CCG GOVERNING BOARD MEETING TO BE HELD ON WEDNESDAY JANUARY 9 TH 2013 AT 12.30PM, BOARDROOM NEW CENTURY HOUSE, DENTON A G E N D A

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1 CCG GOVERNING BOARD MEETING TO BE HELD ON WEDNESDAY JANUARY 9 TH 2013 AT 12.30PM, BOARDROOM NEW CENTURY HOUSE, DENTON A G E N D A 1. Apologies for Absence 2. Declarations of Interest 3. Chairs News Items 4. Minutes of the Meeting Held on December 19 th 2012 Matters Arising Authorisation Update Steve Allinson - Ratification of Chair - verbal Graham Curtis - 2 Way Accountability Agreement Alan Dow/Clare Watson to follow 5. Planning Guidance 13/14 verbal update Clare Watson 6. Finance and QIPP Update Kathy Roe 7. Performance - verbal update Louise Roberts Governing Body Committee Reports 8. Quality Committee Minutes Graham Curtis 9. Medicines Management Committee Meeting 10. Integrated Governance and Audit Graham Curtis Committee verbal update 1

2 11. GM Clinical Strategy Board Summary Report (Raj Patel for Information) 12. Any Other Business Date and Time of Next Meeting February 6 th 2013 at 12.30pm 2

3 CCG GOVERNING BOARD MINUTES OF THE MEETING HELD ON DECEMBER 19 TH 2012 Present: Raj Patel Alan Dow Steve Allinson Kathy Roe Richard Bircher Celia Poole Graham Curtis Tina Greenhough Angela Hardman Amir Hannan Yvonne Pritchard Clare Symons Guy Wilkinson In attendance: Paul Connellan Chair Tameside Foundation Trust Clare Watson, Louise Roberts, Julie Bell Farwell to Dr. Raj Patel The Governing Board expressed their formal thanks for the strong clinical leadership that Dr. Raj Patel has provided to the Primary Care Group; Primary Care Trust; Professional Executive Committee and latterly the shadow Clinical Commissioning Group over the past 15 years. Dr. Patel said that he was not leaving the local community and was still a practicing GP. Dr. Patel was wished every success for his new appointment as Medical Director for GM Local Area Team. Incoming Chair to the CCG The Governing Board congratulated Dr. Alan Dow on this new appointment. It was noted that there would be a range of responsibilities which Dr. Dow would need to consider, following Dr. Patel s departure. 1 3

4 Dr. Dow would be releasing portfolios for Board members in the New Year however, it was noted that certain Governing Board members would continue with their original roles and responsibilities in the interim. Interim Director of Public Health Angela Hardman was welcomed to her first CCG Board meeting as interim Director of Public Health. 1. Apologies for Absence Dr. Ram Jha 2. Declarations of Interest None to declare 3. Chair s News Items Dr. Foster Hospital Guide Raj Patel briefed the Governing Board on the Dr. Foster Hospital Guide The Governing Board was assured that the Report was being presented to the next Quality Committee meeting for further scrutiny. GM Local Area Team It was noted that at a recent workshop, the LAT set out how CCGs and the LAT would work differently. The vision was for a joint collaborative commissioning approach. A further session was being held to address planning and allocations. Fellowship of the Royal College of General Practitioners The Governing Board congratulated five local GPs who had been recognised recently for going the extra mile in their clinical work and their professional roles, by being awarded the Fellowship of the Royal College of General Practitioners; they were Dr Joanne Rowell; Dr Richard Bircher; Dr Raj Patel Dr Joanna Bircher; and Dr Stuart Murray. 2 4

5 Provost of the North West England Faculty of the Royal College of General Practitioners Vikram Tanna was recently elected as the Provost of the North West England Faculty of the Royal College of General Practitioners. The Governing Board noted that this was an honour and a privilege, noting there were over 2,000 GPs in the North West who are members of the RCGP. Business Finance Awards 2013 for the Finance Team of the Year, Public Sector The Governing Board wished the finance team the best of luck having been shortlisted for the above award. The awards ceremony would be taking place on March 6 th in London. 4. Minutes of the Meeting Held on November 21 st 2012 The minutes were agreed as a correct record of the meeting. 5. Authorisation Update Including Panel Report Response Steve Allinson updated on the panel response, which was felt to be very positive overall, particularly noting that our commitment to public and patient engagement and the close working relationships between clinicians and managers, were seen to be areas of significant strength. The Governing Board noted that the panel reports were working documents at this stage. A response had been submitted both to welcome the report which fed back the views of the assessors as presented verbally and to identify actions against areas for which further information would be required. The feedback also corrected a very minor factual error concerning a reference to the CCG s Integrated Governance Audit and risk Committee where this should have been the Governing Body. The Governing Board received an outline of key next steps against each outstanding action, and requested to oversee progress against each action in order to achieve successful authorisation. 3 5

6 Governance Framework i. Association of Greater Manchester CCG s The Governing Board received a draft constitution for the proposed Association of Greater Manchester CCGs. It was noted that the purpose of the Association was:- - To support CCGs in sharing information and good practice and offering each other support when necessary and possible. - To provide a focus for the development and reporting of joint work across the CCGs and reducing unnecessary duplication of effort. - To provide a properly constituted forum for issues where CCGs consider it beneficial to their own objectives to have a collective decision of the GM CCGs in the spirit of mutuality, or to address issues necessitating formal agreement by the GM CCGs. - To provide a basis for Collaborative Commissioning between CCGs in Greater Manchester consistent with the intentions of the Health and Social Care Act Dr. Raj Patel stated that it was important to note that the Clinical Strategy Board, that currently exists, will transfer over to the ownership of the 12 CCG s, however, each CCG will retain its sovereignty for local decision making. The Governing Body discussed this issue at length and the following comments were made:- In terms of the membership, the Governing Board discussed this issue at length, particularly in terms of the Local Area Team s involvement. There was a collective view from the Governing Board about wanting the Association to be an Association of 12 CCG s and whether there had been proposals for the LAT to be a co-opted member of the Association. In terms of voting, the Governing Board noted a potential for some CCG s to be disadvantaged (ie. CCG s who have a population below the national average). The Governing Board also asked for further clarity on devolved accountabilities and how the CCG would have early warning of issues being raised so as to be more actively involved in the decision making. 4 6

