Present:-

Devon County Council

Councillors Davis (Chairman), Barker, Clatworthy and McInnes, Ms J Stephens (Strategic Director, People) and Dr V Pearson (Director of Public Health)

District Council Representative

Councillor P Sanders

Northern, Eastern Western (NEW) Devon Clinical Commissioning Group (CCG)

Dr T Burke

South Devon and Torbay Devon Clinical Commissioning Group (CCG)

Dr D Greatorex

NHS England

Ms C Williams

Environmental Health

Mr R Norley

Health Watch

Dr H Ackland

Joint Engagement Board

Ms C Brown

Apologies:

Mr T Hogg (Police and Crime Commissioner)

*87 Minutes

RESOLVED that the minutes of the meeting held on 6 March 2014 be signed as a correct record.

MATTERS FOR DECISION

*88 Clinical Commissioning Groups

(a) NHS Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group

The Board considered a report (with supporting papers) from the Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) which provided an update in relation to the Community Services Strategic Framework. This process had commenced in May 2013 to establish the strategic direction and delivery arrangements for community services. The co-production phase of the programme was complete, therefore the strategic framework for community services set out the proposed way forward.

A short summary version of the framework (Integrated, Personal and Sustainable: Community Services for the 21st century) was circulated with the papers, but the full draft strategic framework document was available at:

https://www.newdevonccg.nhs.uk/involve/community-services/101039

A presentation from Ms J McNeill was given to engage and invite Board views ahead of the next Clinical Commissioning Group Governing Body meeting in July 2014. The presentation focused upon building on current strengths, views to the future including the six priorities built from engagement activities, the context for the changes required, preventative and personalised support, the pathways for complex needs, urgent care in the community, community specialty services and the next steps.

In addition, the glossary of terms which has been requested at the last meeting was made available for the meeting and also on the web at http://www.newdevonccg.nhs.uk/who-we-are/glossary/100357

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED that comments and feedback from the Board, on the direction of travel for community services, as outlined in the strategic framework, be welcomed and further views could be submitted online, via email to D-CCG.Community@nhs.net or in writing by 8 July 2014.

(b) Shared Ambitions and Priorities

The Board received a presentation from NHS England and NEW Devon CCG on shared ambitions and priorities, in particular to describe Call to Action on Primary Care Phase 1 Report, describe current joint working initiatives between NHS England the CCG, using the integrated frailty pathway as an example of joint working.

Dr Burke first outlined the biggest challenge facing the GP workforce, in that it was aging and had been insufficient graduates choosing General Practice in recent years. The challenge was to ensure a sustainable service for the next decade. In order to support locally-led transformations in primary care, there was a focus at national level on seven areas, namely empowering patients and the public, empowering clinicians, defining, measuring and publishing quality , joint commissioning, supporting investment and redesigning incentives, managing the provider landscape and workforce, premises and IT.

Dr Burke also highlighted the co-commissioning agenda, including Local Primary Care Co-Commissioning Initiatives.

Ms C Williams then focussed upon frailty and multimorbidity (relationships between the number of long term conditions and cost), including an update on the NHS England frailty guidance, changes to the General Practice contract to focus on older people living with frailty, the elements of a pathway of care and interventions (with evidence of how those initiatives worked) at all stages of the pathway.

Also circulated was the national guidance on safe, compassionate care for frail older people using an integrated care pathway which could be found at;

http://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

The presentation concluded with some thoughts around how far organisations had progressed with implementing an end to end pathway of care for older people living with frailty, what support they required and the challenges of that?

The Board discussed;

that a report was due to be considered at the next Board meeting relating to frailty as a topic based report, focusing on supporting people and the impact within communities;

the importance of succession planning and whether lessons could be learned from the teaching shortage and recruitment drive which had occurred several years earlier; and

the need for a flexible workforce and potentially new roles, equipped to work across agencies and traditional skill bases.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED

(a) that the issues raised and contents of the presentation be discussed further at a Health and Wellbeing Board seminar at a future date; and

(b) that the Lead Officer (Helen Lyndon) could be invited to attend and contribute; and

(c) that Mr Norley be asked to prepare a briefing note on the pertinent issues raised under interventions, such as housing (page 69).

