 00 289, 264. 00 514, 469. 00 831, 121. 00 830, 681. 00 894, 516. 00 1, 023, 352. 00 225, 656. 00 1, 061, 278. 00 324, 161. 00 516, 126. 00 696, 159. 00 318, 933. 00 473, 452. 00 579, 614. 00 181, 082. 00 502, 562. 00 1, 172, 855. 00 571, 491. 00 928, 069. 00 335, 839. 00 575, 327. 00 380, 285. 00 553, 676. 00 998, 486. 00 311, 594. 00 Total forecast Overspend or Under spend at 31 March 2018 Overspend(+) Underspend(-) £ 257, 184. 70 £ 161, 896. 15 £ 60, 098. 08 £ 63, 674. 84 £ 56, 712. 25 £ 64, 464. 48 £ 58, 993. 50 £ 23, 980. 46 £ 17, 679. 88 £ 22, 838. 90 £ 11, 160. 02 £ 197. 12 £ 11, 302. 97 £ 43, 704. 18 -£ 2, 226. 01 -£ 13, 379. 08 -£ 24, 858. 47 -£ 16, 808. 24 -£ 32, 497. 85 -£ 22, 916. 96 -£ 41, 260. 91 -£ 27, 690. 20 -£ 27, 463. 24 -£ 15, 323. 34 -£ 51, 946. 47 -£ 41, 141. 87 -£ 49, 987. 97 -£ 40, 359. 83 -£ 42, 463. 65 -£ 57, 605. 82 -£ 61, 855. 45 -£ 61, 379. 38 -£ 78, 011. 54 -£ 94, 393. 79 -£ 98, 008. 51 -£ 108, 717. 84 -£ 104, 237. 75 -£ 117, 369. 05 -£ 111, 768. 29 -£ 129, 161. 32 -£ 168, 788. 69 -£ 250, 331. 13 -£ 309, 587. 91 % Overspend (+)/ Underspend (-) [(F-E)/E] 20. 05% 33. 30% 12. 41% 17. 26% 5. 18% 8. 66% 14. 59% 22. 50% 3. 39% 5. 50% 1. 98% 0. 10% 1. 73% 4. 23% -0. 43% -4. 75% -4. 15% -1. 23% -10. 10% -4. 26% -4. 73% -3. 23% -2. 98% -1. 48% -18. 71% -3. 73% -13. 36% -7. 25% -5. 75% -15. 30% -11. 56% -9. 58% -30. 11% -15. 81% -7. 71% -15. 98% -10. 10% -25. 90% -16. 27% -25. 35% -23. 36% -20. 05% -49. 84% Increase (+) Decrease (-) 0. 58% 0. 15% 0. 20% 0. 19% 0. 09% 0. 25% 1. 14% -2. 70% -0. 23% 1. 53% 0. 34% 0. 64% 0. 31% 0. 20% -0. 10% 0. 01% -0. 03% 0. 63% -0. 58% 0. 36% 0. 56% 0. 09% 1. 59% 1. 45% 0. 10% 0. 34% 2. 42% 1. 66% 0. 38% 0. 43% -0. 86% 0. 64% 2. 33% -1. 65% 0. 14% 0. 11% -0. 36% 1. 48% 0. 39% 1. 89% -0. 16% 0. 87% Budget impact of change in ASTRO PU [Ex. I] Overspend(+) Underspend(-) £ 7, 484. 88 £ 715. 64 £ 961. 82 £ 707. 00 £ 1, 014. 99 £ 1, 828. 23 £ 4, 609. 13 -£ 2, 872. 76 -£ 1, 193. 87 £ 6, 370. 35 £ 1, 893. 74 £ 1, 308. 53 £ 2, 006. 39 £ 2, 027. 25 -£ 535. 98 £ 33. 87 -£ 197. 12 £ 8, 693. 28 -£ 1, 852. 48 £ 1, 935. 80 £ 4, 921. 96 £ 781. 55 £ 14, 681. 08 £ 15, 082. 51 £ 271. 39 £ 3, 721. 95 £ 9, 053. 96 £ 9, 226. 75 £ 2, 799. 28 £ 1, 604. 62 -£ 4, 620. 83 £ 4, 120. 52 £ 6, 041. 04 -£ 9, 875. 64 £ 1, 755. 84 £ 720. 23 -£ 1, 184. 22 -£ 1, 627. 05 £ 10, 197. 42 £ 1, 964. 49 £ 13, 656. 01 -£ 1, 990. 29 £ 5, 422. 