City and Hackney CCG Clinical Commissioning Forum

City and Hackney CCG Clinical Commissioning Forum
Thursday 1st December 2016 St Joseph’s Hospice

Agenda Items Led by Welcome Haren Patel Community ENT Service
Agenda Items Led by 1 Welcome Haren Patel 2 Community ENT Service Kevin Dennett/Gemma Nelson 3 Immunisations for Pregnant Women Tamsin Bicknell 4 Registering Vulnerable Patients Leighe Rodgers 5 Devolution Update Paul Haigh 6 Delegated Commissioning of Primary Care (Delco) and GP Forward View Richard Bull/Mark Rickets 7 GP IT Update Niifio Addy 8 CMC Quality of Care Plans Leah Herridge/Nikhil Katiyar

About Us Launched first award winning Community ENT Service in Southwark 8 years ago Now delivering Specialist Care services to 43 CCG’s nationally Appointments within 4 weeks of receipt of referral CPD Accredited trainers committed to supporting training and education Flexible services – ability to increase capacity as needed

Community ENT (Ear, Nose and Throat) Service
The Community ENT Service provides fast access to specialist care for patients within City and Hackney aged 16 years and over, (not 2WW) including: Routine assessment and diagnosis Routine treatment Follow up of patients where necessary/clinically required Provision of detailed management plans/guidance to GPs Access to regular ENT education for primary care Our Community clinics are run from two easily accessible locations: Tynemouth Medical Practice The Nightingale Practice Tynemouth Medical Practice The Nightingale Practice Ciaran Tynemouth Medical Practice, Tynemouth Road, Tottenham, N15 4RH The Nightingale Practice, 10 Kenninghall Road, Clapton, E5 8BY

Information Flow N3 Cloud Diagnostic Initiated Consultant Triage
GP Referral GP IT System Report issued within 5 days Patient Record Updated Consultant Triage 1 2 Diagnostic Initiated 3 Serious and/or unexpected pathology Alert 4 ENT Consultant input 2nd opinion 5 Report discharged to Referrer or recommended onward referral N3 Cloud

Governance Structure Oversight Complaints Incidents
Checks and Balances Mandatory Training Clinical Supervision Clinical Audit Non-clinical Audit Appraisals Learning Outcomes Tasks Risk Registers Induction Policies and IT Changes to Systems

Referral Pathway How to refer Contact Us Telephone: 020 3879 0135
Completed referral forms should be sent directly to: Our administration team contact all patients to arrange an appointment at a convenient time, date and location. Contact Us Telephone:

RIGHT TO CARE TRAINING DOCTORS OF THE WORLD UK
Entitlement to Healthcare for refugees and vulnerable migrants in the UK [Picture: DOTW clinic in Calais, 2015]

LEARNING OBJECTIVES ON COMPLETION OF THE TRAINING YOU WILL:
understand entitlement to NHS primary and secondary healthcare; have an awareness of the barriers to accessing NHS healthcare; [Picture: DOTW volunteers and service user in Calais, 2015]

MÉDECINS DU MONDE International organisation providing healthcare for excluded people all over the world. International programmes For example, Ebola response in Sierra Leone, Hurricane Mathew in Haiti, healthcare along refugee routes in Europe [Picture: MdM Ebola response in Sierra Leone, 2014] DOTW UK is part of the MdM network An international organisation that provides healthcare for exculded people across the world. Examples of international programmes are Ebola response in Sierra Leone, Hurricane Mathew in Haiti, healthcare along refugee routes in Europe

DOCTORS OF THE WORLD IN THE UK
A drop in clinics in London and Brighton: Short-term medical care provided by volunteer GPs and nurses GP registration advocacy service 1,601 patients seen in 2015. [Picture: DOTW clinic in London] MdM also run domestic programmes in our own countries. The UK domestic programme is the DOTW clinics in London and Brighton A service for people who cannot access the NHS Our service includes: short term medical care, GP registration advocacy In 2015 we saw 1605 patients

Who do we see at the clinic?
[Picture: DOTW UK 2015 Report] Who comes to the clinic? Who cannot access the NHS? Mainly undocumented migrants (55%) and asylum seekers (14%) Wide range of country of origins (COO) – top COO Philippines – usually domestic workers. On average our patients have been living in UK for 6.5 years before trying to access healthcare.

CASE STUDY: MIRIAM Mariam (28) fled Eritrea after escaping conscription into national military service. She had been abused, raped and denied medical treatment. Travelled Sudan > Libya > Italy. Imprisoned in Libya, street homeless in Italy and was raped by a group of men. Smuggled to “the Jungle” in Calais; by this point her mental health was deteriorating: ‘at that moment I was having a lot of stress…maybe I was screaming, things like that. …, I was under a lot of stress.’ [Picture: DOTW clinic in London, 2015] To explain healthcare entitlement and the barriers that patients face when accessing the NHS, we will use the case study of Miriam Miriam came to DOTW in 2015 Read from slide

CASE STUDY: MIRIAM Smuggled into the UK
Street homeless in London, after 2 months taken to a church by a lady she met on the street. ‘I started to beg her, my feet were swollen and I had been walking up and down for 2 days, I hadn’t showered and I hadn’t eaten well. She could see that I was pregnant.’ Allowed to sleep in the church. Members of the congregation bring her food, and sometimes they let her stay with them. [Picture: DOTW clinic in London, 2015] Read from slide

CASE STUDY: MIRIAM What is Miriam’s immigration status?
Undocumented migrant What are her healthcare needs? Antenatal care Mental health Sexual health screening [Picture: DOTW clinic in London, 2015] What is Miriam’s immigration status Based on what we know, what are her healthcare needs?

Is Miriam entitled to free primary care?
CASE STUDY: MIRIAM Is Miriam entitled to free primary care? “Everyone in England is entitled to free primary care regardless of nationality or immigration status.”NHS England Standard Operating Principles on GP Registration [Picture: DOTW clinic in London, 2015] Is Miriam entitled to free primary care?

CASE STUDY: MIRIAM What barriers may she face when accessing healthcare? Turned away from GP practices 3 times: Language barrier Asked to show a visa Asked to provide proof of address [Picture: DOTW clinic in London, 2015] The answer is ‘Yes’ – Miriam is entitled to free primary care What barriers may stop her from accessing this care she is entitled to?