(c) Letter on Co-Commissioning

The Board received both a covering report from the NEW Devon Clinical Commissioning Group and a copy of a letter from NHS England, which outlined how CCGs could submit expressions of interest to develop new arrangements for co-commissioning of primary care services. The work was proposed to be done through the NHS Commissioning Assembly to support CCGs and area teams in developing co-commissioning arrangements.

CCG s were being invited to submit expressions of interest by 20 June 2014.

The Board noted that these expressions of interest should include information on the following areas and include the views of member practices, patient groups, provider organisations and local authority colleagues:

at individual CCG or group of CCGs level;

scope;

nature of co-commissioning;

governance;

monitoring and evaluation; and

engaging member practices and stakeholders

The CCG had not yet agreed or decided at which level or spectrum of potential form the co-commissioning might take, but consultation was underway.

It was MOVED by Councillor Davis, SECONDED by Councillor Clatworthy, and

RESOLVED that the CCG s intention to express an interest be noted and the Board be invited to submit any comments / views to Dr Burke.

(d) NHS South Devon and Torbay Clinical Commissioning Group (CCG)

The Board considered the report of the South Devon and Torbay Clinical Commissioning Group, on the Strategic Plan and progress on other issues such as Care Quality Commission, Musculoskeletal Service (including key work streams), Community Hub Developments and the Pioneer Bid.

The Board noted that the Strategic Plan 2014-19 had been signed-off by the SDTCCG Governing Body in April 2014 and been as subsequently submitted to NHS England. The plan set out the high level priorities for the organisation and partners. In conjunction with the plan, the CCG were required to submit improvement trajectories for the indicators within the Quality Premium. The Board were asked to review this list, which was at appendix A to the report, with particular attention to the local determination indicators, to ensure they were content with the responses.

As part of the CCG update, a report was presented on the CQC National Inpatient Survey 2013, with separate appendices for the Northern Devon Healthcare NHS Trust, Plymouth Hospitals NHS Trust, Royal Devon and Exeter NHS Foundation Trust and South Devon Healthcare NHS Foundation Trust. The report detailed the key findings from the 2013 survey of adult inpatient services. It was the eleventh survey of its kind and involved 156 acute and specialist NHS trusts. There were responses from 62,400 patients (a response rate of 49%). It was important to note there were no areas of failure, but many areas were in line with the average, therefore room for improvement.

The reports relating to individual trusts could be found at;

http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/inpatient-survey-2013

The Board discussed;

clarification of actions required to address concerns, such as medicine delays, and the role of contract monitoring in this process;

caution over terminology the word community hub had a different meaning in Local Government; and

the importance of tackling delays, before acute conditions became chronic.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED

(a) that the Board receive, in November 2014, an action plan from the two CCG s in response to the issues raised in the patient survey. The update should also include provider responses; and

(b) that the national quality premium measures and quality premium local priorities, as outlined in the appendix to the report, be endorsed.

*89 Joint Commissioning in Devon and the Better Care Fund (formally the Integration and Transformation Fund)

The Board received a joint presentation from the Head of Social Care Commissioning (Devon County Council), Managing Director Partnerships (NEW Devon CCG) and the Director of Commissioning (South Devon and Torbay CCG) on current progress with the Better Care Fund. The purpose of this was a drive towards integration and a seamless service user / patient experience being at the forefront of developments around health and social care.

The presentation outlined the journey to date including section 256, the joint strategies and teams, TCS co-production feedback, I Principles and I Plan, the South Devon and Torbay pioneer and also preparation for the Better Care Fund. The plan was submitted in April 2014, having been approved by the Vice Chair, following the agreement of the Board In March 2014 that authority be delegated to endorse the revised submission to meet the deadline of 4 April 2014.