06 Specialist Drugs prescribed Overspend / Under spend forecast at 31 March 2018 Overspend or Under spend on Amount factoring in changes High Cost Drugs at in: 31 March 2018 List size, HCD and depot Overspend(+) antipsychotics Underspend(-) -£ 13, 067. 05 -£ 2, 503. 46 £ 6, 914. 57 -£ 2, 291. 61 £ 9, 662. 06 -£ 1, 479. 65 -£ 13, 911. 18 -£ 603. 36 -£ 4, 342. 29 -£ 3, 826. 94 -£ 456. 69 £ 3, 443. 35 £ 427. 74 £ 6, 112. 63 -£ 5, 004. 50 -£ 1, 332. 34 -£ 166. 20 £ 5, 296. 20 -£ 727. 18 £ 802. 19 £ 8, 706. 37 £ 3, 400. 59 -£ 712. 82 £ 5, 128. 23 -£ 5. 03 £ 4, 790. 84 £ 1, 189. 20 -£ 152. 93 -£ 399. 81 -£ 1, 231. 96 -£ 1, 977. 82 -£ 2, 677. 60 £ 1, 090. 68 -£ 4, 680. 93 -£ 6, 562. 12 -£ 104. 98 -£ 3, 955. 46 £ 1, 324. 22 -£ 10, 883. 24 -£ 2, 747. 17 -£ 5, 134. 32 £ 609. 50 -£ 3, 700. 77 £ 262, 766. 87 £ 163, 683. 97 £ 52, 221. 69 £ 65, 259. 44 £ 46, 035. 20 £ 64, 115. 90 £ 68, 295. 55 £ 27, 456. 58 £ 23, 216. 03 £ 20, 295. 50 £ 9, 722. 97 -£ 4, 554. 76 £ 8, 868. 84 £ 35, 564. 30 £ 3, 314. 48 -£ 12, 080. 61 -£ 24, 495. 16 -£ 30, 797. 73 -£ 29, 918. 18 -£ 25, 654. 95 -£ 54, 889. 24 -£ 31, 872. 34 -£ 41, 431. 50 -£ 35, 534. 08 -£ 52, 212. 83 -£ 49, 654. 66 -£ 60, 231. 13 -£ 49, 433. 64 -£ 44, 863. 11 -£ 57, 978. 48 -£ 55, 256. 80 -£ 62, 822. 30 -£ 85, 143. 26 -£ 79, 837. 21 -£ 93, 202. 23 -£ 109, 333. 08 -£ 99, 098. 07 -£ 117, 066. 22 -£ 111, 082. 47 -£ 128, 378. 64 -£ 177, 310. 38 -£ 248, 950. 34 -£ 311, 309. 20 Prescribing support pharmacist work Up to July 2017 In-year savings realised 24, 752. 00 14, 562. 99 1, 822. 50 2, 021. 05 28, 566. 24 11, 744. 25 13, 002. 39 251. 18 1, 945. 50 480. 00 1, 829. 10 8, 511. 60 15, 421. 18 1, 817. 70 12, 500. 54 698. 63 0. 00 13, 380. 96 6, 422. 10 2, 608. 68 912. 75 10, 251. 71 0. 00 10, 224. 00 336. 75 1, 075. 50 0. 00 10, 518. 33 9, 202. 20 382. 50 1, 649. 78 2, 522. 50 1, 718. 67 0. 00 18, 588. 58 12, 354. 03 13, 298. 00 1, 011. 31 1, 439. 25 3, 652. 50 0. 00 6, 426. 07 5, 480. 00 Additional in-year savings identified - (excl realised savings) 32, 787. 34 6, 581. 58 999. 00 2, 021. 05 26, 990. 63 2, 287. 50 14, 279. 09 1, 085. 55 660. 00 1, 647. 00 1, 871. 34 6, 915. 53 11, 947. 64 1, 817. 70 10, 531. 04 4, 177. 73 3, 203. 85 10, 046. 31 12, 456. 59 6, 625. 00 1, 444. 80 8, 926. 09 1, 097. 63 14, 583. 50 5, 505. 00 182. 00 0. 00 10, 376. 93 7, 586. 08 612. 00 1, 077. 12 2, 808. 50 2, 261. 50 0. 00 15, 178. 71 13, 650. 02 18, 818. 50 260. 25 1, 439. 25 457. 50 2, 392. 30 1, 508. 27 984. 60