7 The Governing Board asked to see the statements of the nominees for the Chair of the Association. There would also be expressions of interest coming out for the 2 Vice Chairs (1 clinical 1, managerial). Amir Hannan specifically stated that patient involvement ought to be strengthened within the arrangements. In summary the CCG Governing Board approved the mandate for CCG engagement in the emerging Association of Greater Manchester CCGs, with a caveat that the Chair and COO relay the comments made by the Governing Board above. Action: Steve Allinson to circulate the statements of the 2 potential chairs of the Association Steve Allinson and Raj Patel to relay the comments above ii Healthier Together The Governing Board received slides showing the proposed governance through which CCGs would work together to deliver the emerging programme of strategic reform Healthier Together. The Governing Board discussed the proposed (CCG) HT Governance arrangements in detail and the following comments were noted:- Communications and engagement were discussed and it was noted that there was a vision for a co-ordinated approach to this across the economy. In terms of public engagement, the Governing Board was assured that patient engagement would be embedded at every step of the process. Clare Watson reinforced this stating that there was a GM approach, and also our local approach with assurances through Planning, Implementation and Quality and the Public and Patient Impact Committee. The Governing Body considered the proposed governance arrangements for collegiate working and decision making and mandated the Chair and COO to agree the proposed arrangements with modification where needed. 5 7

8 Draft Terms of Reference Governing Board Committees The Governing Board received the draft Terms of References for the following Committees:- Finance and QIPP Assurance Committee Integrated Governance, Audit and Risk Committee Planning, Implementation and Quality Quality Committee Public and Patient Impact Committee Remuneration and Terms of Service Committee The Governing Board agreed to adopt the above ToR s, for immediate governance purposes, however, the Board advised that each Committee review the Terms of Reference again, and where any changes were required to be made, those particular Terms of Reference only would be re-presented to the Governing Board for final ratification. Action: Mark Simon to ensure that each Sub Committee Review the ToR. Where any changes are made, those particular ToR only, would be re-presented to the Governing Board for final ratification 6. Policies for Ratification:- Complaints The Governing Board noted that the NHS Tameside and Glossop Complaints Policy had been approved in November It was further noted that the Policy had recently been reviewed by the Complaints Manager and updates had been incorporated to reflect the revised NHS organizational arrangements, and also to take account of guidance updates and ongoing development of local procedures. The review did not identify that any significant changes to procedures were necessary, given that the policy continues to reflect the relevant Regulations (The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009). 6 8

9 Ceila Poole offered a suggestion on the flow chart. She stated that there was a need to alert the Communications and Marketing department, of any potential PR risks. She therefore suggested aligning this to the response to complainant box on the Action Flowchart. The Governing Board also asked about how soft intelligence is picked up. It was noted that the CCG was creating a customer facing service to capture and deal with these types of issues. The Governing Board approved the draft CCG Complaints Policy with the above comments captured, and with a caveat that it is made available to the public; is disseminated internally with appropriate training for staff as required and is uploaded on the Knowledge Management System Action: Mark Simon to ensure the Policy is widely disseminated Safeguarding It was noted that for Authorisation, the CCG is required to have a safeguarding policy, a safeguarding training strategy and a declaration of safeguarding compliance on the web site. The Governing Board reviewed the Safeguarding guidance. Dr. Richard Bircher made a comment about an inaccuracy on page 103 (consistent to be replaced with inconsistent). Julie Bell would feed this information back to the Safeguarding Team. Clare Symons would also meet with the Safeguarding Team to clarify the outstanding issues which were presented to the Governing Board in Red. With the above amendments, the Governing Board was assured that the draft policies fulfilled the statutory requirements. Action: Clare Symons/Julie Bell 7. Healthier Together Clare Watson briefed the Governing Board on how we will engage, influence and lead the agenda locally, with the Greater Manchester Healthier Together Programme. It was noted that the final two cases for change documents Urgent, Emergency and Acute Medicine and Primary Care had been published by the Central team, which make up a the set of 8 work programmes, 7 9

10 with a further one, mental health, being developed following initial feedback from stakeholders. Clare Watson explained the programmes. The Governing Board noted the importance for the CCG to fully engage in the Healthier Together agenda in order to influence the next stages of the programme s development. In early 2013 there will be a formal consultation process on the proposed service models, this would be a far reaching process, to engage with all stakeholders in Greater Manchester. The Governing Board noted that the governance surrounding the Healthier Together programme, and how it links with the future Greater Manchester Association of CCGs, was described in a different Governing Body Paper. The Governing Board discussed Healthier Together at length and the following comments were noted: It was felt that the report was very much based on a national model. The challenge would be for the CCG and its hospital colleagues to feed into the process to develop a local vision. There was a local issue relating to the frail and elderly. With regard to the vision of best care for patients, it was agreed that self care was a fundamental vision that was missing in the document. The Governing Board recognised that a great deal of work had taken place on the urgent care agenda that could be fed back into the wider arena. It was noted that our structures did not map well with the primary care programmes and this would be addressed though the Governance Committee. Integration of IT systems would be a challenge. The Governing Board received three programmes which underpinned our local priorities. It was agreed that Clare Watson would send out to Board members the details behind the other five programmes. 8 10

11 It was further agreed that Richard Bircher and Guy Wilkinson would jointly respond to the Greater Manchester Healthier Together programme (also gathering views from constituent practices and stakeholders), on behalf of the Governing Body, based on the comments made above. In relation to the Primary Care Workstreams Dr. Alan Dow agreed to provide a written response on behalf of the Governing Body. In summary the Governing Board:- - Recognised that each of the proposed cases for change has considerable implications for the health and social care services in Tameside and Glossop, and that the Governing Body would need to embrace the opportunity to engage with the agenda and influence how the vision for each programme will be delivered locally. - Would continue to drive the integration programme with our partners across Tameside and Glossop, and lead the work as our local vision for Healthier Together. - Recognised that each of the nine work programmes is equally important in their own right and collectively. - Supported the Greater Manchester vision for all areas of healthcare. In conclusion the Governing Board received the update, noting that Healthier Together was work in progress. Action: Clare Watson to circulate the details behind the 5 other programmes of work to the Governing Body Richard Bircher and Guy Wilkinson to respond to the Greater Manchester Healthier Together, gathering views from constituent practices and stakeholders, in addition to the comments from the Governing Board. Alan Dow to provide a written response in relation to the Primary Care workstreams 9 11