PRIMARY CARE ENTITLEMENT
“Inability by a patient to provide proof of address/ ID would not be considered reasonable grounds to refuse to register a patient or withhold appointments”NHS Standard Operating Principles on GP Registration [Picture: DOTW clinic in London, 2015] The key document on primary care entitlement is NHS England Standard Operating Principles on GP Registration It says: Everyone in England is entitled to free primary care regardless of nationality or immigration status.” It also says: “Inability by a patient to provide proof of address/ ID would not be considered reasonable grounds to refuse to register a patient or withhold appointments” (The policy is the same in Scotland, Wales and NI, just no document that summarises it like this)

PRIMARY HEALTHCARE: BARRIERS
When DOTW service users approached GPs they faced the following barriers: [Picture: DOTW clinic in London] DOTW ask all patients why they could / did not access the NHS 52% – didn’t even try – believed they were not entitled to access the NHS 29% - administrative difficulties – this means they didn’t have proof of address/ID so were refused registration 17% - didn’t understand how to access NHS - i.e. that you have to be registered with a GP (data from 2015)

CASE STUDY: MIRIAM Came to DOTW clinic, saw a doctor, was registered with a GP. 29 weeks pregnant before first antenatal appointment. [Picture: DOTW clinic in London, 2015] What happened to Miriam when she went to a GP? She was turned away three times. Then she came to DOTW and we got her registered with a GP. She was 29 wks pregnant before accessing antenatal care .

CASE STUDY: MIRIAM What could a GP do to support Miriam?
Use an interpreter. Flag up in patient notes that she vulnerable/homeless Think about how she will get referral letters/test results use address of friend, day centre (or church?) or GP practice (NHS England Standard Operating Principles on GP Registration) Holistic approach to healthcare Consider mental health needs. [Picture: DOTW clinic in London, 2015] The answers on the slides are just suggestions. Participants may come up with other ideas.

Is Miriam entitled to secondary care?
CASE STUDY: MIRIAM GP confirms Miriam is pregnant. Miriam reports coughing up blood. GP refers her to antenatal care (ANC) and for chest x-ray. Is Miriam entitled to secondary care? [Picture: DOTW clinic in London, 2015] The GP wants to refer Miriam to secondary care for a chest x-ray and ANC Is she entitled to secondary care?

ENTITLEMENT TO SECONDARY CARE
OVERVIEW Those not “ordinarily resident” in the UK are charged for secondary care Some groups are exempt from charges* Some services are exempt from charges “Urgent or immediately necessary” treatment will be provided regardless of ability to pay [Picture: DOTW clinic in London, 2015] Secondary care entitlement is very complicated This is an overview We will look in more detail at what each section means

GROUPS EXEMPT FROM SECONDARY CARE CHARGES
EEA NATIONALS WITH AN EU RIGHT TO FREE HEALTHCARE NON EEA NATIONALS WHO PAY VISA HEALTH SURCHARGE (£200) VULNERABLE GROUPS Refugees and asylum seekers Refused asylum seekers supported by the Home Office (s.95/s4(2) support) Refused asylum seekers receiving accommodation support under the Care Act 2014 Children looked after by a local authority Victims of trafficking or modern slavery Victims of violence – domestic violence, sexual violence, torture and FGM treatment directly attributable to violence. Those receiving treatment under the Mental Health Act Those held in immigration detention. [Picture: DOTW clinic in London, 2015] These are the groups that are exempt from charges Read the slide EEA nationals means EU nationals plus Switzerland. Refused asylum seekers supported by HO – this is destitute refused asylum seekers who cannot return home, or who have children. Very high threshold to get this support. Refused asylum seekers under the Care Act – this is refused asylum seekers who are disabled and get accommodation from their local authority because of their disability. This is an incredibly high threshold. DOTW have never seen this exemption work in practice. EU nationals post brexit – we don’t know!

DOTW’S POLICY RECOMMENDATIONS
Full access to free primary, emergency and essential care for everyone living in the UK. Exemptions from healthcare charges for children and pregnant women living in the UK. NHS information should not be shared with the Home Office Health professionals should be supported to take care of all patients regardless of their administrative status. [Picture: George Butler] These are DOTW’s policy recommendations.

THANK YOU Anna Miller Right to Care Project Lead
DOTW can help you with: Training (Healthcare entitlement, Victims of Trafficking and Modern Day Slavery, Unaccompanied Asylum Seeking Minors) Training for receptionists and a practice managers Resources for GP practices [Picture: DOTW clinic in Idomeni, Greece, 2015] Please fill in the evaluation form!

GP Registration for Offenders London
---- Leighe Rogers Senior Project Manager NHS England and London Borough of Sutton

Why offender health- 1 Complex health problems
Physical health, mental health, substance misuse Difficulty in managing their own health conditions due to:- Unstable accommodation, poor communication skills, problems navigating access to services and sometimes an absence of sympathy from health professionals Vulnerable –background deprivation, experiences ----)

Why offender health- 2 Frequent attenders at A&E
Homeless numbers are increasing Life expectancy is half that of the general population 40 times more likely not to be registered with a GP Use eight times more hospital inpatient services

Mental and Physical Wellbeing
Interrelated dynamic elements affecting people’s health Poor Access to Services Stigma and Discrimination Lack of Physical Activity Exposure to violence and abuse Poor Diet Genetics Substance misuse Unemployment Difficulties in communication Inadequate Housing Smoking Social Exclusion Lifestyle choices Low Income Harmful effects of medicine Poverty Diagnostic overshadowing

Health Improvement-What Works?
Access to primary care Positive social relationships Good housing Employment Improve wellbeing and resilience

Health improvement-What works
Support to quit smoking • Tackling obesity • Improving physical activity levels • Reducing alcohol and substance use • Sexual and reproductive health • Medicine optimisation

How the scheme will work in practice
Prison Healthcare check and record GP status Prison Healthcare share with Probation/YOS Offender Manager completes NHS (GMS1) GP registration form with offender Offender Manager identifies local GP practice and sends referral letter and NHS (GMS1) registration to practice Homeless Offender uses Probation as a ‘proxy address’ for registration purposes only

Partnership GP practices are welcoming, and are and supported by local ‘social prescribing ‘services Criminal Justice staff identify and refer to GP Person is supported and encouraged to take personal responsibility for health needs Borough Partners support access (education and use of heath navigators) Person registered and engaging with GP