The Board were reminded of the key features of the Better Care Fund which included some national conditions as well as performance metrics and timelines. A revised submission had to be submitted to NHS England by 27 June 2014, but national guidelines were still awaited on the required content.

The presentation further explained the next steps in the process which included ongoing discussion regarding the holding of shared funds for 2015/2016 and the draft pooled budget agreed for 2014/2015, ongoing engagement with providers, the progression of vision, further development as schemes develop through operational groups (scheme development to take place with locality leads to cover 2014/15 and 2015/16, so performance metrics and national conditions would be met), the local metric to be agreed as well as performance elements for April 2015 and October 2015 and then the governance arrangements.

In respect of the section 256 schemes and funding for 2014/15, the schemes proposed were, increasing social care capacity, admissions avoidance, reablement, rehabilitation and recovery, improved delayed discharge and prevention. The strategic allocation was suggested as;

13,407,857 for social care with a benefit to health (agreement between DCC and NHS England);

3,900,000 NHS funding for post hospital discharge and reablement (agreement between DCC and the CCGs);

the sums above, total 17.3m to be used for the purposes set out above, the impact to be monitored against national and local indicators using the performance dashboard; and

2,980,000 (agreement between DCC and NHS England) to be used for preparing for the implementation of the Better Care Fund in 2015 and to make early progress against the national conditions and performance measures set out in the template submitted in April 2014

It was MOVED by Councillor Davis, SECONDED by Councillor Clatworthy, and

RESOLVED

(a) that Board note the progress on the Better Care Fund, the proposed governance structure and performance proposals for monitoring progress;

(b) that the S256 2014/15 strategic allocation and deployment of funding to be transferred from NHS England be endorsed; and

(c) that the plans for the use of the funding identified to prepare for the Better Care Fund and to support outcomes, as set out above, also be endorsed.

*90 Establishment of a Devon Children, Young People and Families Alliance

The Board considered the report of the Strategic Director People on proposals for the formation of a high level strategic multi-agency Children s Alliance . This was not proposed to be a formal committee of the Council but rather a strategic alliance, owning and ensuring delivery of a multi-agency Children and Young People s plan on behalf of that wider partnership and reporting to the Health and Wellbeing Board.

An appendix to the report outlined the terms of reference, which included purpose, function, core membership and frequency of meetings, together with a diagrammatic representation of the proposals.

The Strategic Director welcomed comments on both the proposals and membership of the alliance, including the addition of representation from NHS England and also that the terminology should reflect the importance of families.

It was MOVED by Councillor Davis, SECONDED by Councillor Sanders, and

RESOLVED that the draft Governance Proposals, as outlined in the report, be endorsed subject to the comments made above.

*91 Pharmaceutical Needs Assessment

The Board considered the report of the Director of Public Health on proposals for the production of a Pharmaceutical Needs Assessment (PNA) for Devon.

The Board noted it had a statutory duty to ensure the production of a Pharmaceutical Needs Assessment for Devon. The Health and Social Care Act 2012 transferred responsibility to develop and update PNAs from Primary Care Trusts (PCTs) to Health and Wellbeing Boards. In accordance with the regulation, each Health and Wellbeing Board had to assess needs for pharmaceutical services in its area, and publish a statement of its first assessment and any revised assessment.

Work had been initiated by Public Health teams in Devon, Plymouth and Torbay (working with NHS England) to agree a consistent but locally relevant format which complied with the regulations. It was proposed that a draft document would be consulted upon in October and November 2014 with the revised Pharmaceutical Needs Assessment being presented to the Board in January 2015.

It was MOVED by Councillor Davis, SECONDED by Councillor Sanders, and

RESOLVED that the proposed approach for the production of a Pharmaceutical Needs Assessment (PNA) for Devon be endorsed.

MATTERS FOR INFORMATION

*92 Children s Safeguarding Board Children s Sexual Exploitation Review

The Board considered a report from the Chair of the Devon Children s Safeguarding Board on the review and progress since their in-depth review of the safeguarding child sexual exploitation (CSE) system within Devon.