12 8. System Transformation Update Clare Watson stated that It was agreed at the August Board meeting that the health and social care economy cannot stand still and needs to work differently in order to improve outcomes and pathways, and deliver industrial scale efficiencies. A number of meetings had taken place with partner organisations over the past 4 weeks to work through the governance, some very early financial modelling and plans for the integration programme. It was noted that the national Operating Framework and the financial allocation are due out imminently. Once the CCG knows its financial position and any national priorities, which are additional to the plans in our 5 year commissioning strategy, the CCG will start the detailed financial work to underpin the service redesign. It was noted that, by working through the options to Checkpoint 2 we will be in a much clearer position on integration; what it can deliver for the patient, whether and/or what efficiencies it can deliver, and how partner organisations are going to work together to implement change and ultimately transform the system The Governing Board received the Ernst and Young Discussion Document. The Governing Board asked when it would receive financial information and what would be the contributions from other stakeholders. It was noted that the Case for Economic Change Heads of Agreements were currently being written and would be presented at the January or February Board meeting, to offer further clarity. Kathy Roe stated that the implications, acknowledged at November Board meeting by the Governing Board (following the Local Authority s presentation on Working Together: Opportunities going forward ) were being discussed at the Local Authority s Board meeting. The outcome would be shared with the Governing Board. The Governing Board stressed that locality plans for integration must demonstrate improved outcomes, engagement and patient impact. In terms of Glossop, the Governing Board was assured that through engagement at the Health and Wellbeing Board in Derbyshire, CCG representatives would actively encourage that the integration work in Derbyshire, dovetails with Tameside s work

13 The Governing Board supported the next steps to develop the full business case, and ensured full CCG Board engagement in addition to Locality GP s (via invitation to the Planning, Implementation and Quality Groups). Action: Clare Watson/Kathy Roe to present financial information to January/ February s Board meeting 9. Public Health Annual Report Clare Watson to invite Locality GP s to the PIQ meetings Angela Hardman stated that the Report had been to the Locality Transition Group and will be presented to the Health & Wellbeing Boards in Tameside and Derbyshire. The aim of the Report was to:- Celebrate Success across the whole system by focusing on the improvements in outcomes and access to health improving services over the last year. This uses nudge theory by highlighting positive health behaviours. It also showcased the collaborative work that is in place. The Top Tips section provided advice on how to protect and improve health with links to supportive services and further information to enable people to make positive choices. The Cost Effectiveness section demonstrated the potential for cost savings to both the health system and the wider economy from public health interventions. Shaping the Future outlined the public health approaches to protecting and improving health within the context of the wider impacts of a shrinking public sector. The section defined some of the plans and interventions which will have a positive impact on health including the wider determinants, health and social care systems and direct support for lifestyle programmes. The Governing Board welcomed the Annual Report, and particularly thanked Elaine Michel for her hard work and dedication in pulling the compelling, yet easy reading Annual Report together. The Governing Board further applauded Elaine Michel s 10 tips for better health

14 In summary the CCG Governing Board received the Annual Report and was assured that it was intrinsic to the CCG s Commissioning Strategy. Governing Board members would circulate as widely as possible through their networks to patient groups and colleagues in their localities. Angela Hardman would also clarify which stakeholders/committees the Public Health Annual Report had already been circulated to, to avoid duplication. It was further noted that 3 local GPs were already taking the lead in promoting early intervention and prevention across the patch. Angela Hardman was pleased to note this stating that the way for success was to have local champions to work, mobilise and be good advocates for public health across the patch. Action: Angela Hardman to clarify the distribution of the Public Health Annual Report 10. Contract Transition Shift Plan The paper summarised the latest DH guidance in relation to PCT closedown requirements and progress specifically relating to the transfer of contracts from the PCT to future receiving organisations (CCG s, Local Authorities, Local Area Teams). The briefing included a chart of who is accountable for all work streams and timelines regarding the transfer scheme. The Governing Body noted that an enormous amount of work had been undertaken by staff in dissecting the Contracts and that a more comprehensive suite of reports will be presented to the January meeting covering all areas of work on closedown; noted progress against the transfer requirements and noted assurance that the CCG is compliant with these timelines. 11. GM AHSN AQUA Paper Steve Allinson informed the Board that there was a proposal to develop Academic Health Science Networks. The aim is to strengthen links between technological and service innovation, and to promote more rapid spread and adoption of proven best practice. This is to 12 14

15 demonstrate that we are fulfilling our duty to innovate and to promote research. The paper made proposals to be considered by the GMAHSN s NHS membership. It addressed how improvement capacity can best be secured for the various AHSN workstreams, how AQuA s existing work with its members can be built upon, and critically how a workable model for membership subscriptions can be developed. After a lengthy discussion the Governing Body supported CCG membership of both AQuA and the AHSN. 12. GM Clinical Strategy Board Summary Report The Governing Board received the GM Clinical Strategy Board Summary Report from the meeting held on December 4 th. The Governing Board particularly focussed on 2.4 Major Trauma, noting the Clinical Strategy Board s confirmation of it support for the use of the GM Safe and Sustainable facility to fund the top up. Further discussion would take place with the CCG CEO s in terms of how the costs will be picked up in the following years. The Governing Board received the Summary Report. 13. Finance and QIPP Update Kathy Roe tabled a new style of financial reporting, stating that this could be refined for the next Board meeting, following comments from the Governing Board. The Governing Board felt the report was an easy read, focussing on a number of key areas more elaborately and would start to expand the Board s knowledge of understanding the CCG s business far more intensely. The Governing Board focussed on the following key issues:- GP Referrals This was a major concern for the CCG. It was agreed that this issue would be raised at the Locality meetings. Clare Watson also stated that a deep dive had been commissioned to interrogate the data. NWAS 13 15

16 This was a cause for concern and was impacting on the 4 hr A & E waits. The Governing Board would await next month s performance report for improvement. Outpatients It was noted that this performance area was increasing and would need careful scrutiny. Elective Activity This performance area was decreasing and further work would be undertaken to interpret what is happening. A general discussion ensued and it was noted that there had been no clinical input at the Finance Committee earlier in the day. This would be addressed in the New Year to ensure clinical perspectives on all performance issues. In terms of Cardiology, Dr. Amir Hannan asked if there was a protocol in place to start to enable patients back into the community. He stated that this issue required activating, as the Locality GP s now knew the status of the patients. In terms of patient experience from our Providers, Dr. Raj Patel urged CCG members to encourage colleagues to share soft intelligence, so as to inform powerful patient stories to include as part of a regular update for the Governing Board. Action: Alan Dow to address the issue of Clinical input into the Finance Committees Clare Watson to ensure GP Referrals are raised at the Locality Meetings/sharing information back on the deep dives Alison Lewin to provide clarity on the protocol for Cardiology patients