Action Plan-Boroughs Identifying local champions from Public Health CCG and CSP Establishment of local stakeholder groups Agree local implementation plans Agree local documentation Complete needs assessment-where are the gaps? Align with other local initiatives

Action Plan-Health Brief senior leaders-Directors of Public Health, CCG Chairs, London Medical Committee Agreed communication with GPs via London Medical Committee Identify local champions CCG and PH Meetings with local LMC members and GP practice staff Agree paperwork- GP letters; guidance; staff training; literature

Challenges for Health Clinical capacity /practice time
Practice links with other services Effective integrated support and training for staff Coordination of care and continuity of care in a fragmented system Some negative attitudes towards ‘offenders’ as a group

What can I do? Be welcoming Show understanding
Be prepared to be as flexible as you can Show patience Work in partnership with others

Evaluation Qualitative study of the patient journey to registration
Prison Healthcare to commence recording of prisoners status re: GP registration Criminal Justice to record referrals and attendance at first GP appointment

Thank You For more information about the scheme and how you can get involved with your local group please contact Or telephone

INFORMATION FOR CCF DECEMBER 2016
DEVOLUTION UPDATE INFORMATION FOR CCF DECEMBER 2016

DEVOLUTION The Hackney business case was submitted at the start of November It is on the CCG website ( publications/devolution-latest-news.htm) The CCG CO, CFO and LBH Group Director presented the business case at the London Devolution Board on 4 November It was well received and next step is pan London negotiation around the devo “asks”

ASKS The main asks from our business case are
Licensing powers to support prevention – details of these are on the CCG website ( publications/devolution-latest-news.htm) – Estates Changes to s75 legislation to support joint commissioning with Local Authorities We are also exploring with NHSE and PHE devolution of commissioning responsibilities for screening and immunisation Timescale for negotiation of all asks is unclear

INTEGRATED COMMISSIONING
We are planning to develop integrated commissioning arrangements between the CCG and the 2 Local Authorities on 1 April 2017 Draft governance model under review by CCG and LA solicitors 2 ICBs (one for Hackney and one for City) – made up of 3 CCG GB members (2 GPs) and 3 Councillors + COs and CFOs. Healthwatch and Director of Public Health attends Takes advice from the Transformation Board Medical Directors and CEOs of local providers, VCS, COL, LBH and CCG The workstreams will report into Transformation Board CEC and Consortia will continue to ensure capture member views and ideas Programme Boards continue for now but responsibilities will transfer over 2017

Fortnightly meetings and gateways
Work continues on the financial framework and mapping budgets which will form the budget Schemes of delegation to be finalised Core primary care is not pooled We are working on the collective decision making arrangements to agree “go live”

Proposed Governance Structure for Integrated Commissioning
London Borough of Hackney City of London Corporation Each ICB makes recommendations to its respective LA on aligned fund services Each LA agrees an annual budget and delegation scheme for its respective ICB (with C&H CCG) Agree outcome improvements and progress across the system Delivery of HWB strategies Delegated decision making for pooled budget Receive financial reports Hackney Integrated Commissioning Board Hackney HWB CH-wide local redesign work with COL dimension Joint Transformation Board Recommendation and advice Local workstreams report into and make recommendations to JTB Implementation of decisions City of London Integrated Commissioning Board City of London HWB Includes: Early years Prevention Planned Crisis Meets in common to ensure alignment Recommendations for aligned fund services Each year agrees budget and scheme of delegation (with local authority) Recommends contracts with primary care Primary care contracts committee/s City and Hackney CCG

Delegated Primary Care Commissioning
December 2016

Question to GP Forum on Delco
The following slides were submitted to the CCG’s Governing Body meeting of 25th Nov Forum members are asked to note the slides and consider whether they support the CCG moving to fully delegated commissioning of core primary care – to be debated at 1 Dec Forum; discussion to be led by Mark Rickets 52

The Governing Body is being asked to:
Note the potential benefits of moving to level three delegated primary care commissioning Agree to the recommendation to submit an application for level 3 delegated commissioning by the 5th December 2016 deadline subject to gateway checks, a due diligence process and feedback from stakeholder engagement. Sign off the proposed gateway checks through to April 2017 Note the proposed due diligence process Note the engagement plan for engaging with members and other stakeholders (including a membership vote on constitutional changes) Note the proposed changes needed to the Terms of reference for the Local GP Provider Contracts Committee, possible new Terms of Reference for a form of Primary Care Commissioning Committee and the CCG Constitution (the Conflicts of Interest Policy has already been recently revised and is included in the November Governing Body Papers for approval). 53

Primary Care Co-Commissioning
Primary Care co-commissioning refers to the process whereby CCGs are given the opportunity to assume greater powers to directly commission primary medical services. Delegated commissioning gives CCGs the option of having more control of the wider NHS budget, enabling a shift in investment from acute to primary and community services. City & Hackney CCG needs to determine whether moving to delegated commissioning will support delivery of our primary care strategy, our wider plans for moving to devolution and crucially, to deliver better care for our patients. Level 3 applications are due on 5 December 2016 for interested CCGs. Successful CCGs would take on delegated authority primary care functions from April 2017. Level 1: Greater Involvement Greater involvement in NHS England decision making Level 2: Joint decision-making Joint decision making by NHS England and CCGs Level 3: Delegated commissioning CCGs take on delegated responsibilities from NHS England There are three levels of co-commissioning. City & Hackney is currently at level 1 – greater involvement. 54

Regional & National picture on primary care co-commissioning in 2016/17
The information below shows the current picture of primary care co-commissioning. NHS England have indicated that they anticipate that less than 20 CCGs nationally will not be fully delegated in 2017/2018. WEL – Delegated Commissioning BHR – Delegated Commissioning SWL – Delegated Commissioning NCL – Joint Commissioning NWL – Joint Commissioning SEL – Joint Commissioning City & Hackney – Greater involvement 114 CCGs – Delegated Commissioning 70 CCGs – Joint Commissioning 24 CCGs – Greater involvement Currently considering moving to delegated commissioning 55