D. Trend in Primary Care Prescribing Spend Primary Care Prescribing Chart comparing e. PACT monthly spend from 2013/14 to 2017/18 2 800 000, 00 2013/1 4 2014/1 5 2015/1 6 2 400 000, 00 2 200 000, 00 2 000, 00 ch ar M br ua ry y Fe nu ar Ja be m ce De ve m be r r r be to Oc No Se pt em be r st gu Au Ju ly ne Ju M ay 1 800 000, 00 Ap ril Spend (£) 2 600 000, 00

D. City & Hackney CCG QIPP Dashboard 2017/18 : Mar-17 to May-17

D. Quality Premium AMR Targets- Trends to June 2017

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ADVERT Metabolic education session Tuesday 10 October, 1. 30 pm – 3. 30 pm (lunch from 1 pm) West Reservoir Centre, Green Lanes, Hackney, London N 4 2 HA Vitamin D – Dr Peter Timms Osteoporosis – Dr Clare Thornton Vitamin B 12 Deficiency – Dr Manisha Sharma An email advert will be send out in September with an Eventbrite link to book this session.

CCG Specific Commissioning Intentions 2018/19

Context - Previously CCG agreed 2 year contracts with providers to cover 17/18 and 18/19. - NHSE guidance is asking for a revalidation of planning assumptions and contract variations (where required) to be signalled by end of September. - Our original ambitions were to consult on commissioning intentions as part of the Integrated Commissioning process by end of the year, but we have had to fast-track some of our known plans at a CCG level for this month. - The CCG has the challenge as a planning assumption of delivering QIPP savings in 2018/19 of 2% of overall funding i. e. £ 7. 8 m (2018/19 Operating plan balance requires minimum of £ 5 m ). - The high level plans that follow will contribute to the delivery of QIPP, but further work will be needed to fully deliver the required level of savings. - We will be articulating these outline plans in a lot more details as part of the workstreams over October and November. 4 3

Planned Care Workstream (1) – CCG Intentions Outpatient Transformation: Working with the Homerton to transform our model of outpatient care locally by: • Preventing unwarranted first attendance/referral- advice and guidance, MDT/GP discussion and feedback, triage to community/primary care/other pathways, GP Education/Training, Patient Self. Management • Reducing unnecessary face-to-face follow ups- patient centred tools, enable self-management, virtual/telephone/primary care follow up • Optimising what should be done in secondary care and by whom- links across specialties to avoid/reduce internal consultant to consultant referrals; e-consultation in patient home/GP premises; group consultations where similar patients are consulted in a group; extended scope practitioners/advanced nurse practitioners/specialist nurse for targeted follow up allowing consultants to focus on complex/surgical work Enablers: 4 4 • e-RS/Follow up arrangements to standardize across specialties (less clinician variation) • Advice and Guidance – First line for GPs and where consultants can shape the next steps to the most appropriate diagnostic/service pathways • Technology – Appointment system updates, Skype FU/Virtual MDT review/Virtual review for FU • MDT review for complex multi issue patients • Triage systems to review referrals for community/other services instead of secondary care

