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1 0 - ICCG GB Agenda Part 1_V3 32 1.3 PART 1 Governing Body draft minutes 14 September_ 73 1.3.1 - Part Two Minutes Updated _14 September 174 1.3.2 - 140916 GB Action Log_final 215 2.1 Final Chief Officer's Report - final 236 3.1 - GB Integrated Finance and Activity Report Nov16 297 4.1 - November 2016 NCL STP_kt 518 4.2 - November 2016 Devolution cover paper 559 4.2.1 - London Health Devolution CCG update 5910 4.3 -H&I Wellbeing Partnership Update 8311 4.3.1 - Oct 2016 ACP report to Joint H&I HWBB 8712 4.4 - November JHWS draft for consultation to ICCG GB 9513 4.4.1 - Islington Joint Health and Wellbeing Strategy 2017-2020 9914 4.4.2 - JHWS Consultation form 12315 4.5 - November 2016 NCL commissioning arrangements 12716 4.5.1 - November 2016 paper 2 Proposal to establish a joint 13717 4.5.2 - November 2016 paper 3 Management arrangements for 19718 4.6 - November 2016 primary care delegation cover 21719 4.6.1 - Appendix A Stakeholder Feedback 22720 4.6.2 - APPENDIX B Outline Due Diligence Information 23921 5.1 - GB CoI Report Sept 2016 24722 5.1.1 - Revised Conflicts of Interest Policy 24923 5.2 - Risk Cover sheet 28124 5.2.1 - Corporate Assurance Framework paper 28325 5.2.2 - Copy of Copy of RM Flow ChartV1 28926 5.2.3 - CAF format ICCG Nov 2016 (2) 29127 5.3 - Report of the Chair of the Audit Committee 31128 5.4 - PPP C update 1 September 16_GB 31729 5.5 - Report of the Chair of the Quality Performance 32130 5.6 - November 2016 S&F Committee report 325

Table of Contents

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Table of Contents

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31 6.1 - NCL PCJC Minutes July Final 33132 6.2 - PART 2 item 2 Governing Body draft minutes 13 July 341

Appendix: 0

AGENDA Part 1

Lead Action required Papers

1. Introduction

1.1 Apologies for Absence and Declarations of Interest

Chair Note Verbal

In addition to being published with this agenda, the Register of Interests is available on the CCG’s website (www.islingtonccg.nhs.uk) or from the Business Support Team, 338-346 Goswell Road, London EC1V 7LQ

1.2 Chair’s Introduction and Opening Remarks

Chair Note Verbal

1.3 Minutes and Actions of the Meeting held on 14th September 2016

Chair For approval

For information

For discussion

Item 1.3

Appendix 1.3.1

Appendix 1.3.2

1.4 Matters Arising Chair -- Verbal

1.5 Questions from the Public Chair -- Verbal

NB: Members of the public will be given the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should not take longer than three minutes per person.

2. Overview Reports

2.1 Chief Officer’s Report Chief Officer For discussion

Item 2.1

3. Quality, Performance and Finance

3.1 Integrated Quality, Finance and Performance Report

Chief Finance Officer

For discussion

Item 3.1

4. Strategy

Islington Clinical Commissioning Group Governing Body Business Meeting Wednesday, 9 November 2016 10.30-12.30 Resource for London, Conference Hall, 356 Holloway Road, London N7 6PA

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http://www.islingtonccg.nhs.uk/

Appendix: 0


4.1 North Central London Strategic Transformation Plan

Chair To Note Item 4.1

4.2 London Health and Care Devolution

Chief Officer,

Director of Commissioning

For Approval Item 4.2

Appendix 4.2.1

4.3 Haringey and Islington Wellbeing Programme – Accountable Care Partnership Report

Lay Member, Governance


Appendix 4.3.1

4.4 Islington Health and Wellbeing Strategy

Director of Public Health, Camden and Islington

To Note Item 4.4

Appendix 4.4.1

Appendix 4.4.2

4.5 North Central London Commissioning Arrangements

Chair For Approval Item 4.5

Appendix 4.5.1

Appendix 4.5.2

4.6 Primary Care Co-Commissioning – Update

Chief Officer For Approval Item 4.6

Appendix 4.6.1

Appendix 4.6.2

5. Governance and Assurance

5.1 North Central London CCGs Conflicts of Interest Policy

Director of Quality and Integrated Governance


Appendix 5.1.1

5.2 Assurance Framework and Risk Report



Appendix 5.2.1

Appendix 5.2.2

Appendix 5.2.3

5.3 Report of the Chair of the Audit Committee

Chair, Audit Committee

For Assurance

Item 5.3

5.4 Report of the Chair of the Patient and Public Participation Committee

Chair, Patient and Public Participation Committee

For assurance

Item 5.4

5.5 Report of the Chair of the Quality & Performance Committee

Chair, Quality & Performance Committee

For assurance

Item 5.5

5.6 Report of the Chair of the Strategy & Finance Committee and minutes

Chair, Strategy & Finance Committee

For assurance

Item 5.6

6. For Information

6.1 Minutes of NCL Primary Care Joint Committee meeting - Minutes of the meeting that took place on 27th July will be available at the next Governing Body meeting.

6.2 Minutes of the 13th July Governing Body Part 2 meeting (item 3) – these minutes were

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Appendix: 0


previously signed off at the Governing Body seminar in October 2016. 7. Date of Next Meeting – Wednesday 11th January 2017, 10:30 - 12.30

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Item: 1.3

Part One Minutes Meeting of the Islington Clinical Commissioning Group

Governing Body 14 September 2016

Resource for London, 356 Holloway Road London, N7 6PA

Members Present: Dr Jo Sauvage Chair, Islington Clinical Commissioning Group Dr Katie Coleman Vice Chair (Clinical) Sorrel Brookes Lay Vice Chair Lucy de Groot Lay Member Dr Afsana Bhuiya Central Locality GP Representative Dr Karen Sennett Dr Rathini Ratnavel Deborah Snook

South West Locality GP Representative South East Locality GP Representative Practice Manager Representative

Jennie Hurley Practice Nurse Representative Alison Blair Chief Officer Ahmet Koray Chief Finance Officer Melanie Rogers Director of Quality and Integrated Governance & Executive Nurse

Non-Voting Members Present: Paul Sinden Director of Commissioning Philip Watson HealthWatch Observer Dr Robbie Bunt Local Medical Committee Representative

Apologies: Simon Galczynski Service Director of Adult Social Care and Health, London Borough of

Islington Julie Billett Dr Sabin Khan

Joint Director of Public Health for Camden and Islington Salaried GP Representative

In attendance: N/A

Minutes: Karl Thompson Head of Corporate Affairs

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Appendix: 1.3

1 Introduction

1.1 Apologies for Absence and Declarations of Interest Apologies received from Dr Sabin Khan, Simon Galczynski and Julie Billett. In terms of conflict of interest, Jo Sauvage informed all that she is a GP in Islington and that her practice is a member of a GP Federation and that other GP members also share this conflict. Members and all attendees were asked to share any additional interests. Other Governing Body members had declared interests which are included in the publicly available register.

1.2 Chair’s Introduction and opening Remarks Jo Sauvage explained that we had a significant amount of business to discuss in the part two of the meeting and that she would ensure the first part ran to time.

1.3

Minutes and Actions of the Meeting held on 16 July 2016

1.3.1

Minutes The minutes for both Party 1 and Part 2 July meetings were accepted as an accurate record. Action Log It was noted that all actions were either on this, a future agenda for discussion or now completed. Katie Coleman provided the following update in relation to the role of the GP Ambassadors:

• She had spoken to Dr Anwar Khan, a GP from Waltham Forest, who is undertaking the positon for North Central London (NCL) linking to our Strategic Transformation Plan (STP)

• The role is supported by the Royal College of General Practitioners • Supporting the primary care offer within the STP • Proving independent support to the system helping to ensure front line GPs

views are captured and fed back to the STP

PS

1.4

Matters Arising There were no matters arising.

1.5

Questions from the Public A member of the public raised the following question in relation to the Quality and Performance report within the papers:

• In respect to item 5.4 of the Quality and Performance report, can you provide any further detail regarding the issues within the Care Quality Commission (CQC) report and the actions underway to address those issues and if there are any particular areas where the committee feels targeted scrutiny is required?

Melanie Rogers provided the following response:

• Assurance was given that discussions had been underway, focusing not just on the high level areas but importantly the detail linked to the actions plans to mitigate the concerns

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Appendix: 1.3

• Within the summary provided it was reiterated that the following areas have been under close review;

o The Adastra detail o Nursing home and domiciliary care performance o NHS 111 and out of hours contract mobilisation

• It was also explained that each main provider has a monthly clinical quality review group which provides the opportunity to discuss performance and provide feedback on their progress against any action plans

• In respect to particular areas of focus, the Camden and Islington Foundation Trust CQC report in its entirety remains a key focus whilst for The Whittington, particular attention is required on their emergency care performance and delivery against constitutional targets as well as an ongoing need to monitor patient experience and safety in relation to any reported incidents.

Jo Sauvage thanked Melanie for her update and suggested that she would be happy to discuss any additional concerns outside of the meeting if that was helpful.

2 Overview Reports 2.1

Chief Officers Report All referred to the Chief Officers Report that was circulated ahead of the meeting.

2.1.1

Alison Blair provided updates on the following:

• We are pleased to confirm that Dr Rue Roy has been elected as the new North location GP representative and Governing Body member

• In relation to the support provided by the North East London Commissioning Support Unit (NELCSU), there is a national expectation that we undertake some market testing of their function. Given the current commissioning arrangements discussion, we are trying to defer this so that it falls in line with any additional changes we may want to make

• The NELCSU and South East London Commissioning Support Unit (SECSU) are also in discussion around how they may work more closely as organisations and so we are also in discussion with them regarding any implications this may have.

• Additional CQC reports are due over the coming weeks and this will be reported back to the Governing Body

• Marie Stopes has voluntarily suspended some elements of their service and so we will continue to monitor any impact this may have for our patients

• The CareMyWay programme has sent letters to Islington residents explaining the service and benefits whilst giving them the option to opt out through their practice

• Primary Care delegation proposals will now come to the November meeting as local discussions continue, particularly in Camden where some of their practice members have concerns that require additional discussion

• Part Two of the Governing Body meeting includes the NCL STP and discussion regarding proposals for new commissioning arrangements across NCL

2.1.2

Robbie Bunt asked if we knew any further detail in relation to the primary care delegation vote that Camden practices recently undertook.

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Alison Blair explained that they had undertaken a vote and that they were essentially three practices short of achieving the required number to support the change highlighting that a number of practices abstained from voting and that Camden CCG would continue to discuss any concerns their member practices had. The Governing Body NOTED the report.

3 Quality, Performance and Finance 3.1 Integrated Quality, Finance and Performance Report

All referred to the Integrated Quality, Finance and Performance Report that was circulated ahead of the meeting.

3.1.1 Ahmet Koray reported the following key areas:

• There are significant pressures for both the Whittington and UCLH, reporting significant over performance in the first four months of the year

• The variation in planned and actual acute activity continues to be a concern with the CCG challenging provider figures

• Further analysis across these areas is underway to better understand the trends and ongoing dialogue continues with the providers

• Whilst we remain confident that we should achieve our financial target this year, any surplus is being eroded and so next year will be an even greater challenge

• The performance report details where pressures continue to be seen and include;

o A&E – Whittington and UCLH o Diagnostic waits - UCLH o Cancer referrals – Whittington and UCLH

Lucy de Groot asked if there had been any further investigation regarding the significant increase in maternity spend. Ahmet Koray said that some of this work had been completed which had highlighted that there had been a minimal increase in birth numbers but that there had been a change in the criteria triggers which effectively mean that payments had increased depending upon the type of birth and that this equates to approximately a 30% increase in costs.

3.1.2 Paul Sinden explained that a clinical audit had been requested to better understand the complexity of this.

3.1.3 Rathni Ratnavel asked if we were confident that we were not being charged for out of borough patients and Paul Sinden explained that this is one of the key areas that is scrutinised in relation to our provider payments and the contract management processes. The Governing Body NOTED the Integrated Quality, Finance and Performance Report.

4 Strategy 4.1 Delivery of A&E waiting time standard for Islington and Whittington Health

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All referred to the papers circulated ahead of the meeting. 4.1.1 Paul Sinden provided updates on the following:

• Reiterating that the plans incorporate patient flow throughout the hospital as well as including discharge and importantly activities prior to patients coming to A&E

• A breach report is required to be submitted to NHSE each time the weekly A&E target is missed, identifying the nature of the breach and helping us better understand the problems and the solutions required for improvement

• Mental Health patients attending A&E has impacted performance and therefore we have plans to develop a ‘place of safety’ for the patients in an alternative mental health setting to help alleviate the pressure

• Improvement plans being developed incorporate the five national key actions required along with local plans

• How we are working across North Central London as part of our Sustainability Transformation Plan is also detailed

• Funding information highlights that we have £2m set aside to support winter pressures for 2016-17 along with highlighting other ongoing investments into schemes that already support improved patient flow and system resilience

• Emergency Care pathways defining the level of demand in comparison to our planning assumptions reflects that current volumes are broadly in line with expectations

• Escalation meeting is scheduled with NHSE to discuss our plans to ensure they are sufficient to improve performance

• The Whittington has met the weekly 95% performance target for three of the last five weeks and so improvement has been seen

4.1.2 Sorrel Brookes asked if the Quality and Performance committee could receive demand information so they have an improved understanding of the pressures

4.1.3 Karen Sennett highlighted that whilst increased bed capacity was important, she was also keen to ensure that funding would be available to other schemes such as the ‘REACH’ waiting list initiative as this helps keep patients out of hospital through admission retention. Karen Sennett also asked about the acute exacerbation and ‘chronic obstructive and pulmonary disorder’ (COPD) pathway, particularly if the scheme was continuing under the plans presented. Katie Coleman responded by explaining that both of these services fall within the rapid response programme of activities and there is a recognition that these pathways should continue and work more closely together. Karen Sennett highlighted the ongoing requirement to inform the public of alternative pathways to A&E, particularly when GP practices are closed so they are clear how to access these services. Paul Sinden explained that their negotiations with the Whittington have been clear in defining that funding should not solely focus on increased bed capacity

4.1.4 Jo Sauvage summarised by confirming that she was assured that there is ongoing scrutiny and challenge in relation to the Whittington performance The Governing Body NOTED the Delivery of A&E waiting time standard for Islington and Whittington Health Report.

4.1.5 Action 09/14 – 01: Paul Sinden to provide demand information to the Quality and Performance Committee

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PS

4.2 Planning Guidance and Commissioning Intentions for 2017/18 and 2018/19 All referred to the papers circulated ahead of the meeting.

4.2.1 Paul Sinden provided updates on the following:

• Reiterated that the guidance had evolved and that the Strategy and Finance Committee had seen the paper previously

• NHSE guidance received in July emphasising that providers and CCGs must achieve financial targets and deliver against NHS constitutional waiting times

• Required that two year operating plans are in place with appropriate contracts in place by December 2016

• Confirmed that work was underway to ensure that discussions with providers would be finalised in time for the December signing deadline to be met and that we would also be building the required financial elements, ensuring that we have a robust baseline and take into account the financial pressures we face and the assumptions made within the NCL STP

• Discussions underway in respect to contract form and incentives and how we move hospital contracts away from payment by results to a more population based focus, acknowledging the finance and performance pressures providers are under whilst creating the right incentives to invest in primary care and prevention

• Highlighted that our commissioning intentions are informed by the national and local priorities, informed by community research and liaison with our practices and other programmes

• Primary Care intentions are included on the assumption that increased delegation is taken on from April 2017 however we may well look to introduce these earlier where appropriate

• Procurements are also included where we believe we may need to test the market to improve local services

• Reminded members that Islington received a ‘Good’ assurance rating from NHSE for 2015-16

4.2.2 Karen Sennett asked that the helpful national list that supports the interface between hospitals and practices is incorporated into our commissioning intentions. Also that diagnostics, particularly in relation to two week referrals, are included as whilst this remains a challenge for providers, its delivery is crucial. Prostate cancer follow up within primary care should also be included as this is a London wide initiative. Paul Sinden confirmed that the national list referred to will be included in our contractual letters to providers and that the London wide cancer requirements will also be included. It was also confirmed where there is a forecast increase in demand, that this would also be reflected in a requirement for increased diagnostics and any other areas where activity will increase. Jo Sauvage also confirmed that there are a number of engagement events where our commissioning intentions are shared with our members, stakeholders and the public. Lucy de Groot asked how the NHSE and the NHS Improvement Team will support

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the need to improve planning assumptions. Ahmet Koray advised that there is a national teleconference to further discuss this. Lucy de Groot also asked what incentives they may consider using and if NHSE would still commission specialist services and if so how they would ensure they were aligned with the improved process. Paul Sinden responded advising that STPs would help with provider discussions helping to ensure they recognise their responsibilities to the wider system. He was also able to advise that there is an NCL specialist commissioning group that meet to help support negotiations. The Governing Body NOTED the Planning Guidance and Commissioning Intentions for 2017/18 and 2018/19 Report.