Our Context: Devolution
Our vision for a health and wellbeing system The vision for Hackney is to work together with our patients and providers to deliver an integrated, effective and financially sustainable system that meets the population’s health and wellbeing needs. We want our acute services to fully integrate with community, social care, primary care and tertiary services and we have many successes to build on. Locally, we are progressing work to redesign the health and social care system to improve outcomes for local people through the Hackney Devolution Pilot. This programme of work offers a chance to drive greater integration across the system to achieve common goals and improve outcomes in the priority areas. Through a focus on the wider determinants of health and inequalities, devolution provides all those working towards improved health and wellbeing for the population of Hackney with an opportunity to better address the challenges the borough faces; Hackney is a vibrant, diverse and deprived inner London Borough with specific health and wellbeing challenges. The partners in the borough have come together to initiate a collective and ambitious approach to delivering new models of care to support these challenges. To tackle the problems we face, we want to really join up public services, make better use of our collective estate and take a new approach to prevention. Whilst we've achieved a lot and have ambitious plans for the next few years, devolution powers will really make a difference to what we can deliver for local people. As part of this work we want to ensure that we also have control of the commissioning of local primary care services through moving to level three delegated commissioning. 56

What we are already doing to deliver our vision for primary care
Our vision for primary care in City & Hackney What we are already doing to deliver our vision for primary care We have developed a primary care quality dashboard that includes nationally and locally determined indicators which is used to inform all quality improvement activity in primary care. We have developed a patient demand management contract with the City & Hackney Confederation for practices to deliver: A digital access offer to patients via practice websites Group consultations for patients with LTCs Develop local utilisation of community pharmacy (e.g. pharmacy first minor ailments scheme) A City and Hackney Health Information App The Primary Care Quality Board manages the contract with the Clinical Effectiveness Group (CEG) to support all CCG Programme Boards and the Confederation with clinical outcome informatics, near patient clinical support, templates and tools to search EMIS databases. All key to the delivery of high quality care. The GP IT committee supporting practices, managing the CSU contract and informing the Local Digital Roadmap. CCG support for the City and Hackney Community Education Provider Network (CEPN) (functioning as the workforce arm of the Devolution project) including £1.4m non-recurrent funding. The Primary Care Quality Board is currently developing contracts to deliver the aspirations of the Five Year Forward View: Enhanced access Resilience support for practices A QI practice development programme (supporting the Ten High Impact Areas of the GPFV) Our plans for primary care commissioning in 2016/17 are informed by our commissioning work to date, priorities identified by our patients, members and other stakeholders and the needs of our 5 year clinical strategy as well as our primary care strategy which was signed off by our Governing Body in November • We are very conscious that demand to see GPs has doubled in the last fifteen years and we need to support practices to manage this alongside the increasing workload from more services and care outside hospital. Our strategy is to ensure that practices have the capacity – both time and manpower – to care for people in the community and to offer a rapid response and consultation service when needed and that they are supported by a range of community services working together to help them. • We support and will commission on the basis of the three specifications in the NHSE London Strategic Commissioning Framework – proactive care, accessible care and co- ordinated care – and in a way that meets the needs of the population of City & Hackney. We also believe that there is an equally important pillar of good primary care provision – effective commissioning behaviours – which we will continue to support, contract for and promote. 2 57

Our investment in primary care
Over the last 12 months we have already invested an additional £8m in primary care services to deliver the following improvements for our patients and improve local outcomes and we are committed to continuing this strategy to continue to deliver tangible improvements: Telephone access to a duty doctor arrangement in each practice during core hours to support patients and link with urgent care providers; Extended consultations for patients with long term conditions or cancer; Practice systems to support earlier detection of cancer; Proactive quarterly home visiting service for our vulnerable population and those at the end of life; Extended opening hours for primary care in the evenings and weekends; Supporting time and systems for practices to participate in clinical commissioning and embedding practice behaviours – audits and peer discussions, consultant outreach and education programmes, education of juniors and locums, referral reflections, reviews of frequent A&E attenders, good prescribing practice, adoption and audit of CCG pathways; Supporting enhanced patient feedback and PPG development, sharing of quality of care issues (both good and bad); Identification and early diagnosis of people at risk of coronary heart disease, respiratory disease and diabetes; Proactively reviewing & managing people with mental health problems with 600 people with mental health problems transferred to primary care management; Seeing each woman during her pregnancy and after delivery to ensure that her needs are being met; Proactively reviewing all children with long term conditions and ensuring that care plans are in place (with a specific focus on the management of asthma) and ensuring support is available to children and their families; Identifying vulnerable children and families in conjunction with Health Visitors. 58

Potential benefits of delegated co-commissioning
Taking on delegating primary care commissioning functions could have benefits for patients, providers and for the CCG as commissioners: We would be better positioned to exercise our duty to ensure continuous improvement in the quality of services provided to our local population e.g. by local decision making on investment priorities and by being able to provide support to practices more quickly; We would be uniquely placed to take a whole-system approach to commissioning, bringing about the necessary shifts in secondary care utilisation; We would be able to have increased clinical leadership and public involvement in primary care commissioning, enabling more local decision making; We would be able to use our local knowledge and relationships with patients and local communities to commission in a way that reflects the needs of local people; We would be able to maximise our relationships with health and wellbeing board members, our Healthwatch representatives and with local communities to ensure local people are engaged in transforming primary care services in their local area. We would be able to work more closely with the City & Hackney GP Confederation to deliver the best possible approach to improving access to GP services locally i.e. working together to better understand local needs We would be able to more effectively design local incentive schemes which align to our Primary Care Strategy. This will minimise duplication or waste of funds on overlaps; We would be able to commission primary care services in a way that supports our integrated care programme as we would have an overview of the health system locally; We would be able to more effectively support practices to achieve the specifications within the Strategic Commissioning Framework for Primary Care Transformation in London, which will improve access, proactive care and co-ordination of care for our patients as well as ensuring we develop our workforce, premises and technology and information systems; We would be able to progress new commissioning models such as devolution that cannot be achieved without integration of services across care providers; We would be able to have greater freedom in planning and investing in our primary care workforce, ensuring that we retain our best staff, develop the staff we have and ensure a greater clinician to patient ratio and thus lead to greater continuity of care and satisfaction for patients; 59

Functions under different levels of co-commissioning
Outlined here is a high level summary of the functions of level 2 and level 3 co-commissioning. Primary Care Function Level 2: Joint Commissioning Level 3: Delegated Commissioning General practice commissioning Jointly with NHS England (London region) Yes Pharmacy, eye health and dental commissioning Potential involvement in discussions but no decision making role Design and implementation of local incentives schemes Subject to joint agreement with NHS England (London region) General practice budget management Contractual GP practice performance management Medical performers’ list, appraisal, revalidation No Source: NHS England, Next steps towards primary care co-commissioning, November 2014 60 60