The report outlined the Peninsula Child Sexual Exploitation Structure and how it was contributing to making improvements including a review and rewrite of the Peninsula CSE working protocol.

Issues arising from the in depth review included the joining up of operational and strategic functions, the roll-out of awareness training regarding CSE, information sharing governance, Early Intervention in terms of sex education of 9 to 13 years (vulnerable children), looked after children (commissioning), development of the operational pathway, missing children (education and runaways) and online safety.

The Board discussed that this was a key priority in the work of the newly formed Devon Children, Young People and Families Alliance and it was important to make the links with corporate parenting, looked after children, schools and educational programmes.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED that the work of the Devon Safeguarding Children Board to improve the safeguarding children practices of staff in Devon, in relation to supporting the content of the Safeguarding Children JSNA, as outlined in the main body of the report, be supported.

*93 Oral Health Strategy

(Councillor Davis declared a personal interest in this matter by virtue of her husband being an NHS dentist)

The Board considered a report from Mr P Howard-Williams which outlined the Local Dental Network (LDN) Oral Health Strategy 2014 2016.

By way of a background, the NICE draft guidelines for local authority oral health improvement strategies were linked on the agenda and could be found at;

http://www.nice.org.uk/nicemedia/live/13664/67139/67139.pdf

The Strategy outlined the key priorities and actions for commissioners to ensure the achievement of better oral health and improved dental services for the people of Devon, Cornwall and the Isles of Scilly starting at an early age and continuing throughout life. The main focus was the introduction of evidence-based preventive strategies delivered within primary dental care, in high quality safe environments by skilled dental teams working collaboratively with the involvement of everyone responsible for delivering health and wellbeing.

Mr Howard-Williams described the links between deprivation, poor health and poor oral health. He stated that poor oral health was preventable and partnerships were crucial in this preventative work.

The Board discussed the following;

the role of public health improvements and the inclusion of oral health in this;

emergency access to dentistry and the role of the 111 system;

issues of affordability, even for NHS dentists, and the impact on other agencies, partners, for example GP s; and

that resources needed to be deployed to the areas of greatest need, thereby reducing health inequalities.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED

(a) that the Strategy and its contents and ethos be welcomed; and

(b) that the link to oral health and its impacts be included within the JSNA; and

(c) that oral health promotion be supported and that further opportunities for oral health promotion and education be explored in light of the Council s new statutory responsibilities.

*94 Winterbourne Review Concordat

The Board considered a report from the Managing Director of Partnerships (NEW Devon CCG) outlining the progress against key winterbourne view concordat commitments. The stocktake exercise had been presented to the Board at every meeting since September 2013 and it had been agreed that regular progress reports be presented to the Board.

This national Concordat plan was developed in response to a Panorama investigation which had showed abuse of patients at Winterbourne View and, as a response, six separate reports were developed nationally. These had generated a multitude of recommendations for many services, including regulators, providers and health and social care commissioners.

The final Concordat was clear about the key aims of preventing further placements of people away from their homes, and supporting those in current services to move back to their community. The end goal was moving people into appropriate community placements by 1st June 2014. Within Devon, (and as a response to Winterbourne View), a seven step pathway had been developed for returning people to appropriate community support arrangements.

The paper further outlined the local progress, focussing on the actions undertaken regarding local services immediately after Winterbourne and the number of people that had to be returned to appropriate community placements and the actions necessary to achieve this, updated figures as at April 2014 which are shown below;

Step 1 - 4

Step 2 - 2

Step 3 - 1

Step 4 - 2

Step 5 - 2

Step 6 - 0

Step 7 - 11

Placed - 10

In addition, the outcomes for individuals, ongoing monitoring of placements and scrutiny requirements were identified.

The report concluded that the health and social care services in Devon were making good progress with the current population and had more people placed in the community. Most of the people had required high levels of planning and coordination to get them home and maintain them safely in their community. There was a challenge for commissioners to create a sustainable position that addressed the young people currently out of area. This required a real cultural shift and changed practice throughout the system.