Planned Care Workstream (2) – CCG Intentions Improving Cancer Care: • Increasing Cancers detected earlier by supporting primary care with education and access to diagnostics tests, decision support tools and audits • Improving screening uptake by working with Prevention Workstream on every contact counts regarding reducing risk factors and behaviours in local population • Supporting patient recovery moving towards a focus on cancer as a LTC and opportunity for increasing time to talk support from GP Confederation • Bereavement Services- plan for continued support of Bereavement services at St. Joseph’s Hospice Anti-Coagulation: • Implementation of the anti-coagulation service with the GP Confederation Continuing Healthcare and Residential Care: • Improve delivery of continuing healthcare locally by implementing recommendations from recent review • Review opportunities within mental health pathways for increased recovery and step-down for patients in existing placements, particularly those outside of borough • Review arrangements for people with learning disabilities in receipt of health and social care packages • Consider opportunities for further integration of CHC within LA arrangements for brokerage and for jointly planning against known gaps in local provision (e. g. nursing care, intermediate care) Obesity Pathway: • 4 5 Working with Prevention Workstream on new obesity pathway including surgical options

Planned Care Workstream (3)– CCG Intentions Medicines Management Initial suggestions for prescribing workplan (including from medicines management team, Prescribing Programme Board and other CCG boards): Reviews of: • Drugs of potential abuse • Women of child bearing age prescribed valproate • Quantities ordered – of repeat prescriptions • Blister pack provision & documentation • Respiratory prescribing- (Respiratory is 1 of CCG’s priority areas for Right. Care) • Emollient prescribing Meetings: • GP Practice-Community pharmacy interface meetings Training: • Polypharmacy QIPP Indicators: 2 respiratory indicators, volume of pregabalin prescribing, antibiotics (in line with NHSE targets), MOLV-LIST products, OTC products Medicines of limited Value list (MOLV-LIST) definition: List of prescribed products considered as having limited evidence, poor safety profile or poor value for money for the NHS. Includes products which could be provided as self-care with support from community pharmacists 4 6

Planned Care Workstream (4) – CCG Intentions Mental Health • Commitment to improve the continuing care pathway with care delivered closer to home in more appropriate settings. Rehab Team to support the review of MH patients within the continuing care service • Revised specification to provide dementia continuing care within safer more clinically appropriate environments • Waiting time and access targets for psychological therapies as part of a new specification • Residential Care – revised contract in line with joint MH and LBH supported living strategy • Improved interface with physical health – smoking cessation, substance misuse, diet and wellbeing • New protocols for anti-psychotic prescribing and primary care support, based on the pilot • Standardised discharge summaries • Development of the Recovery College • Expansion of IAPT LTC service. Other • Review Bi Lingual Translation and Advocacy Services to maximise use of technology and provision of integrated services. • Review of contracts for CPAP provision and the resultant contract cost of equipment to ensure efficiency and value for money. 4 7

Unplanned Care Workstream (1)– CCG Intentions 4 8 • Implement NEL Integrated Urgent Care service (111 + Clinical Assessment Service) and the local model for 24/7 access to urgent primary care. • Improve discharge and reduce delayed transfers of care by implementing local Eight High Impact Change Models. • Implement the Neighbourhood Care Model to ensure patients at high-risk of emergency admissions receive integrated health and social care. Health, social care and the third sector will work together to provide services which best meet the needs of their local population within their neighbourhood areas. • Pending local evaluation, implement the Homerton ambulatory care model to achieve a reduction in emergency/non -elective admissions and reduced length of stay. • Utilise PMS Premium to commission an expanded Frail Home Visiting Service which covers patients at risk of emergency admission who would benefit from proactive case management and a multi-disciplinary care planning approach but who do not currently meet the eligibility criteria of the existing FHV service. • From April 2018 consolidate Enhanced PUCC within the recurrent PUCC contract (following PIC/FPC agreement) ensuring value for money and develop a plan for PUCC to become a Urgent Treatment Centre, meeting the national UTC Standards. • Local implementation of the pan-London Redirection and Streaming Guidance, which will maximise the use of primary care and PUCC / UTCs to reduce any unnecessary ED attendances. • Implement Hospice at Home service, pending confirmation of funding, for residents in their last years of life (24/7 crisis response service) – reducing number of emergency admissions and deaths in hospital setting. • Pending evaluation, continue to provide enhanced pharmacy end of life care medicines service • Develop more accessible training model for GPs on identifying patients approaching end of life and having advanced care planning conversations • Review model of bereavement support services and their integration with other mental health services

