Brent Clinical Commissioning Group to move to Brent Civic Centre

Wembley Centre for Health and Care

Brent Clinical Commissioning Group (Brent CCG)  at its meeting on December 5th is likely to go ahead with a proposal to move from Wembley Centre for Health and Care in Chaplin Road, to Brent Civic Centre.

Brent Council already lets out two floors in the Civic Centre to external organisations and is due to cut their staff further in the next budget.

The report going before the CCG states:

The CCG has expressed an interest to be co-located with Brent Council in its Civic Centre (subject to affordability and commercial terms). Equally Brent Council is extremely keen and supportive of this move and fully recognises the opportunities for greater collaboration that co-locating would bring.

The current HQ premises are spread across the Wembley Centre for Health and Care site with staff working in silos largely within cellular offices. This is not an efficient use of space nor does it foster cohesive working arrangements.

Releasing space at the Wembley Centre for Health and Care, under the NHS Property Services vacant space policy, potentially creates an opportunity to reduce CCG running costs. Strategically this also supports the future aspirations for the site to become an out of hospital hub, appropriately sized and fit for purpose.

There are 76 staff working at Brent CCG, the accommodation on offer at Brent Civic Centre is 48 dedicated desks together with shared offices and breakout areas. This move would require the CCG to adopt the NWL Agile Working Policy which recommends a staff to desk ratio of between 6:10 and 7:10. The proposal complies with the policy with a ratio of 6.3:10. The CCG is required to reduce its office accommodation and desk allocation across its estate; as such this proposal is in line with the overall strategic direction being adopted across NWL.

Current estimated project costs are £85,500 to be covered from existing revenue funding.

There is an annual saving to Brent CCG of £446,000 generated by moving to Brent Civic Centre.

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“GPs are under pressure but help is at hand” says Royal College top doctor

Speaking at a Brent Patient Voice public meeting at the Learie Constantine Centre on last Thursday 15^th November, Dr Pauline Foreman, Medical Director at the Royal College of General Practitioners, said that GPs sometimes felt like hamsters on a wheel. Patients were unhappy at long waits for appointments. The NHS wanted GPs to send fewer people to hospitals. Visits to practices from the Care Quality Commission were quite scary, even though 90% of practices were rated good or outstanding. NHS England targets to replace retiring GPs were not being met.

However GPs should be seen as irreplaceable specialists in the whole range of medical conditions. Being a GP offered an enjoyable career with a huge variety of challenges and the chance to interact with many different patients. “If GPs could be allocated 11% instead of 8% of the NHS budget under the new NHS Ten Year Plan they could do what they were expected to do,” she said. Help for struggling practices was at hand from the Royal College and others. “Any closure of a practice is a failure, both for patients and the NHS. It costs a great deal and is very upsetting.”

Her message was echoed by long-term Brent doctor and new Chair of Brent Clinical Commissioning Group (CCG), Dr MC Patel. He explained that in Brent there are around 2,300 patients per GP, as compared with a London average of 1,670. “We want to make Brent a borough of choice for GPs and other health professionals” he said. The good news was that after Brent took a stall at a recent nursing event 76 people expressed an interest in working in general practice in the borough. The CCG wanted to see all local practices collaborating under the umbrella of the new Primary Care Homes initiative.

“This could involve some patients going to neighbouring practices for long-term care, e.g. for diabetes, but they would still have their own GP at their regular practice,” said Dr Patel.

Questions from the audience recalled the days of the TV programme “Dr Finlay’s Casebook” demonstrating the value of the one-to-one personal relationship between GP and patient. The speakers agreed that this was still very important for long-term patients but recognised that the younger generation often wanted to access services quickly online.

Thanking the speakers for their very informative contributions, BPV Chair Robin Sharp said:

We as BPV and through our Practice Patient Groups are  keen to help practices in these difficult times. We look forward to working with the Royal College and Brent CCG to secure the best results for patients in Brent.

For further information contact: Robin Sharp, BPV Chair on 020 8969 0381 or robisharp@googlemail.com

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Patients' Forum (London Ambulance Service) submits formal complaint to Brent CCG over withheld performance data

The Patients' Forum for the London Ambulance Service has submitted a formal complaint to Brent Clinical Commissioning Group over an alleged breach of its statutory duties.