5 Governance and Assurance 5.1 North Central London Integrated Urgent Care Service Mobilisation

Assurance The Governing Body referred to the papers circulated ahead of the meeting.

5.1.1 Paul Sinden updated on the following:

• The paper provides an overview of the integrated 111 and GP out of hours service that is due to go live on 4th October 2016

• Enfield have produced the paper as the lead CCG for NCL • An assurance group, which includes three community members, has been

established with the provider and the paper summarises the key areas under scrutiny

• In line with national requirements, mobilisation is subject to a national gateway process with NHSE. The last checkpoint meeting has just been held and we await the outcome

• Associated risks have been reviewed by the Strategy and Finance Committee with estates issues and GP rota recruitment being cited as key areas for focus

• Currently GP recruitment reports a rate of over 80% for Camden and Islington and this will continue to be a focus

• The second phase of service development, post live date in October, requires new clinical guidelines to be met in relation to clinical hubs and interoperability between 111 and other parts of the system

Jo Sauvage asked for an update as early as possible in respect to the outcome of the gateway meeting The Governing Body NOTED the North Central London Integrated Urgent Care Service Mobilisation Assurance report

5.1.2 Action 09/14 – 02: Paul Sinden to provide an update to members regarding the outcome of the gateway meeting

PS

5.2 Risk Report The Governing Body referred to the Risk Register report that was circulated ahead of the meeting.

5.2.1 Melanie Rogers highlighted the following:

• Progress on the risk development review which considers how we manage our risks across the CCG and the documentation and process used

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• Good progress has been made with the 29th September Audit Committee receiving and update in advance of the final recommendations coming to the November Governing Body

• In respect to the current risk register, there are nine new risks; o three of which relate to the NCL STP programme; o iHub; o financial reserves; o funded nursing care, nursing homes, domiciliary care o A&E service provision

• Current risks are also updated and an additional update column has been added

Melanie Rogers confirmed that there is a robust process in place for the mitigation of risks

5.2.2 Sorrel Brookes asked if under risk 214, UCLH performance, if diagnostics could be included. In addition risk 323, Increased Autism referrals, there are a number of other services where there are long delays and so perhaps the risk could be reviewed to cover a more generic concern over waiting times.

5.2.3 Lucy de Groot supported the approach to the development of the new framework and looked forward to further discussions at the Audit Committee

5.2.4 The Governing Body NOTED the risk report and the development expected for the September Governing Body meeting.

5.2.5 Action 09/14 – 03: Sorrel Brooks commented on a number of changes to the risk register which need to be implemented. Paul Sinden to ensure these are updated

PS

5.3 Safeguarding Adults and Children Annual Report The Governing Body referred to report that was circulated ahead of the meeting.

5.3.1 Melanie Rogers updated on the following:

• Advised that this is the first joint report • That the report supports the activity and separate annual reports of the

individual Children and Adults Boards in Islington • The Quality and Performance Committee and the Safeguarding sub

Committee have also received the report

5.3.2 Robbie Bunt asked if level three training could be improved for GPs and raised a concern that some practices had reported non-payment for the production of child protection reports. Melanie Rogers noted the concerns.

5.3.3 Katie Coleman highlighted that as part of the CareMyWay initiative, that we would continue to be working closely with adults and children’s social care and that this should enhance the relationship The Governing Body NOTED the report

5.4 Report of the Chair of the Quality and Performance Committee Jo Sauvage asked if the Chair of the committee had any particular highlights or themes they wished to comment on taking into account that the Governing Body have all received their reports and previous minutes.

5.4.1 Sorrel Brookes indicated that there were no issues she wished to raise. The Governing Body NOTED the report of the Chair of the Quality and Performance Committee.

5.5 Report of the Strategy and Finance Committee

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Jo Sauvage asked if the Chair of the committee had any particular highlights or themes they wished to comment on taking into account that the Governing Body have all received their reports and previous minutes.

5.5.1 Ian Huckle indicated that there were no issues he wished to raise The Governing Body NOTED the report of the Chair of the Strategy and Finance Committee.

6. For Information 6.1 No additional minutes were provided

7. Any Other Business 7.1 No other business was discussed

The next meeting was confirmed as Wednesday 14th September 2016.

These minutes are agreed to be a correct record of the Part 1 meeting of the Islington Clinical Commissioning Group Governing Body held on 14 September 2016. Signed:……………………………………Date:………………………….

Dr Jo Sauvage, Chair, Islington Clinical Commissioning Group

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Appendix: 1.3 1

Part Two Minutes Meeting of the Islington Clinical Commissioning Group

Governing Body 14 September 2016


Members Present: Dr Jo Sauvage Chair, Islington Clinical Commissioning Group Sorrel Brookes Lay Vice Chair Dr Afsana Bhuiya Central Locality GP Representative Dr Katie Coleman Vice Chair (Clinical) Lucy de Groot Lay Member Deborah Snook Practice Manager Representative Ian Huckle Practice Manager Representative Dr Karen Sennett South West Locality GP Representative Dr Rathini Ratnavel South East Locality GP Representative Alison Blair Chief Officer (items 1 and 2.1) Ahmet Koray Chief Finance Officer (items 1 and 2.1) Paul Sinden Director of Commissioning (items 1 and 2.1) Melanie Rogers Director of Quality and Integrated Governance (items 1 and 2.1) Robbie Bunt Governing Body LMC Representative (item 1 only) Jonathan O’Sullivan Deputy Director of Public Health (item 1 only) Minutes: Frazer Tams Interim Corporate Affairs Manager

Introduction

1. North Central London Sustainability and Transformation Plan

1.1 Update from the Lock-In held on 7th and 8th September AB provided an summary of events that took place at the Lock-In highlighting the 5 key areas of work:

• Out of Hospital (care closer to home) • Consolidation ( including services across the sites specifically stroke and

Barnet and Chase Farm but also Emergency Surgery and Orthopaedics) • New commissioning delivery models (looking at the future footprint with a

system based approach) • Strategic Narrative (defining what the story is to be for the STP) • Productivity (discussions around how to take work out of the system, the

potential move away from PBR and the opportunities to do things differently including procurement opportunities and payroll collaboration)

AB clarified that day 2 focussed on presenting to a selected panel discussing issues such as:

• Social care not always being apparent in discussions • The need to talk thing through from a patient perspective

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• The system and legal framework and with the focus moving away from competition and towards collaboration

• Behavioural changes, specifically clinical behaviour AB confirmed next submission is required by 21st of October. A draft will be available by the end of September and this can be discussed at the Governing Body Seminar on 12th October.

LDG added that what is required now in order to gain clarity over the governance process is a document that clearly defines:

• What work is being done locally • What work is being done with Haringey (Wellbeing Partnership) • What work is done in partnership with Camden • What is being done on an NCL wide basis

2. North Central London Sustainability and Transformation Plan

2.1 Draft Joint Commissioning Strategy (August 2016) and the Draft Financial Strategy 2017-18 (August 2016) The Governing Body approved the ‘Draft Joint Commissioning Strategy’ (August 2016) and the ‘Draft Financial Strategy 2017-18’ (August 2016). The 2016/17 finance paper will be considered by our Strategy and Finance Committee at its September 29th 2016 meeting.

2.2 NCL Commissioning Arrangement The Islington Governing body:

• Understand the mandatory requirement to use the Sustainability and Transformation Plan as the basis upon which to implement the contracting round for 2016/17 and 2017/18, in the first instance.

• Understand the need for the appropriate governance to be defined to strengthen effective commissioner leadership to support the above.

• Agree in principle to the need for Executive level leadership for NCL to drive this, recognising the need for a strengthened approach to collaborative commissioning, to achieve the transformational change required in commissioning approach. This was however subject to clarification as detailed below.

With reference to the information given, the Governing Body were at this point neither able to approve, nor make recommendations regarding the precise leadership role or other roles proposed within the structure, because of the following:

• The need for clarification around function, accountability and governance of the new roles within the context of our statutory requirements as a CCG.

• Clarity around which current posts would be affected and what functionality/autonomy would remain at a local level, enabling local decisions to be made with local partners.

• The need to understand the consequences of these decisions, including

specific clarity around HR accountability, the time scales for

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implementation and better understanding of the impact of these changes on in-year delivery.

• Understanding of the financial implications of the decisions being made. (high level costings of future state vs. current state) and an understanding of how redundancy and other transition costs will be covered.

This detail will need to be worked through, in order for the Islington Governing Body to be assured of how the new governance arrangements clearly acknowledge our statutory role as a CCG and facilitate a better understanding of the potential risks of the proposed changes and how these might be managed. It is envisaged that a report would be brought to the NCL CCG Governing Bodies in October setting out further detail around the governance and implementation of the structure and it would be appropriate for those papers to address the points above.

Signed:……………………………………Date:………………………….


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Meeting Date Action No. Minutes Reference Action Description Responsibility Target Date Progress details

14/09/2016 09/14 - 01 4.1 Delivery of A&E waiting time standard for Islington and Whittington Health

09/14 - 01: Paul Sinden to provide demand information to the Quality and Performance Committee

Paul Sinden October Verbal update to be given at the November Governing Body meeting

14/09/2016 09/14 – 02 5.1 North Central London Integrated Urgent Care Service Mobilisation Assurance

09/14 – 02: Paul Sinden to provide an update to members regarding the outcome of the gateway meeting

Paul Sinden November Completed - Update provided in the November Chief Offciers report

14/09/2016 09/14 – 03 5.2 Risk report 09/14 – 03: Sorrel Brooks commented on a number of changes to the risk register which need to be implemented. Paul Sinden to ensure these are updated

Paul Sinden October Completed

Appendix 1.3.2 ACTION LOG: Islington Clinical Commissioning Group Governing Body

Appendix 1.3.2

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Chief Officer’s Report LEAD GOVERNING BODY MEMBER:

Alison Blair, Chief Officer

AUTHOR: Alison Blair, Chief Officer CONTACT DETAILS:

[email protected]

SUMMARY:

This paper provides the Governing Body with an update on key local developments and broader policy areas not otherwise covered on the agenda.

This report contributes to:

• Ensuring every child has the best start in life,• Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities,• Improving mental health and wellbeing, and• Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: Not applicable

Patient & Public Involvement (PPI): This paper is for information only and is available on the CCG website for consideration by patients and the public.

Equality Impact Assessment: Not applicable

Risks: Not applicable

RECOMMENDED ACTION:

The Governing Body is asked to: • CONSIDER and COMMENT on the items in this report.

SUPPORTING PAPERS: None

Item: 2.1

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mailto:[email protected]

1. Director of Quality and Integrated Governance

Some of you will already be aware, but I wanted to formally notify you that MelanieRogers will be leaving the CCG. Melanie has got a new job as Director of ClinicalServices and Quality for Genesis Care, a private provider of cancer services. She willbe leaving at the end of November 2016.

Melanie has only been with us for a relatively short time but has made a valuablecontribution to the development of the CCG and the quality agenda. I want to take thisopportunity to thank her for her work.

We have been looking at the options for covering the functions on which she leads.This will be for an interim period as the new North Central London CCGs commissioningarrangements are put in place. I am pleased that Jennie Williams has agreed to provideleadership to the quality and nursing functions in the CCG. Jennie is currently theExecutive Nurse and Director of Quality and Integrated Governance at Haringey CCG.She will cover both roles over the next few months. The corporate governance functionswithin the CCG will be covered by myself.

We are giving thought to what additional resource will be needed to support thisarrangement. I will confirm the detail in November.

2. Adult Social Care changes in Islington

Simon Galczynski leaves Islington in early November to take up a new job in Hackney.Simon has made an enormous contribution to transforming social care and hasoverseen the implementation of the biggest reforms in social care since 1948, andmade an important contribution to developing integrated care in Islington and beyond.We will all want to wish him well in his new role and thank him for the contribution hehas made in just a few years.

His role is being split into commissioning and operational management, and therecruitment process should be starting very soon. In the meantime two interimdirectors who have been appointed:

• Brenda Scanlan is working three days a week covering the commissioning role.Brenda recently worked in a similar capacity in Croydon before joining an integratedhealth and care service in a very senior role

• John Nawrockyi is working full time in the operational position. John was Director ofAdult Social Services in Greenwich until last year and has recently been working in asimilar role in Bracknell Forest.

In addition Marian Harrington is retiring as chair of the Safeguarding Adults Board. Marian’s relationship with Islington extends back to 2011 when she joined as an interim Director of Adult Social Care. She has been a great support in that time and gave the CCG great support in the early stages of our development. Marian will be replaced by James Reilly, who was Chief Executive of Central London Community Healthcare Trust until earlier this year. Previously he was an Executive Director at Hammersmith and Fulham Council and an acknowledged expert Director of Adult Social Services. Like Marian, James will also chair Camden’s Board, and will lead the integration of safeguarding work wherever possible across the two boroughs.

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3. Integrated Urgent Care

The new integrated urgent care service for North Central London (NCL) launched on4th October 2016. Following a robust assurance process, decision to go-live was madejointly by NHS England, the NCL Senior Responsible Officer and Clinical ResponsibleOfficer.

The service combines 111 and GP out-of-hours’ services into a single integratedservice operating a “clinical hub” with GP’s, nurses, paramedics, and pharmacists, tooffer direct access to assessment by a clinician, and a broader range of options foradvice and treatment. This will benefit all residents of Barnet, Camden, Enfield,Haringey and Islington by providing a more responsive model of care which avoidsrepetition of assessment and avoids unnecessary steps in the patient’s journey.

Following the commencement of the new service there have been dailyteleconferences to monitor performance and quality, and to address any early issuesthat arose. Activity within the new service has been broadly above that forecastedhowever call answering in 60 seconds performance has remained strong. Performanceagainst this measure has only dipped when the calls coming into the service aresignificantly greater than forecast- i.e. 90 to 100 calls. Early audits of calls andoutcomes have demonstrated accuracy of assessment with no evidence ofunnecessary referrals to ambulance or Emergency Department endpoints.

The first contract and quality review meeting will take place on 28th October 2016; thiswill be chaired by Enfield CCG Director of Commissioning (contract) and NCL Urgentand Emergency Care (UEC) Clinical Lead (quality).

There are a number of developments which will now be taken forward as part of phasetwo service development. These developments include direct booking into GP practicesoutside the hub and 24 hour access to GPs, interfaces and pathways with otherservices such as mental health, community, end of life and the ambulance service.These will also develop further digital urgent emergency care processes includingrecord sharing, interoperability, and developing effective business intelligence acrossthe whole system to measure the effectiveness of outcomes. This will have a focus onmeasuring the “end to end” experience of the patients journey and will be used to notonly monitor performance but also to evaluate the quality and impact of the service.

4. Primary Care Access

NHS England (NHSE) has set out its intention to deliver seven day services in the FiveYear Forward View. In London the Strategic Commissioning Framework has beendeveloped to support equity of provision across the capital. All CCG’s in NCL havesigned up to the delivery of this framework with an ambition to deliver 8-8 access, 7days a week from April 2017. This has been reflected in the Sustainability andTransformation Plan that sets out an expected additional 189,000 appointments peryear to be delivered through extended access across North Central London.