Unplanned Care Workstream (2) – CCG Intentions Unplanned Care - Mental Health 4 9 • Enhanced Primary Care to increase coverage of older adults to reduce activity in secondary care • Revised specification for the crisis pathway to include the provision of 24/7 home visiting, street triage and no-wait psychological therapies for people in crisis, use personalised crisis plans

Prevention Workstream (1) – CCG Intentions LTC contract: • COPD / Asthma prevalence. Screening smokers at NHS health checks • Introduction of smoking quit rate • Introduction of severe mental illness as an LTC for smoking cessation referral • Time to Talk – Potential budget reduction in line with actual activity • Social prescribing – tied more closely to care planning. Including group consultations and patient activation • Hypertension prevalence. Review / Revise indicator • Increasing AF detection and treatment. Mobile ECGs • HIV testing / screening Social Prescribing: • Proposal to Transformation Board for contract award to Family Action GP Confed – development of domestic violence identification and support to be discussed • Embedding of routine inquiry –possibly through enhanced IRIS training / other but specific resource required 5 0

Prevention Workstream (2) – CCG Intentions Rightcare: (Prevention) Respiratory Recommendations • Improve diagnosis and prevalence of Asthma and COPD • Improve access to smoking cessation support to reduce prevalence of smoking • Improve the effectiveness of respiratory prescribing – define measurement metric • Increase access to psychological therapies for people with asthma and COPD – improving quality of life and ability to self manage. • Continue to reduce admissions for COPD – benchmark against national and similar cohort. • Base smoking cessation adviser within ACERS; Spirometry (practitioners to be accredited and registered and Increased Pulmonary Rehab Capacity - Subject to business case funding approval. Mental Health • Strategy for reaching national employment targets (CPA and IPS) jointly agreed with CCG and LBH • Implementation of the employment pilot

Children & YP Workstream (1) – CCG Intentions Specifications and Reporting • Commission Specialist Nurses via an agreed service specification; enabling monitoring of quality and efficiency impact and opportunity for service developments. • Refreshed CHS service specifications following review in September 2017 • Introduce a new reporting schedule for CHS building on the draft community paediatrics schedule • Health Visitor input to the GP Confederation Early Years contract to be formalised via Service Specification • Realise the quality benefits and efficiencies from the revision of the Hackney Ark specification • Review of CCNT to focus on reduction of use of Children’s emergency services. Changes to commissioned services • The CCG will give notice on the Community Paediatric leadership and input to the Tier 2 audiology service. This will become an audiology led service based at Hackney Ark and John Scott Centre (The importance of continued access to audiology training for paediatric trainees is noted by commissioners) Service Developments (May require NR funding in 2018/19 – subject to approval) • A Tier 3 children’s obesity service to be commissioned as a pilot in 18/19; based on the recommendations of the joint service review undertaken in September 2017 • Joint work with the Orthodox Jewish community in recognition of inequity of access to components of the SLT service Development of Local Tariffs / Activity reductions. • Review of 0 LOS activity on Starlight Ward to determine development of a local paediatric monitoring tariff • Reduce unplanned admissions as a result of introduction of specialist children’s asthma nurse in A&E