The Board discussed the following;

the onerous reporting process regarding Winterbourne View to many different groups and the resource it took away from delivering the action plan;

the role of the adults safeguarding board in closely monitoring the situation;

the data cleansing required in order that out of county statistics were a true reflection;

the role of other authorities in repatriation and the impact on budgets, particularly learning disability budgets;

the legal processes that could add delay into current processes;

the role of Councillors in lobbying MP s; and

the Joint Improvement Board and its role in recommending JSNA updates in relation to transitions between children and adults services.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED that the progress be noted and welcomed, including the role of the Adult Safeguarding Board in providing assurance and that future updates be on an exception basis.

*95 Devon Joint Health and Wellbeing Strategy: Priorities and Outcomes Monitoring

The Board considered a report on the performance for the Board, which monitored the priorities identified in the Joint Health and Wellbeing Strategy for Devon 2013-2016.

The Board received an updates only version of the Health and Wellbeing Outcomes Report. The report was themed around the four Joint Health and Wellbeing Strategy 2013-16 priorities and included breakdowns by local authority, district, clinical commissioning group, inequalities and trends over time.

The indicators relating to Teenage Conception Rate (2013 Q1), Hospital Admissions for Self-Harm, Aged 10 to 24 (2012-13), Alcohol-Related Admissions (2012-13), Injuries Due to Falls (2012-13), Dementia Diagnosis Rate (2012-13), Male Life Expectancy Gap (2010 to 2012) and Female Life Expectancy Gap (2010 to 2012) had all been updated since the last report to the Board.

Following approval at the November 2013 Board meeting, a RAG rating had been added to the indicator list and performance summary on page 2 of the full report, Areas with a red rating included Hospital Admissions for Self-Harm Aged 10 to 24 and Dementia Diagnosis Rates.

The indicator list and performance summary within the full report set out the priorities, indicators and indicator types, and included a trend line, highlighting change over time, and a Devon, South West and England comparison chart for benchmarking purposes.

It was MOVED by Councillor Davis, SECONDED by Dr Pearson, and

RESOLVED that the Health and Wellbeing Outcomes Report be noted, in particular the excellent position in relation to the female life expectancy gap.

*96 HealthWatch

The Board received a report on the current work and progress of Healthwatch, in particular the main activities and focus of Healthwatch Devon since the last Board meeting.

The report outlined feedback from service users and their relatives/carers, which indicated high levels of anxiety about possible Council care homes and day centres closures. In addition, Healthwatch were due to submit its response to the NEW Devon CCG "Integrated, personal and sustainable" strategic framework for community services.

In relation to Mental health Services, the report outlined that concerns had been raised about access to care at times of crisis, delays in accessing psychological therapies, a lack of inpatient intensive care beds in Devon leading to patients being placed out of county and a lack of continuity when people are discharged from hospital back into the community.

A recent survey by Healthwatch Devon, in relation to Access to Non Urgent Care, was undertaken and the results were soon to be reported to NHS England and Commissioners,

The report also outlined current items in their forthcoming work plan.

RESOLVED that the issues raised in the report and the actions taken by Healthwatch in relation to care homes, day centres, the community services strategic framework, mental health services and non-urgent care be noted.

*97 Joint Engagement Board (JEB) Update

The Board received a report on the current work and progress of the Joint Engagement Board.

This included involvement in the Tough Choices consultation and Members of the networks reported they were pleased to have been involved in those engagement and consultation activities, in particular day centres and care homes projects. The feedback and concerns were over;

the appropriateness of alternative provision, some of which was seen as not fit for purpose for vulnerable people, especially those with complex needs;

the gap between the Peoples and Place parts of the Council, given People appeared to be withdrawing from providing services, but Place was encouraging community take-up of services where possible; and

the way in which individual service users will be transferred from existing services to alternative provision and whether this would be carried out sensitively. A real concern that financial pressures would dictate too fast a pace for suitable support to be in place.