As part of the GP Forward View an announcement was made that funding would beavailable to support extended access. In London this equates to £26m to the end of2018/19. North Central London has been allocated £6.1m of which Islington has ashare of £1.3m in 2016/17. We are awaiting confirmation that this allocation will remainthe same in 2017/18.

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In Islington we have had a 7 day, 8-8 service running since October 2015 funded as part of the GP Access Fund pilots (formerly the Prime Ministers Challenge Fund). This has been led by a committed group of clinicians who have been keen to develop a model that meets the needs of local people. A HealthWatch report commissioned in the spring of 2016 reported a generally positive response from patients who had used the service. The contract for this service is held by NHSE but may novate to Islington CCG for the remainder of this financial year subject to confirmation of funding.

The five boroughs are now working together to develop a common specification for extended access that can be rolled out from April 2017. It is envisaged that we will go out to procurement across NCL, with five separate lots (one per borough). As this is a service to extend access to core primary care services it will be a restricted tender open only to GP’s within the borough of the lot. In the meantime I-Hub continues to develop – it is about to launch a campaign for the winter so Islington residents are aware of the offer available, is working in Whittington Health emergency department on Sundays to redirect patients to its hub in St Johns Way and is now working closely with LCW to ensure referrals can be received from the integrated urgent care service (111).

5. Margaret Pyke Centre Changes

In October 2016 the Margaret Pyke Centre contraceptive service re-located from itsbuilding near King’s Cross to the Mortimer Market Centre, near Goodge Street tubestation just off Tottenham Court Road,. The move followed a consultation earlier in theyear by Central and North West London (CNWL) NHS Foundation Trust on its sexualhealth services.

The Margaret Pyke Centre has moved into its own completely refurbished area withinthe Mortimer Market Centre occupying one half of the first floor of the building, with itsown Reception area, eight consulting rooms and a post-procedure recovery room.Further changes over the next few weeks include the introduction of four new, earlymorning nurse-led clinics starting at 7:45 at the Margaret Pyke Centre in its newlocation, mainly for women seeking repeat contraception.

The Archway Sexual Health Service will also increase its Saturday services, starting6th November, increasing the hours for its contraception service and introducing a new‘Quick Check’ service for people who want to have a check-up for HIV or STIs but donot have symptoms. Both Saturday services will run 9:00-2:00 and be available bybooked appointment, with last appointments at 1:00.

Further details can be found at: http://www.cnwl.nhs.uk/services/sexual-health-hiv/

6. CareMyWay Programme

As planned, in early October the CCG and Islington council took delivery of theCareMyWay service for initial test and validation. The delivered service supports GPrecords and includes key GP documentation. Additional data, including Social Serviceand Acute data, will be added to the service over the coming months. On completion oftest and validation the service will be piloted in a select number of GP surgeries andhealth and social care providers.

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http://www.cnwl.nhs.uk/services/sexual-health-hiv/

7. Part Two

There will be a part two of the Governing Body meeting today which will discuss thefollowing:

• Draft NCL STP submission for 21 October;• Supporting workstream delivery plans for prevention, service transformation,

productivity and enablers.

These reports contain sensitive information not yet in the public domain. As before, attendance for these items will be restricted and some members will be excused. Where possible, the minutes of the confidential discussion will be published in the next CCG Governing Body papers.

NHS England has asked that local NHS organisations do not publish their draft STP submission or a summary document at this stage, pending completion of their assurance process, and therefore we have not included the draft STP submission in Part I of our Governing Body in line with other CCGs and providers in NCL.

We wish to make the STP available to the public as soon as possible, and will do so once the NHSE assurance process is complete.

There is more work to do to finalise the granular detail of our delivery plans. We would welcome development of our plans with the full engagement of people who use services and the public to ensure these plans are reflective of local needs.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Integrated Quality, Finance and Performance Report LEAD COMMITTEE MEMBER:

Ahmet Koray Chief Finance Officer

AUTHOR: Anthony Browne - Head of Finance Nick Cabon – Head of Performance and Information

CONTACT DETAILS:

[email protected] [email protected]

SUMMARY: Financial performance at the end of September 2016 (Month 6) can be summarised as follows:

• The CCG has achieved the Month 6 year-to-date surplus target of £3.2m andis forecasting to meet the 16/17 full year planned surplus of £6.5m.

• Before mitigation, acute over-performance continues to represent the mainfinancial risk to the CCG with a year-end overspend of £5.9m forecast. TheWhittington and UCLH contracts remain the majority of this pressure.

• Acute ‘Points of Delivery (PoD)’ reporting is showing levels of activity and costexceeding plan in all areas except forecast elective care and critical care. Thesignificant variation between planned and actual acute activity is such thatmany provider submissions have been formally challenged. The outcome ofthese challenges will be known following the formal quarter 1 reconciliation ofTrust data which concludes at the end of October 2016.

• Non-acute services are reporting a £2.2m underspend at year end largely dueto a hold placed on acute provider incentives and uncommitted investmentswithin the Better Care Fund (£2.9m forecast underspend).

• Continuing Healthcare services are forecasting a £0.7m pressure above plan.Following Internal Audit review and a number of recommendations, a CCGplan is being developed to strengthen governance, monitoring processes andcosts which may lead to an improvement in the forecast position.

• QIPP performance continues to slip against the target and predominatelyacross the non-elective activity schemes.

• The CCG has balanced the position by releasing its remaining reserves andthose accruals and provisions no longer considered necessary.

• A draft 2017/18 financial plan has been developed and reviewed by theStrategy and Finance committee following publication of planning guidance.

Item: 3.1

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There is still much work to complete before final submission in January 2017, but initial modelling suggests the CCG will be able to meet the planning rules as long as acute performance does not deteriorate further and STP QIPP plans are finalised.

The CCG’s performance against the following standards are currently of most concern (cumulative measure versus (vs) annual target).

Constitution targets (2016/17):

• Diagnostic waits (2.1% vs a 1% threshold)

• Red 1 and Red 2 category A (8 minutes) ambulance calls (74.3% and 66.5%vs thresholds of 75%)

• 4 hour A&E waits (90.0% vs a target of 95%)

• A&E at Whittington Health (87.6% vs a target of 95%)

• A&E at UCLH (89.7% vs a target of 95%)

• The following cancer indicators:

o Two week GP referral target (91.5% vs a target of 93%)o Two week breast symptomatic target (79.8% vs a target of 93%)o 62-day GP referral target (80.7% vs a target of 85%)

Other targets (2016/17):

• Mixed sex accommodation (10 cases)

• Infection control (MRSA – 3 cases; C.Difficile – 24 cases)

• Islington CCG’s dementia diagnosis rate remains the highest across London inAugust 2016 at 93.9%

This report contributes to: Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: Performance has been reviewed by the CCG’s Quality and Performance Committee and finance by the Strategy and Finance Committee.

Patient & Public Involvement (PPI): None specific

Equality Impact Assessment: None specific

Risks: This report is one element used to monitor the Clinical Commissioning Group’s financial and other performance in terms of adherence to core statutory duties.

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RECOMMENDED ACTION:

The Governing Body is asked to:

• CONSIDER the contents of this report

SUPPORTING PAPERS:

Appendix A: Islington CCG detailed year to date actual and full year financial position

Appendix B: Performance summary

Please note that a detailed CSU pack of performance is available to Governing Body members on request.

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1. INTRODUCTION

1.1 This paper presents to the Governing Body of Islington Clinical Commissioning Group the integrated finance and performance position as at 30 September 2016.

2. FINANCIAL PERFORMANCE to 30 September 2016

2.1 At the end of September 2016, the CCG delivered its plan position and currently remains on target to deliver the planned surplus of £6.5m.

2.2 Month 6 Financial performance can be summarised as follows:

Table 1: CCG Financial Performance (Month 6)

Year-to-Date Forecast Actual Variance

Budget Actual Variance £'000 £'000 £'000 £'000 £'000

Resource Allocation (168,062) (168,062) 0 (356,025) 0

Acute (In and Out Sector) 96,409 100,004 3,595 198,666 5,848

Other Acute 8,833 8,839 7 17,511 121

Demand Reserve 0 (2,447) (2,447) (3,387) (3,580)

Acute Commissioning 105,241 106,396 1,154 212,790 2,389

Mental Health 23,675 23,650 (25) 47,301 (50)

Continuing Care 4,065 4,408 343 8,606 685 Community Services (incl. Better Care Fund) 11,805 10,458 (1,347) 20,986 (2,624)

Primary Care Prescribing 12,770 12,757 (13) 25,539 0

Primary Care 2,484 2,446 (39) 4,827 (142)

NHS 111 859 827 (33) 1,654 (65)

Programme Corporate Cost 1,447 1,406 (41) 19,623 (117)

Non-Acute Commissioning 57,106 55,952 (1,154) 128,536 (2,313)

Running Costs 2,490 2,490 0 4,980 0

Reserves 0 0 0 3,270 (77)

Surplus 3,225 3,224 0 6,449 0

2.3 The most significant points to note include:

• At Month 6, data submitted by acute Trusts has remained relatively stable witha small £55k adverse movement when compared to the previous month.Before the release of reserves and accruals (those no longer considerednecessary), the CCG is forecasting a full year pressure of £5.9m against itsacute contracts.

• Point of Delivery level reporting across acute Trusts shows over-performanceagainst outpatients (£1.6m), maternity (£1.4m), A&E (£0.9m), non-elective(£0.5m), diagnostic imaging (£0.4m) and drugs and devices (£0.3m). Elective

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services (£0.3m favourable) and critical care (£0.5m favourable) are forecast to underspend against planned contract values.

• At Trust level, the overspend is split between a £1.9m pressure at theWhittington and £2.4m at UCLH. The Royal Free is forecasting £0.7m aboveplan and there is also a notable pressure of £0.9m from Trusts outside of NCLwith Barts (£0.2m) and Guys (£0.3m) the most significant.

• Acute Trusts have been formally challenged on their data submissions andmust provide evidence that counting and coding of activity has remainedwithin contract terms. These challenges will be included in the formal quarter 1reconciliation of Trust data which is expected to be finalised by the end ofOctober 2016.

• Specific points to note with acute contracts include:

o The Whittington Health contract is forecasting to over perform by £1.9m.This is a reduction of £1.2m on Month 5 reporting. The main areas ofvariance remain within maternity services (£496k), diagnostic imaging(£466k), non-elective admissions (£256k), outpatients (£135k), and A&Eattendances (£285k). Some of this is a consequence of changes to thetariff, for example maternity services and complexity criteria, and othersare a result of an increase in activity (outpatients, diagnostics). A&Eattendances is a combination of factors where activity has increasedmarginally, but more significantly, the Trust is coding more accurately thanin previous years which is attracting a higher charge.

o UCLH is forecast to overspend by £2.4m which is a small favourablemovement on the previous month’s forecast. The Trust continues to reportover-performance against maternity services (£1.1m), A&E (£0.5m) andoutpatients (£1.1m). Compensating underspends in drugs and devices(£236k) and elective (£698k) offset some of this pressure.

o The Royal Free contract is forecasting a £0.7m overspend against acontract value of £10.2m. The majority of the over-performance is againstoutpatients (£297k), drugs and devices (£294k) and non-electiveadmissions (£245k).

• Non-acute services are forecasting a £2.2m underspend at year end. Theunderspend is mainly due to a hold placed on acute provider incentive schemesand uncommitted investments within the Better Care Fund (£2.9m favourable).

• Continuing Healthcare services are forecasting £0.7m above plan with aninternal review underway which aims to strengthen governance and monitoringprocesses in this area.

• The Prescribing Monitoring Document (PMD) for the CCG now contains data forthe first quarter of 2016/17. Based on this, the Medicines Management Teamhave advised that a break-even position is deliverable for the year.

• Running costs are being delivered to plan, i.e. within the £4.98m CCGallocation.

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• QIPP performance is currently reporting slippage against the £9m target for2016/17. This is a result of over-performance against non-elective plans.

• The CCG has balanced the position by releasing reserves those risk-assessedaccruals and provisions that are no longer considered necessary. In addition ahold on non-acute investments associated with the Better Care Fund has beenapplied.

3. ACUTE FINANCIAL PEFORMANCE

Table 2: Acute Financial Performance (Month 6)

Year-to-Date Full Year

Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 %

In Sector Agreements The Whittington Hospital 48,437 49,668 1,231 96,874 98,811 1,937 2% UCLH NHS FT 31,566 32,888 1,322 63,132 65,524 2,392 4% Royal Free NHS Trust 5,109 5,623 514 10,218 10,922 704 7% Moorfields Foundation Trust 2,101 2,111 10 4,202 4,209 8 0% North Middlesex University 412 391 (21) 823 780 (44) (5%) RNOH NHS Trust 383 324 (59) 766 646 (120) (16%) Great Ormond Street 301 343 42 602 683 82 14% In Sector Total 88,308 91,348 3,040 176,615 181,576 4,960 3%

Out of Sector Agreements Barts & The London 3,477 3,565 88 6,954 7,203 249 4% Homerton NHS FT 1,905 2,073 168 3,811 3,966 155 4% Imperial College Healthcare 852 876 24 1,705 1,748 43 3% Guys and St Thomas FT 996 1,199 203 1,991 2,321 330 17% Chelsea & Westminster FT 274 346 72 548 689 141 26% Kings College Hospital FT 179 174 (5) 358 338 (19) (5%) St George's NHS Trust 101 74 (27) 202 147 (54) (27%) NW London NHS Trust 95 129 34 190 258 68 36% Barking, Havering and Redbridge NHS Trust 94 54 (41) 188 107 (81) (43%)

Royal Brompton FT 85 92 7 171 183 13 7% Royal Marsden NHS FT 43 74 31 85 130 45 53% Out of Sector Total 8,101 8,656 555 16,202 17,090 888 5%

Other Acute SLA Exclusions 1,037 996 (42) 1,799 1,716 (83) (5%) Non-Contract Activity 976 1,014 38 1,952 2,136 184 9% Emergency Re-admissions 975 975 0 1,950 1,950 0 0% Acute Diagnostics 1,260 1,270 10 2,520 2,539 19 1% Acute LAS 4,585 4,585 0 9,169 9,169 0 0% Other Acute Total 8,833 8,839 7 17,390 17,511 121 1%

Demand Reserve 0 (2,447) (2,447) 193 (3,387) (3,580)

Acute Total 105,241 106,396 1,154 210,400 212,790 2,389 1%

3.1. Acute Point of Delivery (PoD) analysis:

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Year-to-Date Annual Plan Plan Actual Variance Actual Forecast Variance

Accident and Emergency 5,439 5,882 443 10,878 11,731 853 Community 17,064 17,064 0 34,128 34,128 (0) Critical Care 4,302 4,452 151 8,573 8,309 (265) Diagnostic Imaging 5,024 5,212 189 9,958 10,386 428 Drugs and Devices 1,989 2,144 154 3,976 4,275 299 Elective 13,808 13,530 (278) 27,314 26,858 (455) Maternity 7,548 8,228 680 15,056 16,441 1,385 Non-Elective 18,541 18,883 342 37,079 37,573 494 Outpatients 16,746 17,395 649 33,207 34,846 1,639 Other (incl. CQUIN) 5,948 7,213 1,266 12,648 14,118 1,470

Grand Total 96,409 100,004 3,595 192,818 198,666 5,848

Month 6 Year-to-Date Variances by provider Month 6 FORECAST Variances by provider

UCLH Whitt. Health

Royal Free

Other Trusts Total UCLH Whitt.