Roles and Responsibilities under Delegated Authority (CCGs)
Under level 3 co-commissioning arrangements, CCGs have responsibility for: a. Commissioning, procurement and management of Primary Medical Services Contracts, including: Enhanced Services; Local Incentive Schemes (including the design of such schemes); decisions to establish new GP practices (including branch surgeries) and closure of GP practices; decisions about ‘discretionary’ payments; decisions about commissioning urgent care (including home visits as required) for out of area registered patients; b. Approval of practice mergers; c. Planning primary medical care services including carrying out needs assessments; d. Undertaking reviews of primary medical care services; e. Decisions in relation to the management of poorly performing GP practices including: decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); f. Management of the Delegated Funds*; g. Premises Costs Directions functions; h. Co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; i. such other ancillary activities as are necessary in order to exercise the Delegated Functions Source: NHS England, Next steps towards primary care co-commissioning: Annex E (published July 2015) *NB: Under current legislation, NHS England are not able to ‘double delegate’ primary care commissioning functions. This means that the core primary care budget could not be pooled as part of the City & Hackney devolution programme nor could primary care commissioning responsibilities be delegated by the CCG to another body e.g. a Joint Committee with local authorities. 61 61

Roles and Responsibilities under Delegated Authority (NHSE)
Under level 3 co-commissioning arrangements, NHS England retain responsibility for: a. Management of the national performers list; b. Management of the revalidation and appraisal process; c. Administration of payments in circumstances where a performer is suspended and related performers list management activities; d. Capital Expenditure functions; e. Section 7A functions under the NHS Act; (public health functions)* f. Functions in relation to complaints management; g. Decisions in relation to the Prime Minister’s Challenge Fund; and h. Such other ancillary activities that are necessary in order to exercise the Reserved Functions; *The delegation of public health functions are being considered as part of City & Hackney’s devolution proposal. Source: NHS England, Next steps towards primary care co-commissioning: Annex E (published July 2015) 62

Roles and Responsibilities: Operational Delivery
The following documents would support the operational delivery for delegated primary care contracting. NHSE NHS England Delegates responsibilities and accountability for GP services contracts and budgets to CCG Via The Delegation Agreement NHS England Assures delivery of the delegated functions in accordance with national requirements and directions CCG CCG Establishes a Committee*, in accordance with guidance, to deliver the delegated functions in accordance with National, Regional and Local SOP CCG agrees MOU with Commissioning Team (NHSE & CCG) to provide the commissioning activities that enable them to deliver the function NHSE Commissioning Team Provides the operational support to undertake the activities associated with the delegated functions in accordance with MOU Works to the standards agreed in the SOP 63

Due Diligence City & Hackney CCG has commissioned their internal auditors RSM UK to carry out a due diligence exercise in relation to moving to delegated primary care commissioning. The purpose of the due diligence is to identify any potential areas of risk for the CCG and ensure that any known cost pressures such as outstanding DV (district valuation) claims or historical contract issues are identified and the ownership is clear. The due diligence process is expected to be completed in January 2017, after the application for delegation has been submitted to NHS England, however our application on the basis that it is subject to the findings of our due diligence process. The findings of the due diligence exercise will be scrutinised by the CCG Audit Committee prior to a final decision being made on moving to delegated primary care commissioning. The Audit Committee will make a recommendation to the CCG Governing Body based on their findings. This is expected to take place in January / February 2017. The scope of the due diligence includes, but is not limited to: The finance portfolio in detail on a headline and underlying trading basis; QIPP schemes that are in place and if they are recurrent and or not; The status and impact of any QIPP schemes being worked up and their proposed implementation plan; An understanding of risks that are ring-fenced elsewhere and the consequence if authorisation were taken forward; An understanding of all the risks, mitigations and opportunities and how they are managed and play into the financial situation, or not; Procurement initiatives and their status and risks attached; Full sight/detail of the balance sheet and all reconciliations; Understanding of how the ledger accounting process will work going forward; Property portfolio including risk around ownership, voids and subsidies and their status; and The output of internal audit and external audit 64

Potential Risks & Issues
Area Identified Risk Mitigation / Comment Resourcing Following an organisational review of their primary care team, NHS England’s NE London locality team (which includes the team providing support to City & Hackney) will be moving to the STP footprint but will retain their employment with NHS England. However it is not yet clear exactly what this arrangement will look like. The NHS England locality team will be moving to STPs regardless of City & Hackney’s level of delegation. It is acknowledged that if City & Hackney CCG were to deliver a primary care contracting service over and above what is currently provided it may require investment in to the staffing of the team. This will need to be considered as part of the due diligence process. Primary Care Budget No additional funding (over the core primary care budget) will be available to implement improvements in primary care and the CCG would assume responsibility for budgetary pressures, deriving from commissioning primary care, including Quality, Innovation, Productivity and Prevention (QIPP) efficiency savings. The CCG may inherit existing liabilities (such as contract disputes) or material financial commitments (e.g. in relation to premises agreements). These issues will need to be addressed through the CCG’s due diligence process (expected to be completed by January 2017). Where financial risks are identified, the CCG will need to consider how these can be mitigated (or not). NHS England has indicated that money has already been accrued against existing financial risks such as QIPP and contract disputes. Conflicts of Interest Taking on the commissioning of primary care, could create perceived or actual conflicts of interest for GP commissioners. The proposed governance structure includes a number of mitigations such as a lay chair and vice chair, a lay and executive member majority and an independent GP member. NHS England published new conflicts of interest guidance for CCGs in June 2016 including specific recommendations for primary care commissioning committees. These have been incorporated into the CCG Conflicts of Interest Policy. Relationship management with GP practices There may be a changed relationship between the CCG as a clinical membership organisation which will be managing members’ primary care contracts. CCGs already have a statutory duty to support NHS England in managing the quality of GP practices. Individual GP performance will remain a responsibility of NHS England’s Medical Directorate. Under delegated primary care commissioning, day to day contracting activities will be managed against national contracts supported by national and regional standard operating procedures and through a team employed by NHS England who will be moving to work across the NEL STP geographical footprint. 65