As well as Tough Choices, the user networks have participated in high volume of involvement activities including, inter alia, the adults safeguarding board service user sub-group, Devon Carers strategy Board, NHS out of hours services consultation, focus groups on stroke services, Devon Partnership Trust target-setting and work with the Care Quality Commission, Care Direct mystery shopping exercise, RD E carers survey, SEND Pathfinder involvement and listening events for parents of children with special needs.

OTHER MATTERS

*98 Letter from Jane Ellison (MP) Parliamentary Under Secretary of State for Health

The Board received a copy of a letter from Jane Ellison (MP) Parliamentary Under Secretary of State for Health on the Governments public health reforms and how they have shifted power to local authorities.

The letter was written to mark first anniversary of the establishment of Health and Wellbeing Boards and to thanks Boards for their hard work in improving the local population s health in creative and innovative ways. The letter further highlighted some priorities and recent work in and out of Parliament, as well as some of the public health issues that have been of particular interest to parliamentary colleagues in recent months, such as the Collaborative Tuberculosis Strategy for England 2014 to 2019, all Party Parliamentary Group on FGM, Headsmart campaign on brain tumours in children, Debates on cancer and Moving More, Living More the Olympic and Paralympic Physical Activity Legacy for the Nation.

The Director of Public Health reported that she was writing to schools in Devon to encourage them to support the HeadSmart campaign.

*99 Scrutiny Work Programme

The Board received a copy of Council s Scrutiny Committee work programme in order that it could review the items being considered and avoid any potential duplications.

*100 Forward Plan

The Board considered the contents of the Forward Plan, as outlined below (which included the additional items agreed at the meeting).

Date	Matter for Consideration
Thursday 11th September 2014 (2.00pm)	CCG Updates Adults Safeguarding Annual Report Children s Safeguarding Annual Report (BF June - request of DCSB) Better Care Fund Topic based report Health Wellbeing Strategy Priorities and Outcomes Monitoring Healthwatch Update Joint Engagement Board Update Scrutiny Work Programme Briefing Papers, Updates Matters for Information
Thursday 13th November 2014 (2.00pm)	CCG Updates CQC Patient Survey Action Plans (min 88(d)(a) Health Wellbeing Strategy Priorities and Outcomes Monitoring Better Care Fund Topic based report Healthwatch Update Joint Engagement Board Update Scrutiny Work Programme Briefing Papers, Updates Matters for Information
Thursday 15th January 2015 (2.00pm)	CCG Updates Devon Pharmaceutical Needs Assessment Health Wellbeing Strategy Priorities and Outcomes Monitoring Better Care Fund Topic based report Healthwatch Update Joint Engagement Board Update Scrutiny Work Programme Briefing Papers, Updates Matters for Information
Thursday 12th March 2015 (2.00pm)	CCG Updates Health Wellbeing Strategy Priorities and Outcomes Monitoring Better Care Fund Topic based report Healthwatch Update Joint Engagement Board Update Scrutiny Work Programme Briefing Papers, Updates Matters for Information
Items to Add	Equality protected characteristics outcomes framework Children s Safeguarding annual report (annually in June / September) Engage Project possibly as a topic based report Winterbourne View (Exception reporting)

RESOLVED that the Forward Plan be approved.

*101 Briefing Papers, Updates and Matters for Information

Items of interest, including research reports, policy documents, details of national / regional meetings and events and consultations which had come to the attention of the Health and Wellbeing Support Officers were listed on the agenda for Board members information.

These were a Councillors Guide to the Health System in England http://www.local.gov.uk/documents/10180/5854661/A+councillor"s+guide+to+the+health+system+in+England/430cde9f-567f-4e29-a48b-1c449961e31f

*102 Dates of Future Meetings

RESOLVED that future meetings of the Board will be held on

Thursday 11th September 2014 @ 2.00pm

Thursday 13th November 2014 @ 2.00pm

Thursday 15th January 2015 @ 2.00pm

Thursday 12th March 2015 @ 2.00pm

*DENOTES DELEGATED MATTER WITH POWER TO ACT

The meeting started at 2.00pm and finished at 5.08pm.