Health Royal Free

Other Trusts Total

A&E 282 143 30 (13) 443 542 285 58 (32) 853 Critical Care 293 (38) 31 (136) 151 565 (404) (127) (299) (265) Diagnostic Imaging (34) 208 6 8 189 (71) 466 13 19 428

Drugs & Devices (118) (1) 153 120 154 (236) (2) 294 243 299 Elective (365) (104) (4) 196 (278) (698) (151) (88) 481 (455) Maternity 561 237 (81) (38) 680 1,123 496 (161) (73) 1,385 Non-Elective 111 132 129 (31) 342 139 256 245 (145) 494 Outpatients 442 27 151 29 649 1,116 135 297 90 1,639 Other (incl. CQUIN) 149 628 98 392 1,266 (88) 857 171 530 1,470

Grand Total 1,322 1,231 514 528 3,595 2,392 1,937 704 814 5,848

3.2. The Whittington Health forecast over-performance of £1.9m is reflected across the majority of the Trust’s points of delivery - maternity services (£496k), non-elective (£256k), diagnostic imaging (£466k), outpatients (£135k), and A&E (£285k). Critical care (£404k) and elective (£151k) are forecasting underspends at year end.

3.3. Forecast maternity over-performance has increased by a further £0.2m even though data shows a fall in the expected number of births. The financial pressure is due to activity coding changing from the ‘standard’ to ‘intermediate’ antenatal pathway. This trend is replicated across other Trusts and a NCL wide clinical review of maternity services has been arranged to better understand the coding of data.

3.4. An Activity Query Notice (AQN) formally challenging the Trust’s data, identified that outpatient activity (mainly in respiratory specialities) were above plan due to the correction of pricing errors made in previous financial years. As commissioners where not made aware of these changes, the increase in tariff costs has been challenged.

3.5. Non-elective admissions at the Trust continue to reflect high levels of gastroenterology and respiratory activity.

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3.6. The UCLH contract is forecast to overspend by £2.4m against an agreed contract value of £63.1m. The trust is reporting over performance against maternity services (£1.1m), A&E (£542k) and outpatients (£1.1m). Compensating underspends in drugs and devices (£236k) and elective (£698k) offset some of this pressure.

3.7. The Maternity over-performance is driven by an increase in the planned level of births at the Trust and a similar increase to that seen at the Whittington in the more complex and higher cost ‘intermediate’ antenatal pathway. There is also an upward trend in births with complications at the Trust which is adding to the over-performance.

3.8. Outpatient pressures are noticeable in follow-up attendances within dermatology, clinical genetics, respiratory, general medicine and neurology the main specialities overperforming against plan. An activity query notice (AQN) has been issued to the Trust to request further information on the high level of outpatient follow-up activity.

3.9. The Royal Free is forecasting a £704k overspend. The main areas of variance are with drugs and devices (£294k), outpatients (£297k) and non-elective admissions (£245k). Outpatient over-performance is driven by clinical haematology, oncology and ophthalmology. The latter is a known area of backlog and work is taking place with the Trust to agree plans for clearing the waiting list. Non-elective pressures are largely within nephrology and vascular surgery. High cost device pressures are due to an unexpected increase in costs related to cardiology devices. These material variances from plan have all been formally challenged with the Trust by way of an AQN and will be incorporated in to the quarter 1 reconciliation of Trust data in October 2016.

3.10. Out of sector contracts are forecasting a cumulative £0.9m over-performance against plan with Bart’s Health (£249k) and Guy’s and St.Thomas’ (£330k) the most significant. The majority of the pressure within Bart’s Health is elective services (£404k - breast surgery, plastic surgery and colorectal). Guys and St.Thomas’ pressures are within non-elective (£159k across general medicine, plastic surgery, trauma and orthopaedics), elective (£38k endoscopy) and drugs and devices (£33k).

4. NON-ACUTE

Year-to-Date Full Year Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 % £'000 £'000 £'000 %

Mental Health 23,675 23,650 (25) (0%) 47,351 47,301 (50) (0%)

Continuing Care 4,065 4,408 343 8% 7,921 8,606 685 9% Community (Incl. BCF) 11,805 10,458 (1,347) (11%) 23,611 20,986 (2,624) (11%)

Prescribing 12,770 12,757 (13) (0%) 25,539 25,539 0 0%

Primary care 2,484 2,446 (39) (2%) 4,969 4,827 (142) (3%)

NHS111 859 827 (33) (4%) 1,719 1,654 (65) (4%) Non-Acute Commissioning 55,660 54,547 (1,114) (2%) 111,109 108,913 (2,196) (2%)

Programme Costs 1,447 1,406 (41) (3%) 19,740 19,623 (117) (1%)

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Non Acute Total 57,106 55,952 (1,155) (2%)

130,849 128,536 (2,313) (2%)

Note: The Programme Corporate Cost line includes budget and spend relating to Islington’s hosting arrangements for the London Healthy Living Partnership. Islington CCG is not exposed to any risk associated with the hosting arrangements.

4.1. Non-acute services are forecasting a £2.2m underspend at year end. The underspend is due to a hold placed on the Better Care Fund acute provider incentive scheme and uncommitted investments (£2.9m favourable). The underspend in ‘Programme Costs’ reflects vacancies being held in the Programme Management Office (PMO) and Nursing and Quality team.

4.2. Community services outside of those delivered by the Whittington Health block contract and the Better Care Fund are forecasting a net pressure of £278k at year end. The majority of this over-performance is against the Homerton cost and volume community contract. The CNWL contract, where increased activity and length of stay for 121 care in step-down services at St Pancras, is continuing to forecast a £71k year-end pressure. The SIPGPAL Ear, Nose and Throat contract is showing a marginal £9k improvement on Month 5 reporting however is still forecasting £59k above plan despite an increase in budget to reflect the 2015/16 position.

4.3. Continuing HealthCare (CHC) services continue to show pressures a £0.7m pressure which can be split between the cost of increased activity (£0.2m) and the impact of the national change to the Funded Nursing Care tariff (£0.5m). This position is inclusive of the risk assessed release of previous year, without which the overspend would have been greater. Analysis of pseudonymised patient data shows large increases in the number of palliative and fast track cases. The CCG has begun a piece of work to develop a detailed remedial action plan which aims to address the increased cost and activity in this area and strengthen internal controls and governance.

5. 2017/18 INITIAL FINANCIAL PLANS

5.1. Islington CCG’s 2017/18 programme allocation was confirmed as £335,737k during the five year allocation process announced in 2015/16. The programme allocation reflects a 2.67% increase on the 2016/17 resource.

5.2. For 2017/18 planning purposes, the following guidance has been issued:

• As a minimum, to break-even in-year or achieve a 1% surplus.

• As in previous years, CCGs to plan for a 1% non-recurrent reserve,although scope to utilise has been allowed. 0.5% must remain as uncommittedand held as risk reserve with the other 0.5% immediately available to spendnon-recurrently to support the transformation required by STP plans.

• CCGs also have to set aside a 0.5% contingency to manage in-yearpressures and risks.

• Plans for provider contracts to increase by 2.1% for inflation, but thenreduced by 2% for efficiency – a net increase of 0.1% for planning purposes.

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• CQUIN to remain at 2.5%.

• Primary Care investment of £3 per registered patient over the two-yearperiod. This is not being funded by additional resource allocations.

5.3. Initial plans reviewed by the CCG’s Strategy and Finance committee at its October meeting currently assume the 2016/17 surplus (£6.5m) remains in 2017/18 and 2018/19. However, this under review following publication of the NCL STP CCG control total. This allows NCL CCGs to agree individual control totals amongst themselves as long as the overall position is delivered. The NCL control total has been published as follows:

STP 2016/17 Plan

17/18 In-year Control Total

Cumulative Surplus 2017/18

18/19 In-year Control Total

Cumulative Surplus 2018/19

North Central London (25,551) 1,618 (23,933) 7,612 (16,321)

5.4. As it stands the draft plan delivers the business planning rules set out above, meets the mental health parity of esteem requirements, i.e. that mental health spend is at least the level of allocation uplift, provides for the forecast increase in demographic changes and those cost pressures and investments currently deemed unavoidable, for example the £3pph investment in primary care.

5.5. In total, the planning assumptions are estimated to cost approximately £14.6m, of which £8.7m will be met through the CCG’s allocation uplift and £9m from QIPP savings. In summary, each component of current planning assumptions is as follows:

2017/18 Planning assumptions Acute Non-Acute TOTAL

Demographic and non-demographic growth including parity of esteem 4,412 1,541 5,953 Inflation (2.1%) 4,422 989 5,411 Tariff efficiency (2%) (4,011) (943) (4,954) Net CQUIN impact 115 38 153 Full year effect of 2016/17 and reserves 7,192 1,062 8,254 2017/18 cost pressures 1,752 750 2,502 2017/18 unavoidable investments 0 345 345 Total Business Rules 12,130 2,687 17,664

Less: 2017/18 allocation uplift (8,741) 2017/18 QIPP (6,000) (3,000) (9,000)

Net CCG position (77)

5.6. Whilst much work is still required to complete a robust plan, the most significant risk remains the delivery of QIPP both at a local level and at an NCL/STP-wide level. The QIPP value has been assumed at £9m as this is currently the value required to meet the planning assumption costs for Islington CCG.

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5.7. For the purposes of this initial planning exercise, each NCL CCG has been tasked with identifying £3m of local QIPP with the balance from the STP work streams. It may be that once the STP QIPP analysis is completed, the QIPP value may be greater.

6. SUMMARY CONSTITUTION and OTHER PERFORMANCE TARGETS

6.1. The table below shows areas of challenging performance. The table includes an indication of when performance may return to a compliant position. In summary, this month has seen:

• Further poor A&E performance at UCLH although some improvement in A&Eperformance at the Whittington.

• Concerns relating to diagnostic waits at UCLH;

• Confirmation that four of the cancer targets were not achieved in July 2016for Islington CCG. Cumulatively three targets are non-compliant;

• Two mixed sex accommodation breaches in August 2016;

• Continued performance challenges against the RED 1 and RED 2 CategoryA ambulance calls targets;

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6.2. Whittington Health’s A&E performance for Quarter 2 was below the 94% the Trust was required to achieve in order to receive Sustainability and Transformation Funding (STF). An A&E Improvement Plan is being developed through the A&E Delivery Board which anticipates A&E performance at Whittington Health to recover during Quarter 3. UCLH’s performance continued to be poor in August and September 2016.

6.3. UCLH’s performance against the diagnostic waits target remains significantly below the standard in the latest month. The Trust predicts overall compliance in December 2016 following the discovery of a significant backlog in MRI.

6.4. Performance against the cancer targets at UCLH remains poor. Camden CCG issued a Contract Performance Notice (CPN) to UCLH regarding two week wait and 62 day cancer performance and has commissioned McKinsey to undertake a review of the Trust’s Remedial Action Plans (RAPs).

7. Access Targets

7.1. Accident and Emergency

7.1.1. The CCG failed the 4-hour wait target in August 2016 (92.5%). The CCG performance is calculated as a proportion of the CCG’s main providers’ performances and is published with a time lag of approximately two months.

7.1.2. The Whittington’s performance remained below the 4-hour standard in August 2016 (92.7%). Provisional data indicates that the Trust’s performance improved further in September 2016.

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7.1.3. Despite improved performance, The Whittington achieved 91.3% for Quarter 2 which was below the 94% the Trust was required to achieve in order to receive Sustainability and Transformation Funding.

7.1.4. The Trust has recently reported a rise in ambulance attendances with surges at peak times. Bed pressure has been increasing as the average length of stay increases resulting in fewer discharges and problems with flow out of A&E. The Whittington has also reported a rise in frail elderly admissions for respiratory conditions.

7.1.5. UCLH’s performance against the A&E target improved slightly in August 2016 (90.6%). The Trust’s provisional data for September 2016 indicates a deterioration in performance.

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7.1.6. UCLH has reported surges in high ambulance attendances, high bed occupancy and specialty delays as all contributing to poor A&E performance. The Trust has created a new operational post for the Urgent Care Centre (UCC) which will be filled from November 2016. A GP presence in A&E will also commence in November 2016 which will offer a primary care pathway along with patient education which will focus on the appropriate use of healthcare services.

7.1.7. Moorfields has maintained compliant A&E performance and in August 2016 achieved 97.7%. Daily reporting indicates that the Trust’s good performance has continued into September 2016. The Trust has reported some short-term consultant sickness and issues with arranging locum cover at short notice which, on occasion, have contributed to poor daily and weekly performance but not caused failure against the standard.

7.2. Referral to Treatment Times (RTT)

7.2.1. The NHS standard for referral to first definitive treatment is 18 weeks. The target measures those patients whose pathway is incomplete - the number of patients who have been waiting less than 18 weeks as a percentage of the total number waiting.

7.2.2. The CCG’s performance against the standard based on August 2016 data was 93.4% (15,339 out of 16,424 patients waiting less than 18 weeks). All local providers met the incomplete standard for Islington patients with the exception of the Royal Free.

7.2.3. The number of incomplete pathways has seen a significant increase (deterioration) in the latest month due to increases across a variety of specialities, including general surgery, dermatology, and gynaecology.

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Note: “Other” specialties are those that have very little activity. There are many such specialties and collectively they can account for between a third and half of all activity, but individually they do not make a significant enough impact to determine overall performance.

7.3. Diagnostic Waits

7.3.1. The Diagnostic Wait target is set at 6 weeks and the threshold is 1%. Therefore, no more than 1% of patients who had a diagnostic test in the month should have waited longer than 6 weeks from referral.

7.3.2. The CCG has not achieved the target in the last two years, and the latest month (August 2016) shows a non-compliant position of 2.1%.

7.3.3. The UCLH position remains of most concern with performance in August 2016 below the standard at 7.5%. The Trust still has a non-obstetric ultrasound backlog which increased in the latest month. The Trust reports that Computerised Tomography (CT) will be compliant from September 2016 with endoscopy remaining compliant.

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7.3.4. UCLH declared a serious incident as a result of patients not showing on the Queen’s Square outpatient waiting list. The Trust has been validating all affected patients and to date have found no harm as a result of the Magnetic Resonance Imaging delays. However, there are 58 patients where the consultant needs to review the scan before they can assess whether there was any harm. The Trust predicts MRI compliance from November 2016 and overall compliance from December 2016.

7.3.5. Camden CCG issued a Contract Performance Notice (CPN) regarding diagnostic performance at UCLH on 24 June 2016. The CPN requested a new action plan from the Trust which has been produced in draft and is being reviewed.

7.4. Cancer

7.4.1. The table below summarises the CCG’s performance against each of the cancer targets for the latest twelve months. Four targets were not compliant in July 2016 with the CCG failing three targets for the year to date – the two week GP referral, the two week breast symptomatic and the 62 day GP referral target.

7.4.2. UCLH continues to face a number of challenges affecting the delivery of the cancer targets. However, the Whittington is compliant with all applicable cancer targets for the year to date.

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7.4.3. UCLH experienced technical issues with the June 2016 data submission which resulted in a partial data submission. The figures reported for June 2016 therefore do not represent the full picture for UCLH. This will also have a minor impact on the CCG figures where UCLH data is missing.

7.4.4. Two Week GP Referral Target:

7.4.5. In July 2016, the CCG failed the two week GP referral target with a performance of 91.5% against a 93% threshold. Out of a total of 55 breaches, 31 were a result of patient choice and 20 were due to capacity issues. The majority of breaches occurred across the breast and skin tumour sites and at UCLH. Provisional data for August 2016 indicates an improvement in performance.

7.4.6. Two Week Breast Symptomatic Target:

7.4.7. In July 2016, the CCG’s performance against the two week breast symptomatic target remained below the standard at 84.9%. Of the 13 breaches, nine were due to capacity issues and four were a result of patient choice. Many of the breaches have been at UCLH and the Trust has taken steps to address the situation be improving radiologist recruitment to ensure greater resilience in the breast service.

7.4.8. 62-day GP Referral Target:

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7.4.9. Despite achieving 87.5% against the 62 day GP referral target in July 2016, the CCG’s year to date performance remains below the 85% standard at 80.7%. UCLH failed the 62-day GP referral to treatment pathway in July 2016 (68.6%) and has not been compliant any month for the last two years. This issues remain as previously reported with inter-trust transfer delays and complex diagnostic pathways with urology the most prominent tumour site.