Proposed Governance It is proposed that if City & Hackney CCG took on primary care commissioning responsibilities, these functions would be delegated by the Governing Body to a form of Primary Care Commissioning Committee (PCCC). The exact governance solution is under investigation, but the Local GP Provider Contracts Committee (LGPPCC) would continue to make recommendations on commissioning from GP providers to the PCCC. The LGPPCC already has a good track record of robust management of contracts and of managing conflicts of interest in a transparent way e.g. a code of conduct template accompanies all procurement recommendations and documents where and with who the service development has been discussed. The Committee was established to review and make recommendations on CCG contracts with GP practice providers, and its current remit includes making recommendations to the CCG Governing Body on procurements and it also has delegated authority to make payments against existing contracts subject to performance. The future governance structure is likely to see those recommendations flow to the PCCC. Examples of contracts overseen by this Committee include the Out of Hours and the Long Term Conditions contracts. Nov 2016 – Jan 2017: The involved Committee’s terms of reference will be drawn up or refreshed to reflect the additional delegated primary care functions. These will then need to be approved by the CCG’s Governing Body. Dec 2016 – January 2017: The CCG’s Constitution will be revised to reflect the additional delegated primary care commissioning functions. A membership vote to approve the proposed constitutional changes is expected to take place in January This will then also need to be approved by the CCG’s Governing Body. March 2017: The involved Committee’s will need to be familiarised with the type of contracts and decisions which they will be responsible for. It is anticipated that this will be done through development sessions and scenario testing. 66

Draft Conflicts of Interest Policy
The Conflicts of Interest Policy for City & Hackney has been updated following new guidance published by NHS England in June 2016. The key recommendations from the revised guidance which relate to primary care committees are shown in the table here. City & Hackney’s updated policy will be taken to the November 2016 Governing Body for approval. The approved Conflicts of Interest Policy will need to be submitted to NHS England alongside the delegation application to ensure that NHS England are satisfied with the proposed arrangements for managing perceived or real conflicts. Key recommendations from NHS England Conflicts of Interest Guidance relating to primary care committees City & Hackney draft response That the Primary Care Commissioning Committee has a lay Chair and a vice lay chair. The Local GP Provider Contracts Committee will have a lay Chair and a vice lay chair. A possible new Terms of Reference for a form of Primary Care Commissioning Committee will also follow this format. It is recommended that GPs do not have voting rights on the primary care commissioning committee. The arrangements do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision-making on procurement issues and the deliberations leading up to the decision. There are no local GP members as regular attendees on the LGPPCC. An independent GP advisor has been included on the voting membership. A possible new Terms of Reference for a form of Primary Care Commissioning Committee will also follow this format. A standing invitation must be made to the CCG’s local Healthwatch representative and a local authority representative from the local Health and Wellbeing Board as non-voting attendees, including, where appropriate, for items where the public is excluded for reasons of confidentiality. City of London and London Borough of Hackney Healthwatch representatives have been included as voting members on the proposed Local GP Provider Contracts Committee membership and a possible new Terms of Reference for a form of Primary Care Commissioning Committee will also follow this format. Representatives from City of London and London Borough of Hackney Health & Wellbeing Boards are included as non-voting members. The Committee must have a lay and executive majority. This is reflected in the proposed membership of the Local GP Provider Contracts Committee. A possible new Terms of Reference for a form of Primary Care Commissioning Committee will also follow this format. It is recommended that any sub-groups submit their minutes to the primary care commissioning committee, detailing any conflicts and how they have been managed. The CCG’s procurement strategy requires proposals for changed or new specifications for primary care to be accompanied by a code of conduct template setting out who was involved in the development of the proposal. To further strengthen scrutiny and transparency of CCGs’ decision-making processes, all CCGs should have a Conflicts of Interest Guardian. The CCG has already been putting arrangements in place for a Conflicts of Interest Guardian. This person will support the rigorous application of conflict of interest principles and policies. 67

Staffing & Resourcing NHS England’s Primary Care Contract team are currently responsible for managing primary care contracts. As CCGs across London have begun moving to joint and delegated commissioning of primary care services, NHS England has been carrying out a review of this function. It has recently been confirmed that a new organisational structure and operating model for primary care commissioning will be implemented at the NHS England and STP level. The North East London locality team (which includes the team providing support to City & Hackney), will move to the STP footprint to allow for a greater primary care presence at the local level. The changes to NHS England’s primary care commissioning function will take place regardless of City & Hackney’s level of primary care delegation, however should the CCG move to delegated commissioning, it will be important that they can continue to shape how roles and workplans are aligned. 68

Delegated Primary Care Commissioning engagement activities October 2016 – January 2017
The table below outlines the engagement activities that have already taken place or are planned up to January This engagement process will provide stakeholders with the opportunity to share their views and identify those areas where further information or consideration may be required. Oct 2016 Nov 2016 Dec 2016 Jan 2017 27 11 26 25 12 13 Virtually 24 1 7 8 16 23 5 27 11 12 Key Clinical Commissioning Forum Primary Care Quality Board Audit Committee NHS England Governing Body Devolution Transformation Board Health & Wellbeing Boards Local GP Provider Contracts Committee Clinical Executive Committee PPI Committee City & Hackney LMC 69

Gateway Process 1 2 3 4 5 6 Gateway Key Decision / Action
Decision maker(s) Decision Date Approval for CCG to proceed with application for delegated primary care commissioning subject to gateway checks Agree proposal for applying for level 3 delegated commissioning (application due by 5th December 2016) CCG Audit Committee Governing Body Virtually w/c 14/11/16 25th November 2016 NHS England confirm whether CCG has been approved to take on delegated primary care commissioning NHS England confirmation as to whether application has been approved Regional & National NHS England team 9th December 2017 (regional moderation) 5th January 2017 (national moderation) Membership vote on constitutional changes Agree constitutional changes required to move to delegated primary care commissioning GP Members (vote) 5th January 2017 Early review of initial Due Diligence findings Review of due diligence findings including: Ensuring that all identified risks can be managed within the allocation and by reserves set aside for previous years Ensuring that assumptions built into the operating plans are manageable Audit Committee Executive Group (Chief Officer, Chief Finance Officer, Programme Director – Long Term Conditions and Primary Care Quality, Independent GP Advisor) 12th January 2017 Review of final due diligence report and recommendation for Governing Body Review of final due diligence report and stakeholder engagement feedback Agree recommendation for Governing Body Approve refreshed terms of reference for Local GP Provider Contracts Committee and possible new Terms of Reference for a form of Primary Care Commissioning Committee; scheme of delegation and draft constitutional changes Audit Committee (extraordinary meeting) February 2017 Governing Body decide on recommendation to progress with delegated primary care commissioning Review of due diligence findings and stakeholder engagement feedback Confirm whether to proceed with delegation process CCG Governing Body 1 2 3 4 5 6 70