17 14. Performance The Governing Board noted that the November 2012 North of England scorecard showed NHS Tameside and Glossop with an overall RAG risk rating of AMBER, and were now placed 21 st out of 51. The Governing Board scrutinised the following key areas, noting the action plans in place, behind the performance under review and performance under scrutiny. High level Overview Performance Improvement C. dif Performance under review NoE Performance Overview Activity against plan and previous year MRSA NWAS CAT A Performance under scrutiny Cancer 62 day waiters NHS GM Audit GP referrals were further discussed. It was noted that this was an item at the last Quality Committee where it appeared that many referrals related to Care UK. The Governing Board was re-assured to note that a clinical lead would be working with practices from January, and the outcome would be shared with the Governing Board. Louise Roberts stated that there was a new update and that in November 2012 an internal auditor from NHS GM CCG, met with NHS Tameside and Glossop CCG to conduct an audit into our CCG s Board reporting structure around all KPI s. The audit aims to ensure that we have adequate and effective internal controls in place to achieve five key objectives. The draft report showed that 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 at the time of our audit

18 The Governing Board discussed the key issues highlighted by the Audit and were asked to review the governance reporting process going forward to ensure CCG Board have full ownership of all measures that they are responsible for. This was also discussed in depth at Quality Committee and Dr Alan Dow made a series of recommendations to address the issues raised. NHS Tameside and Glossop will attend a meeting the first week in January to discuss the draft report and will also provide a verbal update at the next Governing Board meeting. The Governing Board received the performance update. Action: Louise Roberts to provide a verbal update at the January meeting on the Audit Report 15. Finance and QIPP Minutes The Governing Board received the Finance and QIPP Minutes held on 13 th December PIQ Minutes It was noted that there had been agreement at PIQ to commence the Diabetes Re-design. The implications of which would be presented to the Governing Board in due course. Dr. Tina Greenhough stated that local GP s had started to attend the PIQ meetings and this has been both positive and helpful. The Governing Board received the PIQ Minutes held on November 14 th Action: Clare Watson to update at a future Governing Board 17. Medicines Management Committee Minutes The Governing Board received the Medicines Management Committee Minutes held on 29 th November

19 18. GM Heads of Commissioning Minutes The Governing Board received the GM Heads of Commissioning Minutes held on 23 rd October Any Other Business There was no further business to discuss. Date and Time of Next Meeting January 9 th 2012 at New Century House Board Room

20 CCG Governing Body Finance and QIPP Report Paper prepared by: Date of paper: Subject: History of paper: Executive Summary: Outcome Required of CCG: For Discussion or Approval: QIPP principles addressed by proposal: Direct questions to: Paul Nuttall January 2013 Finance and QIPP Report Monthly Reporting to Governing Board The paper provides and update to the CCG Governing Board on the financial position for the first 8 months of 2012/13 To discuss and note to content of the report To receive the report All QIPP Principles Kathy Roe 20

21 CCG Board Date 9 th January 2013 REPORT OF: Chief Finance Officer - Designate DATE OF PAPER: 9 th January 2013 SUBJECT: IN CASE OF QUERY, PLEASE CONTACT Financial Position at 30 th November 2012 Kathy Roe PURPOSE OF PAPER: This paper provides an update to the CCG Board on the financial position for the first 8 months of

22 Contents 1. CCG Financial Overview 2. Financial Performance CCG Delegated Budgets 3. Contract Performance CCG Delegated Budgets 4. QIPP 5. Risk 6. Recommendations 22

23 1 CCG Financial Overview Key Financial Indicators 1 Operate within Delegated Expenditure Budget ( 000s) Plan Actual Variance Result Trend Cumulative to date 216, ,580 (46) Year end Forecast 331, , Budgets are set to ensure the T&G Locality achieves a 1m surplus. The CCG is reporting a year end under spend, detailed above. This position will be continually monitored, especially regarding the worsening position with Tameside FT. Cumulative year-to-date expenditure Month Plan 000 Actual 000 Variance 000 APRIL 27,453 27, MAY 57,028 56, JUNE 84,365 84,365 0 JULY 106, , AUGUST 132, ,750 (759) SEPTEMBER 163, ,668 (691) 2 Top 2 Contracts ( 000s) Plan Actual Variance Result Trend Tameside (YTD) 74,443 78,204 (3,761) CMMC (YTD) 13,633 13,679 (47) OCTOBER 191, ,475 (75) NOVEMBER 216, ,580 (46) DECEMBER 242,183 JANUARY 268,648 FEBRUARY 294,208 3 Continuing Health Care Expenditure ( 000s) MARCH 331,928 Plan Actual Variance Result Trend Cumulative to date 5,334 4, Year end Forecast 8,013 8,433 (420) 4 Prescribing ( 000s) Plan Actual Variance Result Trend Cumulative to date 28,393 26,542 1,851 Year end Forecast 42,476 39,857 2,619 Key Symbol Symbol Target Result Actual better = underspend Actual meets = breakeven Actual fails to = (overspend) Performance Getting better No Change Getting worse (Actual v Target) from last period to current period 23

24 2 Financial Performance CCG Delegated Budgets Annual Budget 000 YTD Budget 000 YTD Spend 000 YTD Variance 000 Forecast 000 Forecast Variance 000 Acute Services Tameside FT Other NHS Contracts (Activity Based Acute Services) Other NHS Acute Services (Incl CBS, Non Activity Based SLAs, Reablement, High Cost Drugs & EURs) 110,636 74,443 78,204 (3,761) 114,029 (3,393) 50,866 34,262 33, ,040 (174) 34,278 23,003 20,987 2,016 32,059 2,219 Total NHS 195, , ,630 (922) 197,127 (1,347) Private Providers (IS & CATS) 4,828 3,043 3,052 (9) 5,200 (372) NCA 2,391 1,594 1, , Total Acute Services 202, , ,732 (388) 204,429 (1,430) Mental Health GM Core Mental Health Providers 21,597 14,398 14,418 (20) 21,612 (15) Non CHC Spec Placements 3,055 2,037 2,222 (186) 3,334 (278) Other NHS Mental Health Services (84) 725 (203) Total Mental Health NHS 25,174 16,801 17,091 (290) 25,671 (497) Mental Health Private Providers Mental Health NCA LD (Supported Accommodation) Total Mental Health 25,548 17,050 17,334 (284) 26,035 (488) GP Prescribing 42,298 28,349 26,855 1,494 39,945 2,354 Other Prescribing (235) 349 (2) 284 Prescribing Rebates (105) (70) (78) 8 (86) (19) Total Prescribing 42,476 28,393 26,542 1,851 39,857 2,619 Community (primarily T&G Community Healthcare) 36,037 23,573 23,642 (69) 35, Greater Manchester Investment & Reform 1, (29) 1,105 (92) Network Costs Other Commissioning 2,176 1,377 1, ,309 (133) Total Other Commissioning 3,530 2,329 1, ,690 (159) Primary Care (NES, LES, ECG & OOHs) 2,403 1,561 1,575 (14) 2, CHC / FNC 10,778 7,244 7, ,481 (703) Corporate 1, , CSU Recharge Reserves 6, ,069 (1,069) 7,509 (519) Other CCG 103,382 63,139 62, ,434 1,948 Total 331, , ,580 (46) 331,