7.4.10. The Trust had predicted internal compliance in July 2016 and overall compliance in October 2016. However, these dates have been revised with internal compliance predicted in November 2016 and overall compliance predicted in January 2017. UCLH has recruited an additional urology consultant in order provide increased operating capacity from January 2017. 62 day GP referred performance is also impacted by poor performance across the head and neck tumour site due consultant sickness. Additional consultant capacity should result in improved performance from November 2016.

7.5. Ambulance Calls

7.5.1. In August 2016 performance against the Red 1 (suspected cardiac arrest and potentially life threatening trauma) fell significantly below the 75% threshold at 52.2%. Red 2 (suspected stroke) performance remained below the threshold, however, Category A (immediately life-threatening) performance improved to 95.2% against a 95% threshold.

8. Quality Indicators

8.1. Infection Control

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8.1.1. There was one case of MRSA relating to Islington CCG patients declared in August 2016. There are three MRSA cases for the year to date. There is no tolerance for achieving this target. Six cases of C.Difficile relating to Islington CCG patients have been reported in August 2016. The CCG’s threshold for 2016/17 has remained unchanged from 2015/16 at 60 cases. The CCG’s year to date performance is below the trajectory.

8.1.2. The Whittington has reported five cases of C.Difficile for the year to date against a trajectory of 17 cases for the year. UCLH has reported 41 C.Difficile cases in the first five months of 2016/17 with a threshold of 97 cases for the year.

8.2. Mixed Sex Accommodation (MSA)

8.2.1. The CCG had two MSA breaches in August 2016, one at UCLH and one at Barts Health. Breaches at UCLH are often due to bed flow/capacity issues with many occurring in the Post Anaesthetic Care Unit, which is part of ITU. The CCG had already failed this indicator for 2016/17 as there is zero tolerance. It should be noted that there have not been any MSA breaches at the Whittington in the latest twelve months.

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Appendix A - Islington CCG detailed year to date actual and full year financial position (Month 6)

Budget Actual Variance Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 % £'000 £'000 £'000 %

Revenue Resource Limit (27,947) (27,947) 0 (168,062)

(168,062) 0 0.0% (356,025

) (356,025

) 0 0.0%

Acute - In Sector 14,718 14,738 20 88,308 91,348 3,040 3.4% 176,615 181,576 4,960 2.8% Acute - Out of Sector 1,350 1,280 (70) 8,101 8,656 555 6.8% 16,202 17,090 888 5.5% SLA Exclusions 127 510 383 1,037 996 (42) (4.0)% 1,799 1,716 (83) (4.6)% Re-admissions & Threshold 163 163 0 975 975 0 0.0% 1,950 1,950 0 0.0% Acute LAS 764 764 0 4,585 4,585 0 0.0% 9,169 9,169 0 0.0% Acute Planned Care 210 208 (2) 1,260 1,270 10 0.8% 2,520 2,539 19 0.8% Non Contracted Activity 163 392 229 976 1,014 38 3.9% 1,952 2,136 184 9.4% Acute Total 17,494 18,054 560 105,241 108,843 3,601 3.4% 210,208 216,177 5,969 2.8%

Mental Health 3,485 3,491 6 20,910 20,886 (25) (0.1)% 41,821 41,771 (50) (0.1)% Mental Health - CAHMS 154 154 0 924 924 0 0.0% 1,848 1,848 0 0.0% Learning Disabilities 307 307 0 1,841 1,841 0 0.0% 3,682 3,682 0 0.0% Continuing Care 643 649 7 4,065 4,408 343 8.4% 7,921 8,606 685 8.6% End of Life Care 113 113 (0) 679 679 (0) (0.0)% 1,359 1,359 0 0.0% Community Services 615 682 67 3,689 3,868 179 4.9% 7,378 7,745 368 5.0% Better Care Fund 1,175 933 (242) 7,048 5,597 (1,451) (20.6)% 14,097 11,195 (2,902) (20.6)% Sexual Health 65 42 (23) 389 313 (76) (19.4)% 777 687 (90) (11.6)% Primary Care - Prescribing 2,128 2,371 242 12,770 12,757 (13) (0.1)% 25,539 25,539 0 0.0% Primary Care - Commissioning 50 4 (47) 302 258 (44) (14.6)% 604 549 (55) (9.0)% Primary Care - LCS 197 533 336 1,182 1,182 0 0.0% 2,363 2,363 0 0.0% Primary Care - GP Out of Hours 117 203 86 702 650 (52) (7.4)% 1,403 1,200 (204) (14.5)% Primary Care-WIC & Interpreting 50 50 0 300 300 (0) (0.0)% 599 599 0 0.0%

Primary Care - GPIT 0 58 58 0 58 58 0 116 116 NHS 111 143 134 (9) 859 827 (33) (3.8)% 1,719 1,654 (65) (3.8)% Non Acute Total 9,203 8,986 (216) 46,418 44,823 (1,595) (94.8)% 111,109 108,135 (2,974) (65.7)%

Healthy Living Partnerships 10 7 (3) 58 55 (3) (4.7)% 16,937 16,937 0 0.0%

Appendix A – page (i) of (ii)

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Integrated Digital Care Record 5 6 1 27 28 1 4.2% 54 54 0 0.0% Islington & Haringey Wellbeing 21 21 (0) 25 25 (0) (0.3)% 75 75 0 0.0% CSU Contract 66 66 0 395 395 0 0.0% 790 790 0 0.0% Property Services (Programme) 28 278 250 167 167 0 0.0% 334 334 0 0.0% Commissioning Support 53 55 2 319 321 2 0.7% 638 665 27 4.2% Project Management Office 16 (1) (17) 95 77 (18) (18.5)% 190 104 (86) (45.2)% Nursing and Quality 34 80 45 207 187 (20) (9.5)% 413 355 (58) (14.0)% Safeguarding - Adults & Children’s 26 25 (1) 154 150 (4) (2.9)% 308 308 0 0.0%

Programme Costs Total 258 537 278 1,447 1,406 (41) (2.8)% 19,740 19,623 (117) (0.6)%

Total commissioning expenditure 26,851 28,122 1,271 162,348 164,795 2,447 1.5% 341,056 344,713 3,656 1.1%

CCG Running Cost - Pay 205 294 89 1,229 1,229 0 0.0% 2,459 2,459 0 0.0% CCG Running Cost - Non-Pay 28 (61) (89) 165 165 0 0.0% 330 330 0 0.0% CCG Running Cost (CSU) 164 164 0 983 983 0 0.0% 1,966 1,966 0 0.0% CCG Running Cost (PropCo) 19 19 0 113 113 0 0.0% 225 225 0 0.0% Operating Costs Total 415 415 0 2,490 2,490 0 0.0% 4,980 4,980 0 0.0%

Acute Demand Reserve 0 (1,319) (1,319) 0 (2,447) (2,447) 0.0% 193 (3,387) (3,580) (1858.0)

% Contingency (0.5%) 0 0 0 0 0 0 0.0% 77 0 (77) (100.0)% Non Recurrent Reserve (1%) 0 0 0 0 0 0 0.0% 3,270 3,270 0 0.0%

Reserves Total 0 (1,319) (1,319) 0 (2,447) (2,447) 0.0% 3,539 (117) (3,656) (1958.0)

%

Total Expenditure 27,266 27,218 (48) 164,838 164,838 0 0.0% 349,576 349,576 (0) (0.0)%

Surplus 681 729 (48) 3,225 3,224 0 0.0% 6,449 6,449 0 0.0%

NB: The CCG continues to act as financial host for the Health London Partnership (HLP) programme.

Appendix A – page (ii) of (ii)

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Appendix B – Islington CCG Performance Summary

Appendix B – page (i) of (i)

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MEETING: Islington Clinical Commissioning Group Governing Body Meeting -Part 1

DATE: 9th November 2016 TITLE: Draft North Central London Sustainability and Transformation Plan LEAD COMMITTEE MEMBER:

Dr Jo Sauvage, Chair Alison Blair, Chief Officer Paul Sinden, Director of Commissioning

AUTHOR: Paul Sinden, Director of Commissioning CONTACT DETAILS:

[email protected] 688 2906

Overview:

Introduction The draft North Central London Sustainability and Transformation Plan (STP) was submitted to NHS England on 21 October. It has been produced by all the main healthcare organisations and local authorities working together within North Central London (NCL). The draft plan is a work in progress and will now be subject to review as part of a national assurance process.

The aim of the STP is to ensure NCL is a place with the best possible health and wellbeing, where no one gets left behind. It sets out how we are planning to meet the challenges we face in health and social care over the next five years and deliver high quality and sustainable services in the years to come.

We recognise that the STP itself is a technical planning document and therefore is not designed for a public audience. To support the next more detailed stage of engagement, we are producing a summary document setting out the main components of the NCL STP to help stimulate public engagement.

NHS England has asked that the local NHS organisations do not publish the draft STP submission or the summary document at this stage, pending the completion of the assurance process and therefore we have not included the full draft STP submission with the papers going to NHS boards and governing bodies at this time. We expect to be able to publish the summary document shortly.

However the organisations within NCL have a commitment to openness and transparency and the full draft STP strategic narrative has been published by all the local authorities in NCL.

Draft Sustainability and Transformation Plan The Sustainability and Transformation Plan (STP) has been produced by all the main healthcare organisations and local authorities within North Central London. It sets out plans to meet the challenges faced locally and to deliver high quality and sustainable services in the years to come.

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The vision for the STP is for North Central London to be a place with the best possible health and wellbeing, where no one gets left behind. The clinical case for change within the STP describes the changing health and care needs of local people and the key issues facing health and care services in North Central London (NCL). It will be used to guide the transformation of local services over the next five years. The clinical case for change in the STP is aligned to address the gaps identified in the Five Year Forward Plan for health and wellbeing, care and quality, and finance. To support delivery of the vision for the STP and address the clinical case for change a programme of transformation has been designed with four fundamental aspects:

• Prevention: We will increase our efforts on prevention and early intervention to improve health and wellbeing outcomes for our whole population;

• Service transformation: To meet the changing needs of our population we will transform the way that we deliver services;

• Productivity: We will focus on identifying areas to drive down unit costs, remove unnecessary costs and achieve efficiencies, including working together across organisations to identify opportunities to deliver better productivity at scale;

• Enablers: We will build capacity in digital, workforce, estates and new commissioning and delivery models to enable transformation.

Delivering these plans will result in improved outcomes and experience for the local population, increased quality of services and significant savings. To ensure overall delivery as a system, a robust governance structure is being developed to enable NHS and local government partners to work together in new ways to drive implementation. Dedicated resources will be put in place to support delivery. It is crucial that the whole system is aligned around delivery of the STP and work is underway to ensure that the development of the two-year health contracts that are being put in place for 2017/18 - 2018/19 are consistent with the STP strategic framework. There is more work to do to finalise the granular detail of our delivery plans and address the residual challenge forecast. Development of plans in more detail will involve full engagement of people who use services and the public to ensure those plans are reflective of their needs. There is a commitment to being radical in approach, to focusing on improving population health and delivering the best care in London. Our population deserves this, and we are confident that we can deliver it. The second draft of the North Central London (NCL) Sustainability and Transformation Plan (STP) documents submitted to NHS England on 21 October 2016 therefore articulates:

• The health and social care landscape, and its complexity; • The collective understanding of the challenges faced through the clinical case for

change; • The vision for health and care in NCL in 2020/21; • The plans to deliver the vision and address the challenges, and the delivery

framework that will enable implementation of those plans; • The impact expect to be achieved through the delivery of the plans; • Supporting governance arrangements;

o Plans for securing broader public support and engagement with the STP proposals;

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o Next steps for further developing proposals and responding to our residual financial gap.


• Ensuring every child has the best start in life; • Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities; • Improving mental health and wellbeing; and • Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: An additional Governing Body Seminar was held on 12 October 2016 to allow the Governing Body an opportunity to comment on the second iteration of the Sustainability and Transformation Plan prior to submission to NHS England on 21 October 2016. Development of the STP has been further considered at earlier Governing Body Seminars. Patient & Public Involvement (PPI): This report is for information only. The STP is informed by prior patient and public involvement carried out by CCGs, Councils and providers. Further engagement opportunities for comment on the STP will be developed. Equality Impact Assessment: Not applicable for this report. Equality Analysis will be a vital part of ensuring the STP delivers improvements across the diverse population of North Central London. Risks: The Clinical Case for Change identifies key health and care risks for the population of North Central London. RECOMMENDED ACTION: The Governing Body is asked to:

• NOTE the report

SUPPORTING PAPERS:

• None

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: London Health Care and Devolution LEAD COMMITTEE MEMBER:

Dr Jo Sauvage, Chair Alison Blair, Chief Officer Paul Sinden, Director of Commissioning


[email protected] 688 2906

Overview:

London Health Care and Devolution London is on a journey to become the healthiest city in the world. Over the past few years, our health and care system has made significant strides to organise services around the changing needs of our city’s growing and diverse population. In support of this progress, the Government recently invited London to explore whether devolution could make these improvements go further and faster.

In December 2015, all 32 Clinical Commissioning Groups (CCGs), London Councils on behalf of the 32 London boroughs and the City of London, the Mayor of London, NHS England and Public Health England came together as ‘London Partners’, and signed the London Health and Care Collaboration Agreement. Through this, the Partners committed to work more closely together to support those who live and work in London to lead healthier independent lives, prevent ill-health, and to make the best use of health and care assets.

Central government and national bodies backed this vision through the London Health Devolution Agreement, and invited London to explore devolution – the transfer of powers, decision-making and resources closer to local populations – as an important tool to accelerate transformation plans and respond to the needs of Londoners more quickly.

Many decisions about health service planning and budgets are taken at national level. This can sometimes create unintended barriers to delivering the connected and tailored local services that Londoners want. London has already made significant progress in integration and collaboration within the current system through: co-commissioning in almost all CCGs; cross-borough STPs; pooling budgets through the Better Care Fund; joint decision-making by health and wellbeing boards; and innovative transformation through NHS vanguards and integration pioneers.

Devolution aims to allow us to go even further by enabling health and care decisions to be made for London, in London.

Through the devolution agreements, London Partners aim to minimise unnecessary bureaucracy, and provide new opportunities for CCGs and boroughs to support Londoners to be as healthy as possible and to ensure that the health and care system is on a sustainable footing.

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https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf

https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement#parties

https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement#parties

London’s health and care landscape contributes significantly to the rest of the UK: a quarter of NHS doctors and more than half of England’s nurses are trained in the capital, and London is a centre of excellence for health training, education and specialist care. London’s health and care system is also very large, with hundreds of organisations and a considerable proportion of the NHS budget. Given this size and complexity, we are exploring how devolution could work in practice through five pilots. These pilots have focused on our three priorities - prevention, health and care integration and making best use of health and care buildings and land - and are exploring decision-making at the most appropriate and local level. When developing their proposals, pilots have been exploring what is possible within the current system and what explicit devolved powers are sought. It is clear that much can be done within existing powers, but that by overcoming some specific challenges, efforts to transform health and care could go further and faster. Pilots are setting out their transformation vision, ‘offers’ by the local system to accelerate action and devolution ‘asks’ to overcome identified barriers to progress. This paper aims to update CCG governing bodies on the progress of the London Health and Care Devolution Programme as we move towards a second devolution agreement and to confirm ongoing support. We are keen to ensure the asks are coproduced and are reflective of the London-wide system’s thinking. As we draft the final agreement and shape our final asks, CCG governing bodies are asked to: 1. Note progress and the forward timescales to the next Devolution agreement for London,

building on the commitments and priorities agreed in December 2015; 2. Review and provide any comments on the current proposals as they support specific

Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs;

3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.

This report contributes to: • Ensuring every child has the best start in life; • Preventing and managing long term conditions to extend both length and quality of life

and reduce health inequalities; • Improving mental health and wellbeing; and • Delivering high quality, efficient services within the resources available. Prior consideration by Committees and other partners: In December 2015, all 32 Clinical Commissioning Groups (CCGs), London Councils on behalf of the 32 London boroughs and the City of London, the Mayor of London, NHS England and Public Health England came together as ‘London Partners’, and signed the London Health and Care Collaboration Agreement. In November 2015, the Governing Body approved the draft London Collaborative Agreement which underpins the approach to devolution. In addition the development of a proposal for a devolution pilot on estates in North Central London was noted.