Potential Timeline to Delegated Primary Care Commissioning
Outlined below is a high level summary of the steps that would need to take place if City & Hackney CCG were to move to full delegation in April 2017. Gateways Nov 2016: Delegated commissioning proposal presented to Audit Committee & Governing Body Nov 2016 – Jan 2017: Stakeholder Engagement Dec 2016: Application with expression of interest submitted to NHS England and CCG membership vote Jan 2017: Membership Vote Jan 2017: Initial due diligence findings and engagement feedback presented to Audit Committee Feb 2017: Audit Committee & Governing Body agree final decision on delegated commissioning Mar 2017: Primary Care resource arrangements finalised Mar 2017: Primary Care Commissioning Committee development and scenario sessions Apr 2017: GO LIVE 1 3 4 2 5 6 Nov Proposal: This will outline what benefits, opportunities and risks are for taking on delegated primary care commissioning, what the roles and responsibilities will be and what the governance structure could look like to support decision making. Nov – Jan Stakeholder Engagement: CCG constituents will need to be consulted along with other key stakeholders such as, LMC, Healthwatch, and the Health & Wellbeing Board. Dec Application and expression of interest: This needs to be submitted to NHS England by 5th December The application will be reviewed by the regional and national teams with confirmation of approval to be issued in January 2017. Dec-Jan Due Diligence: This process is key in identifying and mitigating any risks and providing assurance to the Governing Body and to NHS England that City & Hackney CCG are in a position to take on delegated authority commissioning arrangements. Jan – Mar Resource arrangements: The final arrangements for how the NHS England primary team will function within the NEL STP footprint and will need to be confirmed by NHS England Feb – Mar Committee Development: It will be important that the Local GP Provider Committee members feel equipped to make GP contract decisions prior to going live in April 2017. 71 71

Question to GP Forum on Delco
The GB agreed at its 25th Nov meeting to submit an application for level 3 delegated commissioning by the 5th December 2016 deadline subject to gateway checks, a due diligence process and feedback from stakeholder engagement Due diligence process (inc. questionnaire to practices) Engagement plan for engaging with members and other stakeholders (including a membership vote on constitutional changes) Changes to the Terms of Reference for the Local GP Provider Contracts Committee (to take on the additional function of the Primary Care Commissioning Committee) and the CCG Constitution Forum members are asked to consider whether they support the CCG moving to fully delegated commissioning of core primary care 72

C&H GP Forum 1st Dec: GP Forward view update
Starting to get some clarity about what money is coming to C&H and what plans we are required to submit – still lots of unknowns and questions. The CCG is required to submit to NHSE (L) a draft GPFV delivery plan on 2nd Dec and a final plan by 23rd Dec, covering 8 key elements: Extended access – C&H isn’t set to receive any access monies until 2018/19 at the earliest; the CCG will roll over Extended Access Contract for a further 3 months (to end of June 2017) to give time to formulate a transition plan Online consultations – £79k for 2017/18 and £106k for 2018/9 – plan to spend these allocation TBC but will informed by current Demand Management Contract (e-consultations, etc) (a) Provider development (resilience/time to care) – national funding for resilience TBC (b) Provider development (£3 per pt CCG investment over 1-2 years – ) – 2-year quality improvement programme approved for local funding; practice resilience programme approved for local funding; any shortfall in £3 per pt TBC Training care navigators and medical assistants – £53k pa for 2017/ /19 – extend GP Confederation’s advanced HCA development programme? PMS plan – TBC; need to agree how CCG will engage with LMC Growth and uncommitted headroom (on core budget) – only applicable if we are level 2 or 3 primary care commissioners Workforce – ref CEPN plans ETTF plans – NHSE (L) are providing commentary on this 73

GP IT update Dec 2016 Dr N Addy

2016/17 Jargon Buster MIG (medical interoperability gateway)
LDR- local digital roadmap NEL CSU (N E London CSU IT support) ETTF- Estates Technology & Transformation Fund BAU- business as usual capital bidding process DSA- data sharing agreement HTTP – hypertext transfer protocol API- application programming interface

IT steering Group Monitors the IT SLA with NELCSU and provides focal point for CCG capital bids, asset management and formulating/ monitoring IT strategy Local developments include: HIE- usage increasing. MIG v2 pending. Barts/ELFT links coming E-referrals- national target to increase E- discharge/OPD/Comm letters- nearly all active GP intranet- initial proposal by planned care for revamped website. Cost £15k to £40k for new development design. Hosting/ support £3-15k p.a.

Intranet development Focus group
Key questions: Should the site be hidden from public or password protected Should pathways be PDF docs for download or webpages for access Would user accounts be helpful for GPs to record reading and CPD points

LDR Priorities National:
Pts have access to detailed coded GP record (National) Pts can book GP appointments & order rpt meds online (10% registered list suggested) London: Empower pts to access health/social care records via a single log-in and ID (London) GPs electronically order tests and receive results in real- time (local) Mobile working. All community care professionals can update info at point of care (local) Care workers access pt info regardless of location

IT enabler/ LDR update LDR Submitted to NHSE June 2016
Good feedback but further work required to refine annual targets NE London region being asked to work towards a single LDR Healthy London Partnership IT enabler programme submitted expression of interest to be the first community in this programme Provides 4 core functions incl document exchange incl crisis +EOL care data + real time care plan updates, data controller console, online account service for pts

ETTF capital bids C&H submitted bids under this estates and tech fund
NHSE asked for bids to align to STPs after a scoring/ prioritisation process C&H bids incl. GP demand management & WiFi installation in practices (rolled into a single NE London bid for WiFi) Demand mx consolidated to another bid to support practices uptake and utilisation of tech-based solutions Left with a) digitisation of paper records by 16/17 b) online sharing of diagnostics & messaging & 2 pan- London bids