25 2 Financial Performance CCG Delegated Budgets Acute Services Total acute services are over spending at month 8 by 388k and are forecast to over spend by year end of 1,430k. NHS activity based contracts are overspending by 2.9m at month 8, a 3.8m over spend at TFT with a combined 800k under spend across other providers. This presents a real concern as it is placing an even greater pressure on QIPP plans to deliver the expected savings. Many of the larger QIPP programmes such as urgent care are planned to deliver results in quarters 3 and 4 of and this has been acknowledged in previous Board reports. Tameside FT (TFT) - Activity is continuing to grow month on month endorsing the reports that the hospital is continuously operating at 100% bed capacity. We have now received the October activity data and there has been a significant over spend against plan of 1.4m in month. This is spread across all points of delivery, with particular pressures across the non elective pathway and in outpatients. One key area for concern is the unprecedented number of A&E attendances, with an average of 218 attendances per day in October (compared with 207 per day in 2011 and 206 per day in 2010). Elective General Surgery, Emergency Paediatrics, General Medicine and Cardiology outpatients are other major over spending areas. An increase in referrals being made is a key driver of the outpatient pressures, with overall referrals made to Tameside FT are up 5.2% on the prior year (GP referrals made are up by 6.8%). To this end, TFT forecast has increased to 3.4m overspend by year-end, an increase from last month of 900k. Further detail is provided in Annex B. Central Manchester FT (CMMC) The Trust continues to over perform against plan, as seen in previous months, with an in-month overspend of 207k against plan. CMMC is now forecast to over spend by 1,051k by year end. In month 8, there has been the added complexity of specialist services migrating out of core contracts to the North of England Specialist Commissioning Group (NoESCG), which now forms part of the NCBs responsibility. However, as part of the migration, a decision has been taken to transfer out planned values rather than actual values to offer financial stability across the local economy. However, the downside of this means that if contracts were under spent, the CCG will be unable to use the financial benefit of the underspend to offset expenditure in other areas. The main activity drivers continue to be linked to 18-weeks, resulting in overperformance both in Daycase and Outpatients. Specialties affected within Daycases are Paediatric Gastroenterology, Clinical Haematology and Trauma & Orthopaedics. Outpatient procedures continue to overspend due to the treatment of AMD using predominantly Avastin or in some cases Lucentis. Although CMMC has been challenged by commissioners on the prescribing practice of Lucentis rather than Avastin, 25 it

26 transpires that patients are choosing not to switch drugs as they still believe that Lucentis offers the best results. IVF is another area of concern with a 50% increase compared to last year reported in the first six months of the year. This increase in demand will be closely monitored in year. Another contributing factor to Central Manchester s overperformance is a small number of patients receiving chemotherapy within Clinical Haematology, whereby they require treatment every 4 to 5 days over a 2 month period, which is a significant increase in activity. Critical Care and Rehabilitation are also overperforming against plan. University Hospital of South Manchester (UHSM) The Trust has previously been under spending against plan. Last month UHSM was forecast to under spend by 321k. This was predominately due to the significant under spends within Burns activity. However, similar to CMMC above, Burns activity has now migrated over to NoESCG at planned values rather than actual and this has resulted in an over spend of 175k by year end. This is a movement of 496k. Pennine Acute Activity at Pennine Acute is significantly less than expected based on outturn from 2011/12. The contract at month 7 is showing an underspend of 718k. The main drivers cannot be assigned to any specific area as all major points of delivery are underperforming against plan, including Daycase, Elective, Emergency Admissions and Outpatients. This unusual under performance at Pennine Acute has been discussed with the Trust and they have confirmed they have no reason to believe that this trend will not continue. Cardiac Cardiac contracts cover the main GM providers, which consist of University Hospital of South Manchester, Central Manchester FT, Wrightington, Wigan & Leigh, Pennine Acute and Stockport FT. Based on the month 7 activity data, University Hospital of South Manchester, Wrightington and Central Manchester FT are under spending YTD, resulting in a combined under spend at year-end of 127k. In month 8, as with CMMC above, parts of the cardiac contract have now migrated over to NoESCG. However, unlike with CMMC core contract migrations, cardiac activity within the UHSM has previously been significantly over spending. These over spends are now being absorbed within the NoESCGs block contract arrangement for specialist services, which has resulted in a favourable movement to CCG budgets of 320k. ICATs are currently being utilised in excess of the guaranteed 85% which is resulting in additional costs being incurred due to changes in the terms of the contract which have been negotiated across GM. Tameside & Glossop s current ICATs 26

27 utilisation has risen to 133%, this is an increase of 5% from last month. The contract stipulates that the CCG will be responsible for either the guaranteed fixed value or the actual utilisation whichever is the greater. This increased utilisation is also leading to other pressures in that many of the outpatients are being seen in ICATs and then being referred to NHS providers incurring further outpatient costs and exacerbating capacity problems. Mental Health The GM Core Mental Health providers are reporting a near breakeven year to date and forecast outturn. The 15k forecast pressure is in respect of a GM risk share agreement for the Chapman Barker Unit at Greater Manchester West FT in respect of drug and alcohol services. An overspend on non CHC specialist placements for Mental Health rehabilitation is driving the overspend on NHS Mental Health overall which is forecast to be 488k. Other CCG Prescribing is forecast to under spend by 2.6m by year end. The key drivers in this are the price reduction of drugs now off patent being realised faster than anticipated. This is particularly the case for Atorvastatin. In addition the continued work with practices to realise savings by switching patients from branded to would be generics in anticipation of patent expiry is having an impact to optimise the savings. This position is based on six months prescribing data therefore is subject to change and will be monitored throughout the financial year. Particular attention will be given to the 24 fold price increase of Epanutin recently advised by Flynn Pharma, as reported last month this will be incorporated into the forecast accordingly. Continuing Healthcare (CHC) is forecast to over spend by 420k at the year end. This is due to the potential increase in costs relating to restitution claims. There have been a total of 238 enquiries made and the majority of these are still being investigated. 1m has been forecast as the potential cost of these additional restitution claims. CHC will be closely monitored throughout the rest of the financial year. Reserves are currently being shown as over committed as this includes the non recurrent investment for business cases which are awaiting finalisation of details to update the appropriate budget areas. To date 2.7 million of business cases have been approved, however there is recently notified slippage of 1.5 million on these. In light of the continuing increasing material financial pressures with the Tameside FT contract, Finance Committee are asked to advise on how 27