The complaint claims that both the CCG and London Ambulance Service has stopped sending the Patients' Forum performance data since August 2017 and that their excuse that the data is 'unvalidated' and therefore not available is not reasonable and in breach of the Freedom of Information Act 2000.

The CCG is thus failing in its statutory duty  to ensure public involvement and consultation in commissioning processes and decisions. (NHS Act 2006 S.14Z2)

Further the Patients' Forum claims that it received no documents for the Clinical Quality Review Group (CQRG) meeting in December 2017 and no papers or notification for the CQRG January 2018 meeting.

Brent could lose Community Cardiology Service after February 2018 - the public have not been consulted

From Brent Patient Voice
 

We have learned that the Brent Clinical Commissioning Group  Community Cardiology Clinics at Wembley and Willesden are closing at the end of February. While we know that the CCG has been discussing the future of this service with local hospital trusts there is no information in the public domain. We have written as below to the CCG Chief Operating Officer, Sheik Auladin, to press for public consultation on this issue as required by the NHS Act
2006. A full response has been promised.

Dear Sheik,

BRENT COMMUNITY CARDIOLOGY SERVICE RE-COMMISSIONING: PUBLIC INVOLVEMENT AND CONSULTATION.

Peter Latham has not yet received any acknowledgement or reply to his letters to you dated 29 November and 5 December 2017 about the future of the Community Cardiology.

We have seen the email letter from Brent CCG dated 30 November 2017 notifying Brent GPs that the current NHS Brent Community Cardiology Service provided by Royal Free London NHS Foundation Trust (RFL) from both Willesden Centre for Health and Care and Wembley Centre for Health and Care will come to an end on 28^th February 2018 with no further extension. RFL are not accepting new patients for this service after 4 December 2017.

Brent Patient Voice are very concerned at the short time now left before the end of the current RFL provider contract for the Brent Community Cardiology Service on 28 February 2018. Brent CCG do not appear to have published anything about their proposals for commissioning such NHS Brent cardiology healthcare services after the end of this contract.

Clearly a number of questions arise. They include the location or locations of replacement clinics, whether equivalent resources will be transferred to new providers, what will happen to patient records and to cases in progress. This list is not exhaustive.

We feel that we must now formally remind Brent CCG that under section 14Z2 of the NHS Act 2006 as amended it would be unlawful for Brent CCG to develop or consider changes in the commissioning arrangements where the implementatiom of the proposals would have an impact on the manner in which the services are delivered to patients or the range of services
available to them without full public involvement and consultation by the CCG.

Please now arrange for someone to respond to acknowledge receipt of this letter and to say how and when Brent CCG propose to inform us as to their proposals for NHS Brent cardiology services after the end of the current RFL contract and for involving the public under the terms of s.14Z2 before final decisions are taken.

Yours sincerely

Robin Sharp
Chair Brent Patient Voice

Brent CCG are looking for Patient Representatives - deadline noon tomorrow

Brent CCG are now recruiting for exciting opportunities for people to get involved in shaping their local NHS and supporting the work within Brent by becoming a non-clinical patient representative.
We are therefore seeking to recruit individuals from Brent, particularly those who have not worked with the CCG before, to become patient representatives on committees.

To apply and download the Patient Representatives Recruitment Information Pack click here.
Please contact Ian Niven by emailing ian.niven@healthwatchbrent.co.uk or call him on 020 8912 5830 if you have any queries.

Please return the completed application form to Sian Avery by emailing her on recruitment@communitybarnet.org.uk or post it to Healthwatch Brent, 3 Rutherford Way, Wembley, MIDDX HA9 0BP

The deadline for all applications is 1 December 2017 at 12.00 noon

Can any WM readers offer Brent Advocacy Concerns any advice? Councillors, Brent CCG, Brent CVS, Brent Healthwatch not responding.

From Brent Advocacy Concerns

Dear Martin,

I was informed today that our office (in Willesden Centre for Health and Care) has been designated as 'a clinical waste dispersal site'.  The building work to convert it is due to begin on the 2nd Jan. 2018.

I have contacted Brent CCG, councillors, Brent Healthwatch & Brent CVS, so far no one has replied.  We have not been informed about any of this but it looks like we will be evicted before Christmas.

Could you ask your readers if that is the way to treat a disability charity that has been providing services for free, for the last 30 years in Brent. 