BAU Capital Bids London allocation £33million (% of National budget)
Covers everything outside ETTF Given limited funds most London BAU bids will need to be submitted via STPs in prioritised order NE London allocated £7.2 million (22% budget) Current bids ranked and prioritized by IT steering group include: GP intranet / Patient website – information for GPs and patient portal to online services; Mobile working – devices with access to full version of EMIS web; Cloud based storage – improved data storage and back-up; Docman extraction – transferring all scanned documents to EMIS web; Patient info displays – to support health promotion and patient online services; Digitisation of patient records – scanning of paper records for electronic storage; Additional equipment – hardware replacement

SMS Messaging in Hackney
Proposal to switch from NHS mail to local EE HTTP API for SMS C&H 32 practices sending 809k appt and 24k FFT SMS NHS mail increasingly unreliable for SMS Currently supplied by EE under national contract Mjog approved to use EE HTTP API to deliver SMS to EE w/o an NHS mail account Allows direct 2 way pt messaging and costs less Benefits: cost saving, no extra work

Homerton IT: current issues and qu’s
Missing pathology requests Adding ethnicity data to T quest Moving to 100% digital radiology requests – are we ready for this? Barriers to increasing e-referrals from primary care. Target 85% electronic referral or increase of 20% on current activity.

Prepared by: Gerard Bowden CMC Clinical Quality Manager
CMC Clinical Quality Initiative - (Development stage) Data shared – feedback requested Evaluated: City & Hackney CCG Prepared by: Gerard Bowden CMC Clinical Quality Manager 07/11/2018 Development Work - Do Not Publish

Care Plan Activity – pre & post EMIS in-context link
EMIS link launch

Care Plan Activity – London
As of 1st October 2016: 950 patients in City and Hackney have had CMC records created. City and Hackney CCG previously had a low uptake of CMC and now has the highest number of patients added to CMC in the last 12 months across London (737).

Overview of this type of report
This report is a development version of CMC’s Care Plan Quality Initiative and is provided as a guide to City & Hackney for internal use only to stimulate affirmation of good practice and improvement strategy where needed in care plan quality. It’s purpose is to give a high level view of an areas care plans so that strengths and areas of weakness can be identified by the relevant clinical teams themselves and improvements made accordingly from the team itself. This report type takes the relevant CMC care plans and searches for the item markers - below left (important to Urgent Care Services), and searches for the specific value in the data fields in the care plan – below right. Where it assesses for the presence of free text in data fields such as Family Awareness – it does not evaluate the content but that information is being shared. Adding information of no value will improve the report but will not help the patient. Because the symptom control plan is so valuable there is variable weighting to number of symptoms anticipated/managed. Note: Many items are not included as they are mandatory. Quality Marker fields Value in the Data Field PPC (actual preference) Actual Place selected or Pt. not able / wanting to state PPD (actual preference) Prognosis Any option chosen Surprise Question Yes or No only Patient wishes Any text Family awareness Cultural / Religious Ceiling of Treatment Any value (other must have free text box value) CPR Decision (Yes or No) Yes/No value Some Symptoms fields interacted with <2 One field only - Any text Number of Symptom fields interacted with 2 to 4 fields - Any text 5 fields & above - Any text Contacts - family Any name & any telephone number Contacts – professionals In-hours Out-of- hours Mobile telephone number Published within last 90 days Last days only Yes 07/11/2018 Development Work - Do Not Publish

90% 70% 67% 56% 20% 16% 6% 74% 69% 21% 38% 28% 98% Plan Items
Plan Items Preferences & Prognosis General wishes/awareness /spiritual Advance Treatment Plan Contacts & Published Date 1 - PPC 5 - Patient Wishes 8 - CPR Decision 11 - Personal Contacts 2- PPD 6 - Family Awareness 9 - Ceiling of Treatment 12 – Contacts – Professional 3 – Prognosis 7 - Cultural/ Religious 10 - Symptom Treatment Plans 13 – Recently Published 4 – Surprise Question All red items in this gridbox are priority items for effective Urgent Care support Notes: CMC Care Plans should aim to provide information that would be useful to Urgent Care Services at 2am. ‘Think 2am’ . 1066 Care plan creations for May 1st to November Very good care plan creation activity. [1-3] Most care plans have a capture of a preferred place of care with less for dying (or indication that patient not able or wishing to discuss). [4] Surprise question – quite good. This will become more important going forward for reporting of EOLC cohorts V non EOLC cohorts. [5-7] ‘Soft holistic areas’ not so good. Cultural / religious might have been stronger for such a diverse CCG area. [8-10] Good CPR decision provision (Yes or No) – very helpful in 74% of care plans. Ceiling of Treatment very helpful to Urgent care Services - 69% of plans. 21% only have Symptom/Problem management plans. This area is vital to support Urgent Care Services to know how to achieve the indicated Preferences and the Ceiling of Treatment. Would you expect more Symptom Management Plans for your patients? Do these plans exist elsewhere? Could they be fruitful within CMC? [11-12] Contacts (can make a big difference to Urgent Care Services) – Relative/NOK 38% of plans only – this can leave LAS, 111 and OOH GP in the dark. All CMC care plans capture the GP contact details. Most of care plan published/republished within the last 120 days – very good. Summary: Great quantity. Place preferences & CPR/COT good. Treatment plans generally absent - vulnerability. NOK Contacts poor. Publishing great.

Development Work - Do Not Publish
Request for Feedback Is this information useful/meaningful to receive? Are you able to interpret the quality of the care plans? Are there any easy changes/improvements that your team could/should make? Is the level of commentary on the slide adequate and understandable? How often would you want this data? And in what form? Who should we send this data to within your area? How often? What about seeing several service providers (CCGs) compared together? How can we at CMC improve this quality initiative? for feedback on this quality initiative For your information: for any incidents (patient identifiable data) 07/11/2018 Development Work - Do Not Publish

Development Work - Do Not Publish
Patient Pilot ‘Enrol’ The Coordinate My Care service is piloting new functionality that will allow patients to view their CMC urgent care plans online. City and Hackney CCG have been invited to participate in the pilot. In order to view their care plans online, patients will need to be enrolled by their GP/nurse at their GP Practice. The CMC team will work with your practice to identify the most suitable CMC patient cohorts to target. CMC will provide support on printing, postage and any stationary costs incurred as well as supplying patient leaflets and labels to the participating practices. If you are interested in taking part in this pilot please get in touch with Samina Qutub, communications manager for Coordinate My Care on or call by December 9th. 07/11/2018 Development Work - Do Not Publish

City and Hackney CCG Clinical Commissioning Forum

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