28 they want to manage any further investment in non recurrent business cases and to consider whether to reinvest this slippage into further investments or not. The financial position reported above is based on information available to date regarding future commissioning routes. This may be subject to change through 2012/13 as the national commissioning hierarchy is developed further; any changes will be actioned accordingly. The financial position detailed by practice is shown in Annex A; again two presentation versions are available, one as previously reported and one by service group as in table 2 reported by locality. In line with the previously agreed CCG reporting timetable this will be based on the period for which activity data has been received which is to October An Acute Performance Report is included in Annex B; the detail of this is also based on the period for which activity data has been received. Annex C shows the overall financial position of the total T&G allocation. The overall required surplus is 1,000k; therefore budgets are set to deliver against this plan. Current indication is that T&G Locality is on target to deliver this surplus. The month 8 report includes seven months secondary care activity data and six months prescribing data. These are high risk areas therefore a degree of caution should be taken when projecting this data to a forecast outturn. 28

29 3 Contract Performance CCG Delegated Budgets Based on activity information (7 months data) 29

30 4 QIPP Summary Report as at 30th November 2012 QIPP Work stream Plan Full Year Forecast Planned Savings at Actual Savings at Recurrent Position M8 M8 000s 000s 000s 000s 000s Level 2 Child and Family CVD/Stroke/LTC 1, Mental Health Pathology Planned Care Urgent Care Sub-total 2,375 2,173 1, Level 1 Budget Reviews 30 1, Continuing Care Estates Prescribing Running Costs Workforce and Non- 1, Pay Sub-total 2,125 2,327 1,100 1,676 1,447 Total 4,500 4,500 2,115 2,337 2,108 30

31 4 QIPP Savings as at 30th November 2012 Level 1 savings are currently 1,676k which represents 152% over performance cumulative year to date against plan. Level 1 savings comprise budget reviews, prescribing and workforce costs with regard to vacant posts. In stark contrast, Level 2 savings are currently 661k and therefore only achieving 65% of plan which is causing significant concern and prompting serious scrutiny and critical challenge from GM as noted earlier in this report. The table given at Annex D gives further detail on the performance of Level 2 schemes at month 8 together with supporting commentary. For reference, of the 4.5m QIPP target, 2.3m has been achieved year to date and 2.1m has been saved recurrently. The QIPP reports are currently being reviewed by both finance and commissioning teams and a different format of QIPP reporting will be produced next month which will more accurately meet the requirements of CCG. The reports are being designed to more effectively demonstrate the progress being made on QIPP programmes and how this is being critically challenged and subsequently informing commissioning intentions and plans. 31

32 5 Risk Risk CCG Under / (Overspend) RAG Rating Worst Case Best Case Most Likely (Reported At Month 8) Tameside FT Red High (5,000) (2,000) (3,393) Other NHS Acute Services Amber Medium 1,500 2,750 2,219 Prescribing Amber Medium 1,750 3,250 2,619 CHC / FNC Amber Medium (1,000) 500 (703) QIPP Amber - Medium (350) The above table recognises the amount of financial risk included in the position shown in section 2 of the report. There are 7 months secondary care activity based data available when forecasting the outturn position but there is significant concern regarding the continued growth in activity at Tameside FT for which daily admission data highlight the trend has continued to deteriorate throughout November and December. There are 6 months prescribing data available when forecasting the outturn position. The Continuing Healthcare (CHC) position is particularly volatile due to the uncertainty of the value of the restitution claims. 1m cost has been included in the position for these claims. The month 8 position assumes the QIPP target of 4.5m for 2012/2013 is achieved. There are significant concerns regarding level 2 schemes as detailed in section 4 of this report. However the CCG has reserves to mitigate much of this risk. 32

33 6 Recommendations Members are asked to note the contents of the report focusing particular attention on the financial risks associated with: Continued growth in activity at Tameside FT over and above seasonal plan which is placing increased pressure on QIPP plans to deliver expected savings. Continuing Healthcare (CHC) restitution claims. Potential growth in prescribing, with particular emphasis on the increased cost of Epanutin, as the current prescribing underspend is mitigating pressures in other areas. 33

34 ANNEX A (i) 34

35 ANNEX A (ii) 35

36 Acute Performance Report Month 7 October December 2012 Tameside FT continues to overspend on a YTD basis, with October 2012 the highest cost calendar month on record Significant pressures in urgent care, which we expect to continue into November Outpatient & day case activity significantly over plan. A key driver of this is thought to be increase referral rates. Tameside Core Contract Source Data: M7 SLAM. Total PCT Values In the first 7 months of 2012/ m was spent against the PCT core contract with Tameside FT. This represents an overspend of 3.2m against plan. Pressures are spread across the board with particular issues in outpatients, emergency admissions, critical care, planned admissions, accident & emergency and PbR excluded drugs. Urgent Care As previously highlighted there have been significant cost overruns for emergency admissions during 2012/13. This overspend was further exacerbated during October where we encountered a pressure of 540k for emergency admissions. At 3,579k October was the most expensive month for emergency admissions that the Tameside FT core contract has ever seen: The pressures we have been experiencing on a year to date basis have been further extended in October, where the in month overspend was 1.356m. The absolute in month expenditure of 10.8m is the highest we have ever experienced on the Tameside core contract, with monthly expenditure exceeding the previous record level set during the extreme winter of 2010/11. Note that the charts and tables in this report reference the total PCT contract value, which includes activity which will ultimately be commissioned by the National Commissioning Board (e.g. secondary dental) or Local Authority (e.g. falls clinic). Spend on CCG areas of responsibility was 65.8m. Almost all areas of spend were overspent during October, but emergency admissions stand out with a 540k in month overspend, against a YTD pressure of 745k. Related to this, A&E was over spent by 65k in October. Outpatients and day case admissions also stand out with in month pressures of 355k and 365k respectively. Offsetting this, there was under performance of 153k on elective admissions, but PbR excluded drugs were 107k in excess of plan. Other areas of the contract performed slightly in excess of expectation: In part this figure may be artificially high because of the underspend in this area experienced in September. As explained in last month s report PbR payment and counting mechanisms operate on the basis of discharge date, as such in month spend may appear distorted if a significant number of discharges were delayed from the end of one month into the start of the next. September 2012 contained a 5 th weekend, while the final two days fell over a weekend, where discharge rates are traditionally lower than they are during the working week. The result of this was elevated discharge numbers in early October, which in turn increased the expenditure attributable to the period under PbR rules. The combined effect of September & October taken together is an overspend of 269k. While this net figure is not quite as alarming as the reported variance, at an average of 135k per month the pressures in urgent care are still significant and are driven by a real increase in demand for services. This increase in demand can also be seen in A&E attendances, which cumulatively from April October 2012 were 1,215 higher when compared to the same period last year (an increase of 3.2%). The financial impact of this increased demand is an adverse variance of 305k in the data presented above. 36