Just today I had to turn down a business from NW10 who had asked us to represent one of their clients in an ESA benefit appeal next week.  They wanted to know who would be able to help them but there is no one.  I did suggest Brent CAB but they normally require a lot of notice, whereas we could have helped them now.

...................................................................................................................................................................

The background to this distressing issue can be found HERE

If we have to close down, who will help the disabled in Brent?

From Brent Advocacy Concerns (for background see LINK)

Yesterday a 74 year old disabled lady visited our office for her third appointment.  Her main issue is that she lives in a council flat with no heating and is on the third floor in a block with no lifts.  She has to stay in bed all the time to keep warm.  We have had to pass her case onto Brent Start, as we do not know how much longer we can remain in our office.  Normally we would do the work ourselves but we could not be certain that we could complete her case before we had to leave our office.

Brent Clinical Commissioning Group informed us  exactly one month ago today, that they need our office for clinical use but they have not given us any further information and they do not reply to our emails.

This time last year (23rd Nov. 2016) the CCG and the council gave us assurances at 'The Well Being Scrutiny meeting' that they would support us to remain in Brent but they have not been in touch and the councillors do not reply to our emails either. 

The Dementia luncheon club adjacent to our office are still waiting to hear back from the CCG about their future.

Burnley Medical Practice have published on their website that they will start their new contract to deliver GP services from April, 2018.  But before they move in, they have reported that the construction of 8 new clinics will begin in January 2018 on the space currently used by the luncheon club.  A further 4/5 clinics will be based in the area which includes our office.

Burnley also report that they have held several meetings with the CCG and which have included the architects, the planners and others involved in the design of the practice relocation.

But to date, we have not been invited to any meetings concerning our future, nor have we been told anything about Burnley's relocation plans. Like you Martin, I can search and find out relevant information that affects us but it would be nice if the CCG would actually reply to us to officially tell us what is going on.

If we make it to next June (2018) we will have been providing services across Brent for 30 years, so we feel up for a fight, as there are still many disabled people needing our help and if we go who will take our place.

Brent childen's mental health - forum tomorrow

From Brent Clinical Commissioning Group

You are invited to the Health Partners Forum to input into the development of mental health services for children and adults in Brent.

Children Adolescent Mental Health Services (CAMHS) in Brent are presently undergoing a period of transformation as set out in the Local Transformation Plan.  The overall objective of the plan is to support improved mental health and wellbeing for children and young people in Brent. An important part of the plan is incorporating a new approach and thinking into CAMHS, which is known as the THRIVE model. 

http://www.implementingthrive.org/about-us/the-thrive-framework/

Involving residents and service users in this on-going work is an integral part of our continued commitment to developing CAMHS services.

At the Health Partners Forum we will:

·       Summarise plans for services for Brent to improve outcomes for children and young people

·       Update you on where we are with creating more joined up services

·       Summarise what we have heard from you during community engagement so far

·       Work with you to help shape the next phase of transforming services

Your attendance and participation at this event is therefore cordially requested as follows:

Date:       Wednesday 18^th October, 2017

Time:       6-8pm (registration of hot buffet from 5:15)

Venue:    The Sativis Patidar Centre, Forty Avenue, Wembley

Park, Middlesex, HA9 9PE

Please register at: http://bit.ly/2wAKzEx

Further information on the subject

Please visit the following links for further information on local plans for supporting and improving children and young people’s mental health in Brent:

http://brentccg.nhs.uk/en/publications/cat_view/1-publications/12-plans-and-strategies/451-camhs

SEND reform key document is here:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf

http://democracy.brent.gov.uk/documents/s56252/8a.%20Child%20and%20Adolescent%20Mental%20Health%20Services%20in%20Brent.pdf

Action Plan for Brent SEND children services to be approved tonight

The Brent Health and Wellbeing Board will tonight consider a Written Statement of Action following concerns expressed following a joint inspection of the authority's and Brent Clinical Commissioning Group provision for chldren with special educational needs and disabilities. The officer's report states:

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Although some aspects of the inspection were very positive, a Written Statement of Action has been requested. Brent Council, Brent CCG and health providers have worked together to address these concerns and respond to them so that children in any setting can get the right health advice and treatment to support their education. The most challenging of these concerns to address is the waiting times issue that has arisen due to wider shortages of specialist NHS staff. Brent CCG has appointed a specialist Designated Clinical Officer to oversee and speed up the programme of health reforms. 