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https://www.london.gov.uk/what-we-do/health/london-health-and-care-devolution/testing-health-and-care-devolution

https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf

Patient & Public Involvement (PPI): This report is for information only. Equality Impact Assessment: Not applicable for this report. Risks: There are currently no risks relating to this on the CCG’s corporate risk register. RECOMMENDED ACTION: The Governing Body is asked to: 1. NOTE progress and the forward timescales to the next Devolution agreement for

London, building on the commitments and priorities agreed in December 2015; 2. Review and provide any COMMENT on the current proposals as they support specific

Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs;

3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to APPROVE and sign off the agreement on behalf of the CCG.

SUPPORTING PAPERS:

4.2.1 - London Health and Care Devolution CCG Update

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London Health and Care

Devolution

Enabling health and care transformation through devolution:

Update and next steps

19 October 2016

Appendix 4.2.1

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Background

• This paper aims to update CCG governing bodies on the progress of the London Health and Care Devolution Programmeas we move towards a second devolution agreement.

• Following the devolution agreements in December 2015, London partners have been working with five local and sub-regional pilots to support the development of business cases for devolution.

• When developing their proposals, pilots have been exploring what is possible within the current system and what explicitdevolved powers are sought. It is clear that much can be done within existing powers, but that by overcoming some specificchallenges, efforts to transform health and care could go further and faster. Pilots are setting out their transformation vision,‘offers’ by the local system to accelerate action and devolution ‘asks’ to overcome identified barriers to progress.

• The emerging work of the pilots has reiterated the need for multi-level action, based on the foundational principle ofsubsidiarity. The devolution agreement last year described three levels for devolved powers: borough-level, STP-level andLondon, with aggregation only where necessary.

• This paper contains:

‒  A summary of current devolution proposals.

‒  This includes a description of the current thinking on the most appropriate approach for individual proposals (e.g. London level or voluntary draw-down by individual boroughs).

‒  These proposals continue to evolve as pilots finalise their business cases and with ongoing input from national bodies and central government and wider engagement. As such, the detail of proposals and spatial levels is still evolving. The proposals are therefore draft and work in progress.

‒  Timeline and process for the next steps

2

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London already has a shared vision for better health and care

2012

London Health

Devolution Agreement

2013 2014 2015

London Health Board formed

London Health and

Care Collaboration

Agreement

London Health and

Care Devolution Programme established

Health and Social Care Act passed

Better Care Fund

Transformation in integrated health and social care

Better Health for London

64 recommendations

for London

Five Year Forward View the NHS’ strategy

Greater Manchester’s

health and social care devolution

deal

Better Health for London: Next Steps

First collaborative vision for London

2016

44 STPs under

development

Sustainability and

transformation plans (STPs) announced

Healthy London

Partnership established

Nat

iona

l m

ilest

ones

Lo

ndon

m

ilest

ones

Devolution pilots

underway

New Models of Care

Programme

DRAFT

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Transformation plans

Devolution aims to unlock barriers and enable transformation plans to go further and faster

Improving the health and wellbeing

of Londoners

Devolution

Learn more at: https://youtu.be/ir7oKEND9zs

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The devolution journey

Test how devolution could work in five areas of London

Secure devolution based on

robust business

cases

Devolution available across London

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Key: type of pilot

Local prevention – note that this borough is also part of the sub-regional estates pilot

Sub-regional care integration Sub-regional estates Local care integration

Integration in Lewisham: creating “One Lewisham Health and Social Care system” by combining mental and physical health services and social care

Integration across Barking & Dagenham, Havering and Redbridge: delivering a personalised health and care service focusing on self-care, prevention and local services that enable the sustainability of the health and care system

Prevention in Haringey: exploring licensing and planning powers needed to ensure that local environments support health, and looking at early intervention to support those who have fallen out of work due to mental health issues

Integration in Hackney: Bringing together mental and physical health services, and health and social care budgets

Estates in Barnet, Camden, Enfield, Haringey and Islington (‘North Central London’): making better use of health and care buildings and land

London’s five pilots are exploring how devolution could work at different spatial levels

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01 Current status of proposals If you have any questions on the following please contact the programme team [email protected]

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Some asks are for the whole London system, others would be permissive, subject to local appetite and business cases

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The terms of application of each proposed ask are specified in the pages below. These broadly fall into two categories:

-  ‘London level’ asks, which consist of the freedoms, powers and variations which, if granted, will apply to the London system as a whole; and

-  ‘Local/multi-borough draw-down’ asks are the freedoms, powers and flexibilities which, if granted, will be made available to sub-regional and local health economies to adopt should they so wish, subject to robust business cases.

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9

Integration: Summary of potential devolution asks

2c

Greater alignment between NHS England, NHS

Improvement and CQC for regulatory functions in

London

The ability for an integrated / single delivery

system to be regulated as a whole, despite underlying

distinct organisational operating units*

Supporting greater integration of the health and care

workforce and addressing recruitment/retention

challenges (London, sub-regional/local)

Funding and governance to support workforce

transformation (London/sub-regional)

Delegation / devolution of NHS England functions including primary care

commissioning, capital and transformation budgets

The ability for a joint local authority/CCG structure to

take on commissioning functions, with pooling of

budgets*

Commissioning levers and financial flows Regulation Workforce

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Draft scope of ask

Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)

London level

Other

*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework

Freedoms and flexibilities during the development and

initial implementation stage of the pilot

Supporting pilots to co-develop and adopt innovative payment

models

•  Enabling the delivery of integrated care and more consistent mental health and acute care; strengthening primary and community care, reducing hospitalisation and improving outcomes.

•  Thus, enabling people to live more independently and contributing to the financial sustainability of the system

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10

Estates: Summary of potential devolution asks

2c

Delegation of capital business case review and

approval functions (sub-regional or London,

depending on the delegation limit)

Retaining the capital receipts generated by the London

system to enable investment in health and care in London

Adoption of a commissioner capital control total

(London with sub-regional draw-down)

A London estates board comprising local health economies, London and

national partners to ensure clarity on London’s assets, projects and capital needs,

building up from STP estates strategies.

An estates delivery unit to consolidate existing

London-level and national expertise to support local

areas to develop and deliver high-quality capital cases

London governance and delivery Business case approval Capital

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Draft scope of ask

Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London)

London level

Utilisation

*Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework

Accountability within London for utilisation of existing health and

care estates

•  Releasing capital from surplus estate to invest in primary, community and hospital estate •  Releasing surplus land for housing and wider public sector use •  Accelerating estate transformation by streamlining decision-making

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London partners recognise significant opportunities to enable greater value for Londoners from the NHS estate. These form the basis of London’s devolution proposals. An estates board aims to directly solve some of the challenges of NHS estates approvals and disposals, by providing a single forum for NHS estate discussions in London and through early involvement of London government partners and national bodies. As it matures, the Board would also provide a mechanism to administer devolved responsibilities, including delegated business case approvals.

The Board aims to enable strategic and decision-making functions to enhance efficiency, quality and transparency of discussions and decisions that are currently taken nationally. These functions would be phased over time, with the Board commencing with strategic and advisory role.

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An estates board for London

The Board would aim to operate according to key principles: •  Subsidiarity, with decisions taken at the lowest appropriate level, and only taken at the London level when needed. •  Transparency – with all relevant discussions taking place at the London estates board •  All partners bringing the collective expertise of their constituent organisations to achieve the greatest value for Londoners. •  Decision-making will seek to achieve consensus so far as is possible, while respecting the views and statutory

accountabilities of constituent organisations.

The role and function of the board has significant interdependencies with wider devolution proposals. Detailed discussions continue to clarify the proposed nature and scope of such devolved powers, and the board in its initial phase will be a valuable vehicle to collate expertise and streamline decision-making in this respect, allowing proposals to be developed at pace. The board’s ability to fulfil the desired objectives would therefore be contingent on these devolved or delegated powers and resources being granted.

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Prevention: Summary of potential devolution asks

Devolution asks focusing on prevention have been progressed across three themes:

Powers to address problem gambling

Health as a fifth licensing objective for alcohol

(for local trial)

Powers to reduce tobacco consumption, distribution and illicit

circulation (some pan-London

elements for illicit tobacco)

Devolve part of health and work budget to trial

initiatives tailored to local needs (London ask with

funding devolved to local/multi-borough level)

Contractual variations to Fit for Work

service

Planning, licensing and fiscal powers to

encourage healthier high streets

(London and local)

Use sumptuary tax revenue to invest in

London health priorities

Tackling Obesity Healthier environments Health and Employment

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Draft scope of ask

Local/multi-borough voluntary draw-down (commencing with Haringey prevention pilot)

London level

Complement individual Londoners’ efforts on staying healthy in their daily lives. Using devolution as a means to create better environments in which people can flourish

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Ongoing activity

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Iterating proposals

Exploring governance and accountability

Engagement on devolution asks and

offers

Discussions re: legislative change

Sharing learning

•  Workshops with central government, national bodies, London partners and pilots to align objectives and test the appropriate devolution levers to bring about intended health outcomes

•  Maximising opportunities for alignment with STPs •  Supporting pilots to develop business cases by late October

•  To be developed based on emerging pilot governance proposals and engagement with constituent organisations and London partners.

•  Phased approach based on devolution requirements e.g. need for financial accountability

•  In partnership with DH, DCLG, NHSE and NHSI. London is examining amendments to existing legislation and considering additional legislative requirements

•  Engagement on and iteration of devolution offers and asks with the wider London system

•  Including shared learning from the pilots and development of a support package for non-pilot areas

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01 Shaping final asks and the December agreement

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02

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CCG involvement in shaping devolved health powers in London

•  Engagement has been key to developing the current set of asks and proposals. The high level proposals are subject to ongoing discussions with borough leaders, CCG Chairs and Chief Officers, LHCOG, BCF leads, London Prevention Board, LRET, HWBB chairs and the ADPH network.

•  These opportunities for engagement with the developing devolution propositions will be critical, but they will not by themselves offer the mechanism for propositions to be explored comprehensively in detail, nor will these opportunities allow for the detailed and ongoing engagement likely to be required in the run up to December. For example, as pilot areas develop asks and discussions with London partners refine the detail, London’s health and care system leaders may wish to be able to offer engagement which can respond flexibly and in an iterative way.

•  The strategy for reaching agreement on London’s December asks will require an approach which recognises that decision making will be necessary for different asks at different spatial levels. For example, where asks are emerging which would not of themselves affect all of London if granted (i.e. they are permissive and discrete to local or sub-regional footprints) then the appetite and support from a pan-London level would be beneficial but may not be essential to the case being made by the pilot area. However, where asks are emerging which would affect the whole of London if granted (i.e. where a pilot is making the case for devolution which would impact on all boroughs), then broad agreement of the London system would be needed.

•  We are keen to ensure the asks are coproduced and are reflective of the London-wide system’s thinking. As we draft the final agreement and shape our final asks, CCG governing bodies are asked to:

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1.  Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015.

2.  Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs.

3.  Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.

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Engagement with local government

16

Month Meeting or event

June Healthwatch Hackney July London Councils and HSCIC Meeting September Chief Executives (of local councils) of London Committee (CELC) September Health and Wellbeing Board Chairs October CELC November CELC (TBC) December Health and Wellbeing Board Chairs (TBC)

Local councils are engaged in discussions about health and care devolution. Illustrative engagement undertaken to date is described below:

In addition, significant engagement is underway at local level within pilots, among all stakeholders and political leadership.

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Key dates

CCG engagement

Develop business cases and clarify asks and offers

Oct Nov Dec Jan Feb Mar April April June Aug Sept July

STPs submitted

LHB

Pilots Iterate business cases and negotiate

devolution

Menus of devolution developed for London

Implement shadow

arrangements

Develop business cases for devolution if locally desirable

London-wide

activity

Spreading learning

Sharing learning from pilots

Develop new working arrangements with phased implementation of activities within current powers

(TBC) Further devolution

announcement

2016 2017 2018

STP operational plans submitted

Non-pilot areas Engagement on devolution asks and offers

Implement shadow

arrangements

Implement devolved

arrangements

Develop London-level proposals Develop new working

arrangements with phased implementation of activities within

current powers

Implement shadow

arrangements

Implement devolved

arrangements

Chief officers meeting London

Prevention Board

CCG chairs

12 14 14 15 29

27

19 Chief officers

LTG

LTG LTG 20 LTG

7 CCG CFO 17 Chief

officers & Chairs

5 CCG CFO

14 Chief officers

Themes, processes, timelines

Excerpts of draft

agreement and emerging

proposals

Updated agreement

and proposals

Final agreement

Pilot OBCs developed

Current programme and engagement timeline

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01 Initial agreements published in 2015

Annex

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•  The London Health and Care Collaboration Agreement •  The London Health Devolution Agreement

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Two London agreements were signed in December 2015

Agreement to transform health and wellbeing outcomes and services, recognising:

•  the need to shift from reactive care to prevention, early intervention, self-care and care closer to home

•  the scale and complexity of the health and care system in London - transformation will be driven at three geographical levels

•  the need to tailor solutions to the different needs of people and places and that locally shaped solutions will progress at different paces

•  The importance of enablers, including estates

Full report available here: https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf

The London Health and Care Collaboration Agreement

Commitment by government and national bodies to work with London to explore:

•  aligning capital programmes and removing barriers to make best use of the NHS estate

•  flexibility of payment mechanisms

•  developing place-based provider regulation

•  workforce planning and delivery of education and training

•  devolving transformation funding

•  using planning & licensing to support prevention

•  joint working on employment and health.

Full report available here: https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement#parties

The London Health Devolution Agreement

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Summary of agreements

The key elements of the agreement are: i) Multi-level action: Given the size of the London system three levels of action will be needed: borough (local); multi-borough (sub-regional); London-wide (regional). ii) Underpinned by the principle of subsidiarity: This means that decisions should always be taken at the most local appropriate level and aggregated up to multi-borough or London-wide only as needed. iii) London’s health and care system is highly complex. We have a large number of health and care organisations and population and patient flows occur with frequency across local boundaries. For these reasons London will be running pilots to test different elements of health and care devolution at different spatial levels. iv) Focus on integration, prevention and estates What does it mean for London? Through Better Health for London, our city already has a plan making it fairly unique in England. All organisations have committed to delivering on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and in doing so, deliver on the NHS Five Year Forward View. If decisions about London are made within the London system, they will respond more closely to the challenges and opportunities of our city and population. We plan to test how this works in practice through devolution pilots with the ambition to scale up across the city. For Londoners we expect this to mean a more effective, streamlined health and care service, greater support to stay as healthy as possible for as long as possible and ensuring health and care resources are used most efficiently.

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Aspirations and objectives of London devolution (from 2015 agreements)

The parties have a shared commitment to deliver on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and, in doing so, deliver on the NHS Five Year Forward View and secure the sustainability of health services and social care.

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To meet these aspirations, the parties share the following objectives: •  To achieve improvement in the health and wellbeing of all Londoners through a stronger, collaborative focus on health

promotion, the prevention of ill health and supporting self-care

•  To make rapid progress on closing the health inequalities gaps in London

•  To engage and involve Londoners in their health and care and in the health of their borough, sub-region and city including providing information so that people can understand how to help themselves and take responsibility for their own health

•  To improve collaboration between health and other services to promote economic growth in the capital by addressing factors that affect both people’s wellbeing and their wider economic and life opportunities, through stronger partnerships around housing, early years, employment and education

•  To deliver integrated health and care that focuses on maximising people’s health, wellbeing and independence and when they come to the end of their lives supports them with dignity and respect

•  To deliver high quality, accessible, efficient and sustainable health and care services to meet current and future population needs, throughout London and on every day.

•  To reduce hospitalisation through proactive, coordinated and personalised care that is effectively linked up with wider services to help people maintain their independence, dignity and wellbeing.