37 The PCTs original QIPP plan for 12/13 envisaged a 5% reduction in A&E attendances from November onwards. We no longer believe this is achievable, but 141k was taken out of our contract between November and March as a result of this original expectation. As a result we expect the overspend in A&E will start to accelerate in the months to come which will result in a larger financial variances being reported. We know that October was the most expensive month on record for the emergency care with an average number of emergency discharges of 70 per day across the FT as a whole and an average of 218 A&E attendances per month. Using preliminary trust wide data from the urgent care dashboard we can look ahead at comparable data for November & December: Planned Care As reported previously, much of the overspend ( 745k YTD) for day case admissions is thought to be related to the national bowel screening programme. This has prompted a significant increase in the number of colonoscopies performed and an increase in the numbers of procedures to the colon. The other significantly overspending day case specialty is Trauma & Orthopaedics, where 18 weeks issues are prompting additional throughput. The table below shows that the position has improved since last month, but we should expect elevated T&O activity to persist until the target of 92% is achieved: Incomplete Pathways September Percentage <18 Weeks Incomplete Pathways October Percentage <18 Weeks Specialty General Surgery 1, % 1, % Orthopaedics 1, % 1, % Adult Medicine 1, % 1, % Gynaecology 1, % 1, % ENT % % Ophthalmology % % Cardiology % % Dermatology % % Oral Surgery % % Other 2, % 2, % Total 10, % 10, % In outpatients we have 1,031k total YTD overspend of which 300k relates to October. 18 weeks will be a factor, as are specific issues such as the locum consultant in cardiology. However a key driver of outpatient activity is referrals, both from GPs and other sources (predominantly other consultants at the trust and A&E). Referrals are higher in 2012/13 that they were last year, up 6.9% for GPs and 3.3% for referrals from other sources: Average Daily Values (all commissioners) Emergency Discharges A&E Attendances September October November December (1st - 14th) While A&E attendances were down slightly, they are still high relative to historic averages (204 in Nov 10, 198 in Nov 11). With emergency discharges the number actually rose a little during November. We don t currently have the detailed patient level data to allow us to accurately gauge how many of these patients are T&G registered or if the case mix for November will be as expensive as it was in October. But on the basis that Tameside & Glossop patients account for about 90% of emergency admissions at Tameside FT, it is probably reasonable to assume the significant overspend witnessed in October will persist throughout November. Therefore as demand for outpatient attendances at Tameside FT increases, it should come as no surprise to see the contract overspending. While it is not shown on the top 5 specialties above the biggest increase in GP referrals comes in the colorectal surgery specialty which has seen a 26.3% increase (303 patients) in referrals, presumably this is related to the bowel screening programme mentioned earlier. Conclusion Increased growth in activity month on month is presenting significant financial pressures with the Tameside FT contract. As the urgent care dashboard suggests this trend is continuing with no reprieve throughout November and December, this will be the focus of stringent scrutiny for the remainder of It is important that any investment decisions are prioritised to alleviate the service issues outlined in this report. 37 ANNEX B

38 T&G Allocation I&E (For information only) Year to Date Year End Change in Year End Position Budget Spend Variance Budget Spend Variance Previous Month Movement in Month NCB 62,728 62,981 (253) 94,239 93, (44) CSU 8,709 8,835 (126) 13,864 14,177 (313) (289) (24) LA 3,892 3, ,858 5, (51) CCG 216, ,580 (46) 331, , (89) 119 Total 291, , , , PCT Allocation Surplus / (Deficit) 292, , , , ,000 1, The overall required surplus is 1,000k, therefore budgets are set to deliver against this plans. The month 8 report includes seven months secondary care activity based data and six months of prescribing data, and as these are high risk areas a degree of caution should be taken when projecting this data to a forecast outturn. The continued growth in activity at Tameside FT represents a significant financial risk as this trend is continuing throughout November and December. Continuing Healthcare (CHC) is forecast to over spend by 420k at year end. This is due to the potential increase in costs relating to the restitution claims. 1m has been forecast as the potential cost of these restitution claims. CHC will be closely monitored throughout the rest of the financial year. All reserves have been shown as CCG budgets until further guidance is issued on the split of reserves. The financial position reported above is based on information available to date regarding future commissioning routes. This may be subject to change through 2012/13 as the national commissioning hierarchy is developed further; any changes will be actioned accordingly. 38 ANNEX C