The inspectors required the local area to provide a Written Statement of Action in regard to the following concerns:

·      strategic leadership of the CCG in implementing the SEND reforms 


·      the fragmented approach to joint commissioning causing gaps in services 


·      the lack of opportunity for therapists to respond to draft EHC plans before they 
are finalised 


·      poor access to services for some vulnerable groups; in particular, to audiology, 
OT and speech and language therapy, limited opportunities for parental involvement when designing and commissioning 
services. 

The draft Written Statement for  Action can be found HERE.

It has to be submitted by October 23rd

 


Wise to start 'Choosing Wisely' prescribing policy engagement again North West London CCGs told

Brent Patient Voice has written to Clare Parker, Chief Officer of the Collaboration of North West London Clinical Commissioning Groups, raising vital issues about the 'Choosing Wisely' engagement on prescribing policies in the eight North West London CCGs.

Here is the letter:

The Steering Group of Brent Patient Voice (BPV) has asked me to write to you urgently about the confusion surrounding the current phase of the “Choosing Wisely” engagement process relating to prescribing policies with the 8 NW London CCGs. The Collaboration of NWL CCGs which you head appears to be leading this process.

The history of this exercise seems to be as follows:

On 19 June Christian Cubbitt for the Collaboration informed BPV that there was an engagement exercise ending 30 June about achieving savings via proposed changes to prescribing arrangements in NW London. We learned that the exercise was deemed to have begun on 12 June, though we have seen no evidence that emails or letters were sent to anyone in the week beginning 12 June, either by the Collaboration or Brent CCG. When we asked Brent CCG in the pre-Governing Body questions from the public session on 2 August why BPV as a body and various individual members who are on the CCG engagement lists had not received notification of the exercise before Christian’s message of 19 June they could not provide an answer. It is not credible to suggest that both BPV and individual members had dropped off the CCG list accidentally. Therefore in our view the effective time allowed for the engagement was 2 working weeks. This was totally inadequate on any conceivable scenario.

However the scenario itself was also deeply flawed for two main reasons.

The first was the absence of information about the existing situation needed as context for a rational judgment about changes which were claimed to be capable of saving over £10 million. We pointed out - and others have done so - that the public would need to know the annual prescribing expenditure on each of the medications listed as not to be prescribed or as suitable for private purchase instead of NHS prescription, accompanied by a clinical assessment of short term and long term medical conditions where savings could be made without risk to patient safety. Manifestly no individual patient reading the questionnaire was likely to have personal experience of more than a small percentage of the medications and would therefore need to know the wider potential impacts before answering the questions.

Secondly the theme suggesting that GPs could ask patients if they minded paying for all or any of these medications out of their own pockets raised obvious issues about ability to pay which were directly affected by a person’s economic situation. There was no indication of any attempt to ensure that the questionnaire would reach a representative selection of individuals in recognised socio-economic groupings or requirement that respondents should indicate what their income bracket or situation in respect of benefits might be. 

In addition it is our view that an Equalities Assessment should have been carried out before the engagement was launched to ensure that it was organised in such a way as to secure that groups with protected characteristics would be reached.

As things stand we have no idea as to the geographical location (even by borough), socio-economic class or long-term medical situation of those who responded to the first online and hard copy exercise. While much material in response to the online survey was available to read (some 300 plus responses), the same does not apply to the 800-900 written replies. We question whether some of the key objections given in the online response were adequately summarised in the papers submitted to Brent CCG GB on 2 August. For the written responses from individuals we have no idea whether these were tick box responses and where they came from.  

Following this deeply flawed sequence of events Brent CCG considered proposals on Choosing Wisely at the Governing Body meeting on 2 August. Among the papers before them was an EQIA from PHAST which contained a series of negative findings about the impact of the proposals on protected groups. No reference was made in the discussion of the item to the nature of these findings but only to the arrangements for the public EQIA Validation event in Harrow on 8 August. The decision was to go ahead with the proposals subject to the outcome of the 8 August meeting. In BPV’s view the decision was defective because no reason was given for ignoring the negative findings of the EQIA. There was also no reference to the National Health Act which determines who should be exempted from prescription charges.