•  To invest in fit for purpose facilities for the provision of health and care services and to unlock the potential in the health and care estate to support the overall sustainability and transformation of health and care in the capital

•  To secure and support a world-class workforce across health and care

•  To ensure that London’s world-leading healthcare delivery, academic and entrepreneurial assets provide maximum benefit for London and the wider country and that health and care innovation is facilitated and adopted in London.

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All parties agreed to the following principles

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•  Improving the health and wellbeing of Londoners will be the overriding driver for reform and devolution.

•  We will work to secure a significant shift from reactive care to prevention, early intervention, self-care and care close to home that supports and enables people to maximise their independence and wellbeing.

•  London will remain part of the NHS and social care system, upholding national standards and continuing to meet and be accountable for statutory requirements and duties, including the NHS Constitution.

•  Joint working will improve local accountability for services and public expenditure. Where there is local agreement to change accountability arrangements, accountability to NHS England will be maintained – in relation to issues including delivery of financial requirements, national standards and the NHS Constitution. Changes to current accountabilities and responsibilities will be agreed with government and national bodies as necessary and may be phased to balance the pace of progress with ensuring a safe transition and strong governance. We commit to fulfil the legal requirements for making significant changes to commissioning arrangements.

•  Decision-making will be underpinned by transparency and the open sharing of information between partners and with the public.

•  Transformation will be locally owned and led and will aim to get the widest possible local support. We will ensure that commissioners, providers, AHSNs, patients, carers, the health and care workforce, the voluntary sector and wider partners are able to work together from development to implementation to shape the future of London’s health and care.

•  All decisions about London will be taken in or at least with London. Our goal is to work towards resources and control being devolved to and within London as far as possible, certainly in relation to outcomes and services for Londoners.

•  Collaboration and new ways of working will be needed between commissioners, providers, patients, carers, staff and wider partners at multiple levels. Recognising that the London system is large and complex, commissioning and delivery will take place at three levels: local, sub-regional or pan-London. A principle of subsidiarity will underpin our approach, with decisions being made at the lowest appropriate level.

•  Given London’s complexity we recognise that progress will happen at different paces and in different orders across the different spatial levels. We will ensure that learning, best practice and new models for delivery and governance are shared to support and accelerate progress in all areas. Subsidiarity as a principle will extend to the adoption of ideas piloted in other areas to allow flexibility and adaptation to local conditions.

•  The people that work in health, health care and social care are critical to achieving London’s transformation goals. We will build on London’s position as the home of popular and world-class health education, to develop new roles, secure the workforce we need and support current and future staff to forge successful and satisfying careers in a world-class London health and care system.

•  We recognise that considerable progress can be made, building on existing foundations, with existing powers and funding – and we are committed to doing so. But devolution is sought to support and accelerate improvements. A series of devolution pilots will be established through which detailed business cases for devolution of powers, resources and decision-making can be developed in partnership with government and national bodies. Through these, devolution may be secured both for the pilots themselves and also for other parts of London, contingent on these areas also developing suitable plans, delivery and governance arrangements.

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Continued…

• While embedding subsidiarity, we will ensure the strategic coherence and maximise the financial sustainability of the future health and care systemacross London. Political support for jointly agreed change will be an important feature of the arrangements.

• New London-level arrangements, including governance and political oversight, will be established to secure this. We commit to minimising bureaucracyas much as possible to enable delivery of local innovation.

• In 2016/17 - and drawing from the experiences of the pilots - sustainability and transformation plans for health and care will be developed as part ofNHS and local authorities’ planning arrangements. These will draw on learning from the devolution pilots, other transformation initiatives including theVanguard programme and any London-wide initiatives.

• A London-level picture, drawn from sub-regional health economy plans, will enable oversight of the impact on health outcomes and financialsustainability of the system across the capital.

• We recognise that London provides expertise and services for people who live outside the capital and that benefit the country more widely. London willwork collaboratively with other regions and national bodies to consider and mitigate the impact of London decisions on surrounding populations relianton London-based services.

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Item: 4.3

MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Haringey and Islington Wellbeing Partnership LEAD COMMITTEE MEMBER:


AUTHOR: Paul Sinden, Director of Commissioning

CONTACT DETAILS:

[email protected]

SUMMARY:

This paper provides an update on the work being undertaken across health and social care jointly across Haringey and Islington through the Haringey and Islington Wellbeing Partnership, and in particular highlights a proposal to develop an Accountable Care Partnership locally.

The report attached was considered by the Joint Haringey and Islington Wellbeing Board held on 3 October 2016. The report sought, and received, agreement in principle to the development of an Accountable Care Partnership (ACP) for Haringey and Islington, and that work to develop the detail of the ACP would now be carried out.

In support of the ACP proposal the report set out the progress the Wellbeing Partnership has made in a short period of time, bringing together a range of organisations, both commissioners and providers of health and social care, to work differently and collaboratively to improve the health and wellbeing of the local population. These organisations currently comprise the London Boroughs of Haringey and Islington, Haringey and Islington Clinical Commissioning Groups, the Whittington NHS Trust, the Camden and Islington NHS Foundation Trust and Barnet, Enfield and Haringey Mental Health NHS Trust.

The partnership has also worked closely with a wider range of partners, within the context of the North Central London Sustainability and Transformation Plan. This broader relationship working has included partners such as North Middlesex University Hospital NHS Trust and University College London Hospitals, which also serve the population of Haringey and Islington.

The Accountable Care Partnership would bring together commissioners and providers to work collaboratively, and take responsibility for, the cost and quality of care for a defined population (Haringey and Islington) within an agreed budget, thereby further progressing the work of the Wellbeing Partnership.

An Accountable Care Partnership would work differently from an Accountable Care Organisation as it would not establish a single organisational structure but would harness

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the strengths and assets of existing organisations by working more effectively within a formal partnership with shared governance, accountabilities, risks and incentives. The ACP would need to be underpinned by partners signing an Accountable Care Partnership Agreement to affirm collective accountability for outcomes, define mutual responsibilities to deliver integrated care and to formally agree a joint governance structure to make decisions, allocate and manage funds, manage performance, share resources, risk and rewards and hold each other accountable for delivering outcomes. To develop the detail of the Accountable Care Partnership (including principles and outcomes, finance, engagement, intelligence, legal and governance) it was proposed and agreed that the Joint Health and Wellbeing Board empower the Sponsor Board of the Wellbeing Partnership to draw up a project plan. Key proposals would then be brought back to the Joint Wellbeing Board for Haringey and Islington for endorsement and decision. The plan would set out further work to: • Develop a Memorandum of Understanding to underpin the set of principles and

outcomes agreed by the Wellbeing Partnership as a stepping stone to the more formal Accountable Care Partnership Agreement;

• Determine the scope of the ACP Agreement – including the inclusion of primary care, mental health, and hospital services;

• Identify the potential for the use of system financial control totals as well as traditional individual organisational control totals;

• Move from individual quality, innovation, productivity and prevention (QIPP) targets, cost improvement programmes and savings plans within organisations to plans that reduce system wide costs and optimise use of resources in the medium to long term;

• Identify contract forms and incentives to support the above; • Develop a clear and meaningful communications plan, fully engaging with key

stakeholders and creating transparency through all stages of the process; • Develop governance arrangements to the formal partnership arrangement. This report contributes to: • Ensuring every child has the best start in life; • Preventing and managing long term conditions to extend both length and quality of life

and reduce health inequalities; • Improving mental health and wellbeing; and • Delivering high quality, efficient services within the resources available. Prior consideration by Committees and other partners: The paper was approved by a joint meeting of the Haringey and Islington Wellbeing Boards held on 3 October 2016. The paper was also considered by the CCG Governing Body Seminar held on 12 October 2016. The Strategy and Finance Committee has previously received updates on the work of the Haringey and Islington Wellbeing programme, and received this report on 27 September 2016.

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Patient & Public Involvement (PPI): This report is for information only. Patient and public involvement and co-design will be an integral part of the Wellbeing Partnership in order to inform and support the areas of focus and priority workstreams for delivery. Equality Impact Assessment: Not applicable for this report. Equality Analysis will be a vital part of ensuring the programme delivers improvements across our diverse population and does not impact negatively on any specific groups. Risks: The work of Programme Sponsor Board is supported by a risk register. RECOMMENDED ACTION: The Governing Body is asked to: • NOTE the approval of the Joint Haringey and Islington Wellbeing Board to:

a) Adopt the principles and high level outcomes as developed by the Sponsor Board of the Haringey and Islington Wellbeing Partnership;

b) Agree in principle to the development of a form of accountable care partnership which best supports the outcomes sought by the Haringey and Islington Wellbeing Partnership;

c) Endorse further work to develop the detail of such a partnership, with the aim of gaining agreement on the final structure and form from constituent decision making bodies by April 2017;

d) Require the Sponsor Board to report back on progress in developing and implementing a project plan;

e) Request the Sponsor Board to consider as a matter of priority how community and stakeholder engagement will be undertaken and involve key stakeholders including Healthwatch.

SUPPORTING PAPERS: 4.3.1 Report to the Joint Haringey and Islington Wellbeing Board held on 3 October 2016 – Developing an Accountable Care Partnership across Haringey and Islington

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Appendix 4.3.1

Report for: Joint Health and Wellbeing Board – 3rd October 2016 Title: Developing an Accountable Care Partnership across

Haringey and Islington Report authorised by : Zina Etheridge Lead Officer: Rachel Lissauer, Director of Commissioning, Haringey

Clinical Commissioning Group Charlotte Pomery, Assistant Director, Haringey Council

Ward(s) affected: All Report for Key/ Non Key Decision: Non Key 1. Describe the issue under consideration 1.1 This report provides an update to the Joint Health and Wellbeing Board on the

work being undertaken around health and social care jointly across Haringey and Islington through the Wellbeing Partnership. Specifically, the report highlights work to develop an Accountable Care Partnership locally.

1.2 Members of the Joint Health and Wellbeing Board will be familiar with the

overall programme of work underway across the two populations to drive a more integrated approach and to maximise use of resources for local health and care benefits. This Joint Health and Wellbeing Board meeting is an example of the different ways of working together which are already being put in place. As part of this work, the benefits of a more formal partnership structure to ensure that this work is taken forward at pace and scale, and with optimal accountability to local populations, are being explored.

1.3 The report proposes that now is an opportune time to build on the significant

work already completed within each of Islington and Haringey across partner agencies to improve patient and user pathways, to build community and resident engagement, to streamline decision making and to develop shared governance over resources and seeks agreement in principle to the development of an Accountable Care Partnership for Haringey and Islington.

2. Recommendations

3.1 The Joint Health and Wellbeing Board is asked to:

a) adopt the principles and high level outcomes as developed by the Sponsor

Board of the Haringey and Islington Wellbeing Partnership

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b) agree in principle to the development of a form of accountable care partnership which best supports the outcomes sought by the Haringey and Islington Wellbeing Partnership

c) endorse further work to develop the detail of such a partnership, with the aim of gaining agreement on the final structure and form from constituent decision making bodies by April 2017

d) require the Sponsor Board to report back on progress in developing and implementing a project plan

e) request the Sponsor Board to consider as a matter of priority how community and stakeholder engagement will be undertaken and involve key stakeholders including Healthwatch

3. Background information and next steps 3.1 This paper proposes that the development of an Accountable Care

Partnership across Haringey and Islington is agreed in principle and that work to develop the detail is now carried out.

3.2 Accountable care partnerships can take many forms but at their core are designed to be accountable to local populations for the care they deliver, collaboratively. They offer an innovative way of addressing some of the fundamental challenges facing health and social care in meeting the needs of local populations. Accountable care partnerships differ from Accountable Care Organisations as they do not seek to establish a single organisational structure but rather to harness the strengths and assets of existing organisations by working more effectively within a formal partnership with shared governance and shared accountabilities, risks and incentives. An accountable care partnership for Haringey and Islington would build on work already underway to reset our local commissioner-provider relationships – embedding a culture of acting within a single system with collective agreement as to how we allocate resources and deliver better for our local populations. There would need to be shared responsibility for the care of the whole population – and agreement as to how we continue to deliver at a very local level for our diverse local communities whilst working to shared principles and outcomes at a population level. This will mean working differently with our local populations and engaging effectively with them in planning and delivery.

3.3 A local accountable care partnership would itself need to operate effectively within the wider North Central London (NCL) sub-region and the complex landscape of health and care organisations which the Sustainability and Transformation Plan describes. We believe that our populations across Haringey and Islington are large enough to sustain an accountable care partnership – but we also know that they are not static and that they move across borough and organisational boundaries in different ways, accessing different services to meet their needs, as part of a global city. Many providers operate across populations and any partnership we develop would need to recognise the complexity of this landscape and the strength and myriad of relationships to be developed with partners, both locally and at a regional and national level. In developing further an accountable care partnership, we would need to demonstrate how it will help to achieve wider NCL goals for

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system transformation and sustainability and enable us to play a stronger role in meeting NCL’s wider challenges.

3.4 The Haringey and Islington Wellbeing Partnership (the Wellbeing Partnership)

has made significant progress in a short period of time and brought together a range of organisations, both commissioning and delivering health and social care, to work differently and collaboratively to improve the health and wellbeing of their local populations. These organisations currently comprise the London Boroughs of Haringey and Islington, Haringey and Islington Clinical Commissioning Groups, the Whittington NHS Trust, the Camden and Islington NHS Foundation Trust and Barnet, Enfield and Haringey Mental Health NHS Trust.

3.5 The work carried out to date has led to:

3.5.1 A deep and rich understanding of our local populations, their needs and desired outcomes

3.5.2 A developing awareness of existing issues and complexities 3.5.3 Effective engagement with our communities, with close ties with local

populations and strong support for more integrated provision 3.5.4 Strong, progressive relationships in place across local government and NHS;

across providers, commissioners and front-line staff and with strong clinical and practitioner engagement

3.5.5 Significant progress in our integrated governance arrangements through the Wellbeing Partnership

3.5.6 A growing track-record of delivering successful integrated care initiatives across both boroughs, including working together to address the wider determinants of well-being and health (housing, employment etc).

3.6 The Wellbeing Partnership is also overseeing a broad programme with a

number of work streams which will shape service redesign, resident and patient pathways, workforce development and have the potential to change fundamentally the way services are delivered locally. This paper does not cover further detail on this part of the programme.

3.7 Despite the work of the Wellbeing Partnership, the focus of and drivers for

each organisation remain their own goals and finances given current accountability and governance arrangements. These individual organisational priorities can hinder further collaboration, contributing to inefficiencies and limiting our collective ability to achieve more, within our constrained resources. The work undertaken so far has confirmed that duplication of some services across providers still exist, that resources are not deployed optimally around some of our key drivers including prevention and early intervention, that staff work within fixed organisations boundaries and that we do not always work to a strong evidence base, often because of the poor quality of

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our information and data resources. Our current analysis and case for change often focus on system wide issues which can have a significant impact on both our service users and front-line staff – but without a system wide approach which can tackle them effectively.

3.8 One of the workstream groups, the Strategy and Commissioning Group, of the

Wellbeing Partnership has been meeting to consider what if any changes to governance and structures would best support the existing work programme or whether the Wellbeing Partnership’s ambitions can be delivered within existing structures. The group has now reached consensus in a number of areas and supports the thinking that changes to organisational structures through an Accountable Care Partnership, as described above, would help to drive integration across Haringey and Islington, improve outcomes and make most effective use of resources. In particular, the group suggested that the following issues will need to be addressed in developing such a partnership for Haringey and Islington:

3.8.1 The Wellbeing Partnership already has in place a firm set of principles and

outcomes which are aligned to facilitate greater collaboration and strengthened joint governance and which will need to drive any next steps. It is suggested that agreement to this set of principles and outcomes could be further cemented by the development of a Memorandum of Understanding across all partners to underpin the detail required to determine the form of the appropriate accountable care partnership for Haringey and Islington.