39 QIPP Workstream Project Title Commentary Child and Family CVD/Long Term Conditions CVD/Long Term Conditions CVD/Long Term Conditions Urgent Care - Paediatric NEL Admissions Cardiology Pathway and Redesign Management of AF/Anticoagulation Diabetes Pathway Redesign Month 7 data - no savings realised at TFT. However, when we compare paediatric NEL admission rates per 1000 across GM we are the third lowest. A deep dive data meeting is due to take place week commencing 10th December to discuss current issues, one of these being the number of days the paediatric area of A&E is kept open to support the work of the Specialist Nurse Practitioners. To be reviewed again with month 8 data. Month 7 data - initial review of data shows this area to be over performing, this appears to be due to waiting list activity and an increase in consultant to consultant referrals. However, outpatient information has now been received from the majority of practices. This information will be costed by finance once all practices have submitted their data. Therefore, at present we are still anticipating the same level of savings. If necessary the forecast will be revised next month based on the latest costed information. Review again on receipt of month 8 data. Month 7 data - shows this area to be overperforming, therefore no savings recorded. However, we have seen a reduction in activity when compared to 2011/12, this clearly demonstrates evidence of a richer case mix in 2012/13. Commissioning and BI are reviewing activity data and work is ongoing with General Practice to reduce activity at TFT. To be reviewed again with month 8 data. Month 7 data - shows this area to be over performing, therefore no savings recorded. Data shows that over performance is mainly due to internal FT and not GP referrals. Plans are in plae for GPs to review existing outpatient caseloads at TFT, this work will commence in January. Activity to be reviewed again with month 8 data. CVD/Long Term Conditions Telehealth Month 7 data - Scheme on track to achieve full delivery by the year end. Activity to be reviewed again with month 8 data. YTD Planned Savings YTD Actual Savings YTD Variance % Achievement '000s '000s '000s % % % % % % CVD/Long Term Conditions Stroke GM Pathway No savings now expected, revised forecast to nil Mental Health Repatriation costly out of area placements No savings realised to date. Commissioning Lead and Finance to review month 8 data. Mental Health Mental Health Stock take This workstream is no longer taking place in 2012/13. Scheme Pathology Joint Tender for Pathology across GM to be revisited in 2013/14 Savings were anticipated from Quarter 3. However, at present discussions are being held at GM level to ascertain consistency of reporting and the level of savings to be realised by the year end. Planned Care Maximise use of ISCATs Savings based on month 5 data and are slightly higher than profile as originally savings anticpated from Quarter 3. On going communication with GPs at Locality meetings has proved successful in ensuring increased activity levels at GP Care. However, we are now in a position where utilisation is higher than the agreed contract level. Therefore, discussions are being held with localities to ensure this service is not used instead of direct access. Planned Care First to Follow Up Ratios Based on month 5 data - no savings recorded. After further analysis it is unlikely that the planned savings target will be achieved (original savings were based on reductions by speciality whereas now savings are based on specific procedures). Therefore, the forecast savings have been reduced to a more realistic level. However, a culture of specifying FU ratios is also being established to increase the number of procedures across specialities that can be monitored. Therefore, there is the potential for an increase to activity levels and savings, but at present this cannot be quantified. Planned Care Reduced C2C referrals The protocol is effective from October, therefore savings are now expected from Quarter 3. However, latest data available is month 5 due to technical problems with TFT submitting the data. Therefore, awaiting more up to date information to confirm if savings are being realised. Planned Care Ophthalmology Based on month 5 data - savings recorded. Scheme is on track to achieve full delivery by the year end. Internal activity analysis on going, to be reviewed again with month 8 data % % % % % Planned Care Reduction in Elective Surgical Admissions Month 7 data - savings realised to date have been recorded. However, due to referral to treatment targets (RTT) pressures the full level of savings may not be realised in the planned timescales. Data will be reviewed again at month 8, we should then be able to confirm the revised savings forecast % Planned Care Urgent Care Low Clinical Value Procedures Admission Avoidance and Reducing LOS Urgent Care Ambulatory Care - Admission Avoidance Based on month 5 data - savings recorded. Scheme is on track and YTD savings are currently higher than the original profile. Data is showing that this work stream will produce higher savings than originally anticipated. Threfore, the forecast has been increased. Internal activity analysis is on going. To be reviewed again with month 8 data. Intermediate Care facility opened 1st November. Further savings now anticipated at the end of quarter 4. Position based on Month 7 data. Long term local prices have still not been agreed, discussions are ongoing. The interim price is set at 50% of a full PbR admission and therefore year to date savings have been made. Data to be reviewed again at month 8. Urgent Care Primary Care Pilot in A&E Scheme stopped. Alternative schemes to be discussed with providers. Urgent Care Care Homes Pilot Scheme decomissioned following the evaluation at PIQ. Urgent Care Primary Care Capacity & Demand Project Commissioning leads are considering other options and discussions with providers are ongoing. Two potential initiatives. Planned to commence in January % % % % % 39 ANNEX D

40 CCG Governing Body QUALITY COMMITTEE Paper prepared by: Date of paper: Subject: History of paper: Executive Summary: Heather Harrisson October 11 th 2012 Quality Committee Quality Committee meets regularly, promoting and providing assurances to the Governing Board, on all matters relating to the vision and strategy for continuous quality improvement. The Quality Committee is responsible for the development and implementation of a Quality Strategy, which sets out the framework for Quality Improvement and Quality Assurance of Commissioned Services. Outcome Required of CCG: For Discussion or Approval: QIPP principles addressed by proposal: Direct questions to: To discuss and note the key issues discussed and agreed at the meeting on 11 th October To receive the report Quality Graham Curtis 40

41 Greater Manchester Clinical Strategy Board Tuesday 4 th December Introduction The purpose of this briefing paper is to outline the agenda items considered and key decisions taken by the GM Clinical Strategy Board at its meeting on Tuesday 4 th December Attendance: Terry Atherton (chair) Jerry Martin Stephen Liversedge Chris Duffy Simon Wootton Mike Eeckelaers Bill Tamkin Ian Wilkinson Hamish Stedman Annette Johnson Paul Bishop Andy Sutton Steve Allinson Vikram Tanna Jerry Hawker Kate Ardern Jenny Scott Warren Heppolette Anne Talbot Phil Harris NHS GM NHS Bury CCG NHS Bolton CCG NHS HMR CCG NHS North Manchester CCG NHS Central Manchester CCG NHS South Manchester CCG NHS Oldham CCG NHS Salford CCG NHS Salford CCG NHS Salford CCG Wigan Borough CCG NHS Tameside & Glossop CCG NHS Tameside & Glossop CCG Cheshire CCGs GM DsPH Specialised Commissioning NHS GM NHS GM NHS GM 1.1 Apologies: Raj Patel (Chair) Tim Dalton Martin Whiting Ash Patel Nigel Guest Claire Yarwood Trish Bennett Helen Stapleton In attendance: Leila Williams Julie Rigby Jonathan Martin Alex Heritage Jess Williams Julie Daines Sue Sutton Craig Harris Andrew White NHS GM NHS Wigan Borough CCG NHS North Manchester CCG NHS Stockport CCG NHS Trafford CCG NHS GM NHS GM NHS GM NHS GM NHS GM NHS GM NHS GM NHS GM NHS Oldham CCG NHS GM NHS Manchester GM CSU 1.2 Minutes and action log of the meeting held on 30 th October Page 1 of 8 41