At the EQIA event there was no attempt to “validate” (i.e. check against reality) the EQIA document as laid before the Brent CCG GB. Instead participants were grouped by tables and invited to consider issues under the Equalities Act. Despite this unsatisfactory procedure participants (including several from BPV and pharmacist representatives) contributed what they considered to be relevant concerns about the proposals which they insisted on having recorded. I am to ask for a record of the meeting and in particular the contributions made by participants. Can you please specify a deadline as to when this will be available and on the Collaboration website?

Now to the crux of the matter as far as this letter is concerned.

During the course of the “validation” meeting and apparently on the basis of decisions taken before it began, the Chair, lay member Angeleca Silversides, announced that there would be a further engagement exercise based on modified proposals and “Easy to Read” questionnaires, some copies of which were handed out. A new deadline of 15 September was mentioned. We have learned that Ealing CCG has written to its stakeholders about this exercise with a copy of the new leaflet. In Brent we have heard nothing.

BPV are taking the view that this new or extended engagement has not been communicated by the Collaboration or Brent CCG to those who received the earlier notifications or to those who responded to them, in so far as different. An announcement at a meeting attended by a small fraction of the 2,000,000 people affected cannot be regarded as a satisfactory communication for the purpose. Nor is it clear if this is a revised proposal on which all are invited to comment irrespective of any previous input.

Can you please say urgently therefore:

1. What is the status of this further exercise?

2. Does it replace the first round of engagement and responses to it?

3. If not are people who responded to the first round to respond to this one?

4. If the proposals have been modified how can the two sets of results be amalgamated?

5. Why has the new questionnaire and an explanation not been sent to all stakeholders in NW London and all who responded to round one?

6. What is the status of GB decisions which in the case of Brent envisaged an August start to the new arrangements? (Presumably Ms Silversides has no power to set them aside.)

In view of all these uncertainties would it not be preferable to draw a line under what has happened so far and start afresh with a planning group involving pharmacists, GPs and patients to produce a properly explained and representative survey of prescribing arrangements and possible improvements to them? 

Brent voluntary organisations face crisis as NHS Estate's Market Rent policy is implemented

The NHS Estates programme is scheduled to be completed by June 2017, according to their website which will mean 6 or 7 Brent voluntary organisations providing back-up health services will be faced with paying market rents from April 2017.

Many will not be able to afford them and will be faced with finding new bases despite the Sustainability and Transformation Plan being based on collaboration enhanced by location in the same premises.

At a previous Scrutiny Meeting, it was reported that The Willesden Centre for Health and Care (with its PFI legacy) was "presenting a particular challenge" but the Brent CCG also reported "that plans were in place" to sort it out.  The CCG agreed to "detail in its commissioning intentions how it will use the Estates strategy to support and enable the voluntary sector" (Agenda item 5, NHS  Estate in Brent, 23/11/16.)

Brent Advocacy Concerns, one of the voluntary organisations affected, has approached Brent Healthwatch and Brent CVS for assistance, so far without success. 

Assurances had been given when I raised the issue previously that assistance would be given to voluntary organisation to enable them to be part of contracted services. access grants to enable them to be able to pay market rents, improve their financial viability or to share sessional space at centres.  So far none of these options have resulted in concrete proposals.

Brent Advocacy Concern meet tomorrow lunchtime with the shadow of closure hanging over them with little information on which to plan their future.

Local STP and Health inequalities Jan 25th Bridge Park

You can register:

·        Online: https://brentnhshealthforum_Jan2017.eventbrite.co.uk
·        By emailing: brentccg.engagement@nhs.net

Brent CCG takes another step towards endorsing STP this afternoon after Brent Council gives its approval to strategy

Brent Clinical Commissioning Group is set to move forward on the the controversial Sustainability and Transformation Plan this afternoon at a meeting starting at 2pm at the Chaplin Road Centre.

The public can attend. Tickets HERE

The Governing Body will receive this statement from the Brent Health and Wellbeing Board:

Statement from the Brent Health and Wellbeing Board

The Brent Health and Wellbeing Board supports the priorities set out in Brent CCG’s Commissioning Intentions 2016/17 especially their linkages with the Sustainability and Transformation Plan and their ability to address the real health needs of Brent residents. The Board will support the CCG in ensuring the delivery of these priorities results in high standards of care and enhanced access and that integrated care offers the best possible outcomes for Brent. 