Children & YP Workstream (2) – CCG Intentions Looked After Children • Integrated Commissioning for looked after children nursing service to be agreed Long Term Conditions – GP Confed • Sickle cell –transition arrangements to be progressed as per plan for 17/18 • Information sharing protocol to be consistent across LTCs • New dashboard and reporting to be agreed for the children’s components, including Time to Talk, to improve evaluation of clinical impact and value for money Childhood Immunisations – GP Confed • Reduced NR bid (compared to £ 220 k in 17/18) for additional Nurse sessions to be utilised across practices to support achievement of herd immunity Whittington • Children’s special school therapy costs to be reviewed as part of the block CHS contract Bart’s • Commission Tier 2 audiology -led service (without HUHT Community Paediatrics) CSU • Agree new commissioning arrangements for children’s complex care and management of Personal Health Budgets

Children & YP Workstream (3) – CCG Intentions Maternity • HUHT maternity specification will be refreshed – KPIs (including improve real time patient feedback response rate) and new guidance • Continuity of midwifery care to be monitored from Q 4 17/18 • Recommission tongue tie - subject to PIC funding approval • CHS contract Breastfeeding funding to be continued (subject to PIC funding approval) to align with public health’s breastfeeding evaluation recommendations. • Maintain focus on reducing Infant Mortality, including avoidable admissions to NICU • Maintain focus on reducing maternal deaths. • Maintain Programme Board focus on the maternity strategy, recommendations arising from the staffing reviews for midwifery and doctors and the named professional on labour ward audit • Development of targeted work on maternal obesity • Vulnerable women’s pathway - Perinatal mental health : contribute to development of work on good emotional health in children under 5 years • Adopt bereavement model for bereaved parents

Children & YP Workstream (4) – CCG Intentions Perinatal Mental Health • Draft STP bid has been shared – increasing staffing of community specialist perinatal mental health services • National bid not released yet, but STP well placed for submission Non Recurrent schemes to be re-commissioned – subject to PIC approval: • Bump Buddies (Shoreditch Trust) –crisis support and peer mentoring for vulnerable pregnant women • Bonding with baby service (Hackney Playbus ) – postnatal support for vulnerable parents CAMHS and First Steps • Development of CAMHS crisis services in line with the FYFV • First steps productivity QIPP and commitment to CAMHS transformation plan Early Years – GP Confed • Early Years – recurrent funding commissions the 16 w and 6 w checks; NR funding covers all other interventions including HV support for children on UPP. Contract value to be maintained subject to PIC NR approval. • Pregnancy pack to be introduced from April 2018 • GP Confederation audits September 2017 to inform any other contract changes. • Compliance with children’s safeguarding training – whole practice level reporting to be included in CEG dashboard

CCG PPI Priorities 1 We are committed to ensuring that the voices of local patients and residents continue to inform our decisions throughout the commissioning cycle. Our high level strategic priorities for 2018/19 are focused on: 1) ensuring that the CCG meets its legislative duties around patient and public involvement 2) reviewing and establishing patient and public involvement structures in the context of Primary Care Co-Commissioning 3) reviewing and establishing joint patient and public involvement structures in the context of Integrated Commissioning.

CCG PPI Priorities 2 • Maintaining our ‘business as usual’ PPI functions to ensure that the CCG’s Governing Body can be assured that the legislative duties around patient and public involvement are met • Establishing City and Hackney CCG Involvement Alliance as the main forum for local patient and service user involvement extending into primary care by working closely with GP practice based patient participation groups. We want to use the alliance model to increase participation at all levels and to promote and raise awareness of services aimed at supporting local residents with staying healthy and well and manage their conditions better. • Where applicable, establishing a process for aligning public engagement priorities as well as sharing and joining up PPI functions with our Integrated Commissioning partners. • Continuing to work with our local authority partners in City of London and in London Borough of Hackney to deliver a joint community grants scheme (previously Innovation Fund and Healthier Hackney Fund) aligned to local clinical priorities, aimed at identifying new and innovative ways of meeting local health needs as well as maintaining and strengthening our relationship with community and voluntary sector partners.

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