Cllr Krupesh Hirani, Chair of Brent Health and Wellbeing Board

Meanwile, perhaps rather late in the day, Brent Central Constituency Labour Party is holding the following meeting:

The Future of Local NHS Services

Dear Brent Central Labour Party member,

Happy new Year!

You are invited to attend our first Brent Central Labour Party General Committee meeting of 2017.

All members are encouraged to attend, although only delegates to the General Committee will be entitled to vote. 

Date:   Thursday 19th January
Time:   7.30 - 9.30pm
Venue: Christchurch Nursery, St Albans Road, Harlesden NW10 8UG

Extraordinary Brent CCG meeting on Wednesday to further controversial health plans

There is an Extraordinary Meeting of the Governing Body of the Brent Clinical Commissioning Group at noon-1.30pm on Wednesday 14^th December at the Boardroom Wembley Centre for  Health and Care.  The meeting is open to the public and 30 minutes has been allocated to questions from the public.

The meeting is about the business case for Shaping a Healthier Future and the CCG consider this essential for ‘delivering’  the controversial NW London Sustainability and Transformation Plan. Cllr Krupesh Hirani confirmed in the Brent and Kilburn Times today that Brent Council intends to sign the STP despite the fact that neighbouring Ealing and Hammersmith and Fulham councils have refused to do so.

As usual the documents are massive, jargon ridden and with enough acronyms to fill Wembley Stadium.

Anyone who manages to plough through them AND understand them deserves an honorary degree.

Those who think that the STP, though argued on the  basis of benefits to patients, is really a cover for cuts may be interested in the Strategic Outline Case for investment to eventually save money: 

For trusts under the ‘comparator’ scenario, where no commissioner QIPP is assumed to be delivered and with business-as-usual CIP delivery, all our provider trusts will be in financial deficit, with a combined deficit of £114m at 2024/25. However, if commissioner QIPP were delivered, trusts’ I&E would improve to a combined deficit of £18m as additional CIPs can be achieved (termed the ‘SaHF scenario before reconfiguration). The CCG QIPP delivery is dependent in part on the building of the hubs, which is why it is not included in the ‘comparator’. If we receive the capital funding we are requesting, the trusts’ financial projections demonstrate that all trusts will have a sustainable I&E surplus position of £27.6m at 2024/25, with the reconfiguration contributing a c£50m benefit (termed the ‘SaHF scenario after reconfiguration’). 

Currently the trusts are running in-year deficits which would require an estimated cash support of £1.1bn over the next 10 years (and continue thereafter), which would reduce to £0.5bn under the ‘SaHF scenario before reconfiguration’ (where additional CIPs are delivered, partly due to hub investment to enable QIPP delivery). Under the SOC part 1 option (‘SaHF scenario after reconfiguration’), the cash deficit support in the 10-year period would reduce further to £0.4bn and are eliminated post reconfiguration. 

If the capital investment were funded by loans, two of the trusts would have a below target Financial Sustainability Risk Rating (FSRR) and be unable to meet the loan repayments. As the loan funding scenario is unaffordable from a liquidity perspective, we have explored two further scenarios and have concluded that our preferred option is for Public Dividend Capital (PDC) funding, and an accelerated timeline. 

We have also demonstrated that the case is affordable under a range of scenarios by conducting sensitivity analyses.

Documents

BrentCCG SaHF SOC Part 1 cover sheet 14122016

Shaping a Healthier Future SOC Part 1 Covering Report

14 December GB Agenda

Shaping a Healthier Future - Strategic Outline Case Part 1

This is the Brent Cabinet decision as recorded in the minutes of the October 24th Cabinet meeting:

1.     Cabinet noted the STP submission for North West London. 


2.     Cabinet welcomed the principles adopted within the STP of prevention, out  of hospital care, dealing with the social care funding gap and the need to work across the public sector to maximise benefits from changes to the NHS and other public sector estate. 


3.     Cabinet noted that the STP will need formal sign off by the end of December and that between October and December the following issues need to be clarified both within the submission and through other NHS processes, in 
 order for the council to give full support for the plan:

a.     That the IMBC on which delivery area 5 is based is released, debated and understood; 


b.     That the flow of monies from acute to out of hospital settings are clarified; 


c.      That the specification for out of hospital settings, in particular social care, are clarified
based on an agreed model of out of hospital care; 


d.     That a full risk assessment for the plan and relevant mitigations are included.