3.8.2 The way funding flows within an accountable care partnership is often significantly different from current, organisationally based funding. The Wellbeing Partnership is already exploring what a single control total across organisations could mean – in effect, it could constitute the agreed, pooled financial resources for the local population in respect of health and care. It is noted that not all aspects of service provision or all budgets for organisations would necessarily be within the scope of the single control total – for local mental health trusts in particular, it is recognised that delivery within Haringey and Islington may constitute a relatively small element of their overall budget and operation. From experience, we know that there are challenges in working out pooling arrangements between two organisations and that moving to new ways of thinking about population level pooling will add further complexity to this picture which can be supported by operating to shared outcomes and criteria.

3.8.3 A further issue is the determination of which services and budgets would be brought within or would remain outside scope of the accountable care partnership. Primary and community care, as well as wider forms of community based provision, are critical to a model which operates at a population level, enables prevention and early intervention and delivers system wide transformation, both financially and in terms of outcomes for local residents. This is a key decision which will shape the future scope of the outcomes to be delivered. This oversight is required if we are to change service delivery on the ground to drive improved outcomes and reduce costs in the system.

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3.8.4 An accountable care partnership would move away from individual Quality,

Innovation, Productivity and Prevention targets, Cost Improvement Programmes and savings plans within organisations to plans that reduce system wide costs and optimise use of resources in the medium to long term. A new contract form with acute /community providers will need to be explored and would need to apply across all acute providers delivering to local populations. The intelligence we hold with and about our local populations would need to be effectively used to make decisions and build the ongoing evidence base for greater collaboration. Whilst it is constructive to start with the money in order that we can work through to consider the appropriate governance model, we need to ensure that our interventions reflect a strong understanding of what works locally, within the context of Haringey and Islington. We would begin to map the growing consolidation of partnership arrangements as we move, in time, from sharing information through to exercising shared decision-making.

3.8.5 The areas of work suggested above would aim to facilitate the ‘bottom up’ work of scaling up areas of good practice so that there is a constant iteration between new ways of planning, resourcing and delivering services and an organisational form that facilitates these approaches. Our aim is for these approaches to engage fully with local communities and to build their voice into everything we do and engaging on principles with both residents and our workforce will be a core plank in the process. Work to develop a clear and meaningful communications plan will be required, fully engaging with key stakeholders and creating transparency through all stages of the process.

3.8.6 Learning from others, rather than starting afresh, is already being implemented as an approach and work with both the King’s Fund and UCLP has informed the thinking to date. It is suggested that this approach should continue, with workshops led by such organisations who have been working with other health economies to understand how they progressed from the stage of the accountable care partnership concept to the next stage of working together in practice.

3.8.7 Finally, the governance arrangements required to support the vehicle for an accountable care partnership which is fit for our local populations and context will need to be worked up in light of the issues identified above.

3.9 To take forward the key areas identified above, which span principles and outcomes, finance, engagement, intelligence, legal and governance, it is proposed that the Joint Health and Wellbeing Board empower the Sponsor Board to draw up a project plan, setting out what is required to work through the steps identified above, and to bring key proposals back to the Joint Board for endorsement and decision. It is acknowledged that there are significant issues that will need resolving and it is considered that the Joint Board structure has the appropriate authority across the health and care landscape to consider these and respond with the best course of action.

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3.10 It is acknowledged that the partnership will work closely with a wider range of partners, within the context of the Sustainability and Transformation Plan, affecting the outcomes that can be achieved across the population. This broader relationship working will include partners such as North Middlesex University Hospital NHS Trust and University College London Hospitals, which also serve the local population in a number of ways.

4. Contribution to strategic outcomes

4.1 These proposals support the strategic principles and outcomes of the H&I

Wellbeing Partnership as well as priorities in the key strategic plans of all partners to the arrangements.

5. Statutory Officers comments (Chief Finance Officer (including

procurement), Assistant Director of Corporate Governance, Equalities)

5.1 Assistant Director for Corporate Governance

5.1.1 Accountable Care Partnerships are relatively new organisational forms intended to bring together commissioners and providers to take responsibility for the cost and quality of care for defined population, in this case Haringey and Islington, and within an agreed budget. Information available, suggest that accountable care partnerships may take many different forms including a fully integrated care systems with an opportunity to break down traditional barriers between organisations and to improve the quality of services. This form of system wide integration under a collectively defined and managed budget would require partners to sign an Accountable Care Partnership Agreement to affirm their collective accountability for outcomes, define their mutual responsibilities to deliver integrated care and to formally agree a joint governance structure to make decisions, allocate and manage funds, manage performance, share resources, risk and rewards and hold each other accountable for delivering outcomes. There may also be individual agreements between commissioners and providers that sits alongside or are aligned with the Accountable Care Partnership Agreement.

5.1.2 Section 195 of the Health and Social Care Act 2012 (duty to encourage

integrated working) provides that, a Health and Wellbeing Board must, for the purpose of advancing the health and wellbeing of the people in its area, encourage persons who arrange for the provision of any health or social care services in that area to work in an integrated manner. The recommendation to the Haringey and Islington Health and Wellbeing Board to endorse the move towards an accountable care partnership falls within the function of the respective Boards to encourage integrated working across health and social care. The same also apply to the proposal that partners agree a memorandum of understanding on principles, outcomes, expectations and responsibilities and as a prelude to the accountable care partnership arrangements.

5.1.3 In scoping out the work required to move towards this new partnership model, partners should, amongst other matters, consider whether there is likely to be

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changes to services provided to residents of the respective boroughs. If so, the nature and extent of the changes and the need for public consultation, in particular, if there is likely to be an adverse effect on services delivered to residents. Partners should also consider the implications on existing contractual and other partnership arrangements for example Section 75 Health and Social Care Partnership Agreements and how this can be aligned with the proposed accountable partnership arrangements.

5.1.4 Partners must ensure that they seek the required authority of their respective decision making body to enter into the proposed partnership arrangement. For the local authorities, this would require a report to their respective Cabinet for a decision.

5.2 Chief Finance Officer 5.2.1 The creation of an Accountable Care Partnership that potentially could involve

the budgets for Adults Social Care and Health in LB Haringey, Haringey CCG, LB Islington, Islington CCG and partner healthcare trusts is a major undertaking. While it may provide significant opportunities for synergies and efficiencies across the partnership, there are also risks about individual organisations having less direct financial control of parts of their finances at a time of financial constraint. Moreover, there are likely to be significant resources required to bring such a partnership into being.

5.2.2 At this stage, the report is seeking an agreement in principle to the concept

and to carry out more work to establish the practical steps that would be necessary. The Haringey and Islington Health and Wellbeing Partnership should ensure that it has access to sufficient resources to undertake this activity.

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Item: 4.4

MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Islington’s Joint Health and Wellbeing Strategy (JHWS) – Draft for

consultation LEAD COMMITTEE MEMBER:

Julie Billett, Director of Public Health

AUTHOR: Baljinder Heer-Matiana, Senior Strategist, Public Health

CONTACT DETAILS:

[email protected] 020 7527 1233

SUMMARY:

Joint Health and Wellbeing Strategies (JHWSs) explain what priorities Health and Wellbeing Boards have set in order to tackle the needs identified in their Joint Strategic Needs Assessments (JSNAs). They are not about taking action on everything at once, but about setting a small number of key strategic priorities for action, that will make a real impact on people’s lives.

This draft Islington Joint Health and Wellbeing Strategy 2017-2020 builds on the successes of the previous Joint Health and Wellbeing Strategy over the past three years and looks to the future to focus on those issues which have a big impact on health and wellbeing outcomes and which require a multi-agency partnership approach.

The Health and Wellbeing Board approved the draft strategy for public consultation on Wednesday 19th October 2016. There will now be a six week consultation period to enable residents, communities and stakeholders to input and comment. It will be taken to a range of meetings and events and communicated through a variety of approaches. As part of the consultation we are seeking the views of CCG members and patients and encourage the CCG to submit a formal response. The final strategy will be presented to the Islington Health and Wellbeing Board in January 2017 for sign off.

This report contributes to: • Ensuring every child has the best start in life;• Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities;• Improving mental health and wellbeing; and• Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: • CCG Executive Management Team 5 October 2016;• Islington Health and Wellbeing Board meeting 19 October 2016;• Islington CCG Strategy and Finance Committee 27 October 2016.

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Patient & Public Involvement (PPI): This report refers to a public consultation which will seek to gather the views of patients and the public. Equality Impact Assessment: Not applicable for this report. Equality Analysis will be a vital part of ensuring the programme delivers improvements across our diverse population and does not impact negatively on any specific groups. Risks: Not applicable for this report RECOMMENDED ACTION: The Governing Body is asked to:

• NOTE progress on the development of the draft Joint Health and Wellbeing Strategy;

• SUPPORT the public consultation to take place between October 2016 and December 2016 by raising awareness of it in relevant bulletins, newsletters and meetings;

• CONSIDER and respond to consultation.

SUPPORTING PAPERS: 4.4.1 - Islington’s Joint Health and Wellbeing Strategy (JHWS) – Draft for consultation 4.4.2 - JHWS Consultation form

Background

1. Islington’s current Joint Health and Wellbeing Strategy (JHWS) (2013-2016) sets out the Health and Wellbeing Board’s (HWB) commitment and approach to tackling health inequalities and promoting health and wellbeing for the population of Islington. To build on the successes of this strategy and to provide a strategic framework and focus for the Board’s work going forward, the JHWS and its priority outcomes needed to be reviewed and refreshed.

2. Members of the HWB, at the April 2016 meeting, reflected on progress and

achievements under the current strategy and agreed that there had been benefits to having three broad priorities, supported by more action-focused delivery plans (which were starting to show signs of success). The HWB agreed it was important to maintain a degree of continuity of focus, given the ongoing importance of these three priorities to the health of the population of Islington and in order to continue with much of the positive work and actions in train.

3. Based on a review of the needs and evidence set out in the Islington Joint Strategic

Needs Assessment (JSNA), a number of conversations and engagement sessions with senior officers across the council, the CCG and other key partners, as well as the outputs from the HWB development session held in July 2016, a refreshed draft strategy has been developed (see appendix 1). This strategy was approved for public consultation by the HWB on 19th October 2016.

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4. A six week period of public consultation between 26th October 2016 and 7th December 2016 will now take place to gather the views of Islington residents and key partners across the health and wellbeing system. The consultation period will allow the public and other key stakeholders to provide feedback on the proposed actions and measures described within the strategy under each of the overarching priorities. Appendix 2 to this paper sets out the consultation questions.

5. In addition to an online survey and paper version, we will consult with stakeholders

by attending a wide range of meetings, public events, cascading through stakeholder organisations and using social media, websites and newsletters (see table 1). Table 1: Proposed engagement activities

Organisation Meetings/ method Date

Meetings CCG Strategy & Finance meeting 27 Oct CCG Governing Body meeting 9 Nov CCG Pan Islington Patient Participation Group (PPG) Forum

tbc

CSIG – Children's Services Improvement Group

30 Nov

Integrated care programme board 25 Nov Islington Prevention and Early Intervention Steering Group

27 Oct

Islington Health and Social Care Scrutiny Committee 17 Nov Early Years Transformation Board 8 Nov Islington Mental Health Advisory Group 1 Nov Islington Children and Families Board 26 Nov Ward Partnership Meetings tbc Third Sector Forum Meeting tbc

Communications Websites – LBI consultation page, CCG and Healthwatch

26 Oct

Newsletters/ Bulletins - HASS newsletter, Public Health newsletter, Whittington Health Bulletin, GP bulletin, Resident's ebulletin, Carers Hub newsletter, ICbulletin (Islington council internal), VAI newsletter

Oct/ Nov

Social media – Twitter - @IslingtonBC, HLP facebook page

Oct/ Nov

6. The CCG is invited to respond to the consultation and to make further suggestions on how we can engage with patients and the public to support the consultation.

7. The deadline to make a response to is 7 December 2016.

8. The findings from the consultation will be presented alongside the proposed final strategy to the Board in January 2017 for approval.

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Islington’s Joint Health and Wellbeing Strategy 2017-2020: Draft for consultation

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Appendix 4.4.1

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CONTENTSForeword 3

Introduction 4

Our vision for Islington 6

Our population in Islington 7

Islington’s Health and Wellbeing Priorities 8

Priority 1: Ensuring every child has the best start in life 9

Priority 2: Preventing and managing long term conditions to enhance both length and quality of life and reduce health inequalities 14

Priority 3: Improving mental health and wellbeing 19DRAFT

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3Islington’s Joint Health and Wellbeing Strategy 2017-2020: Draft for consultation

FOREWORDWe have a lot to be proud of in our vibrant borough, but poor health outcomes and health inequalities continue to affect local people’s life chances. We are committed to making Islington a fairer place: Improving residents’ health and giving people the support they need to improve their wellbeing is at the heart of this agenda. In working towards this goal, we recognise that more needs to be done to help prevent those things that contribute to health inequalities and to provide better early intervention, to make a real difference to the lives of our residents.

Over the past three years, we have made some real progress in improving the health and wellbeing of Islington residents. To name but a few of these successes, we have significantly increased childhood immunisation rates, reduced overall mortality rates from preventable causes, and made improvements in treatment recovery rates for patients with mental ill health. We will build on this positive progress as we refresh and take forward a new Islington Joint Health and Wellbeing Strategy for 2017-2020. We will continue to maintain a focus on three important areas - giving every child the best start in life, preventing and managing long term conditions, and promoting and improving mental health and wellbeing - in order to achieve our ambition of improving health and wellbeing and reducing health inequalities to make Islington a fairer place.

This refreshed Joint Health and Wellbeing Strategy focuses on those specific areas where there is evidence of most pressing need and where we can make the greatest impact. The strategy also looks at those health and wellbeing issues that cut across our three priority areas, and across the health and wellbeing system in its broadest sense. This includes, for example, the impact of poor housing, the environment, or lack of employment on wellbeing. It is in tackling these more complex, cross-cutting issues that the Health and Wellbeing Board, in its key role as a system leader, can add most value and where a systematic focus on prevention and early intervention can deliver real benefits by preventing the

emergence or escalation of problems. We also understand that the health of our residents and communities is affected by much more than access to and the quality of health services. Health and wellbeing is shaped by the conditions in which we live, the extent of our social connections, and whether we have stable and supportive work, amongst other things. Our Joint Health and Wellbeing Strategy for 2017-2020 underlines the importance of addressing these wider determinants of health.

The health and care landscape looks significantly different to when we published our previous strategy in 2012/13, and further changes are likely. This new strategy is intended to help maintain a focus on those key issues that impact on the health and wellbeing of Islington residents, in the context of a complex and changing health and care landscape. We see these changes as an opportunity for continued close working between partners to drive system transformation and a step-change in outcomes, under the leadership of the Health and Wellbeing Board.

Cllr Richard Watts Leader Islington Council

Dr Jo Sauvage Chair Islington Clinical Commissioning Group

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4

What is this strategy?This is Islington’s Joint Health and Wellbeing Strategy (JHWS) and it sets out Islington’s overarching plan for improving the health and wellbeing of people living in Islington for 2017-2020. Islington’s Health and Wellbeing Board (HWB) is responsible for finalising the JHWS and monitoring progress with its delivery between 2017 and 2020.

Over the past three years, we have focused on three priorities:

➤➤ Ensuring every child has the best start in life

➤➤ Preventing and managing long term conditions to enhance both length and quality of life and reduce health inequalities

➤➤ Improving mental health and wellbeing

We will continue focusing on these three priorities for 2017-2020, building on our successes so far and working on areas where challenges remain. For each of the priorities, areas of focus have been selected where we feel the HWB and a partnership approach across and beyond Islington can make the biggest impact and drive real improvements in the health and wellbeing of Islington residents. It is not intended to be an exhaustive list of all of the work that we do to improve health and wellbeing in the borough.

Through this strategy, we want to achieve a stronger focus on health and wellbeing within the context of the family and/or household. Risk and protective factors at this level, as well as at the social and community level, are a key determinant of an individual’s health and wellbeing across the life course and are important for a thriving population.

How has the Joint Health and Wellbeing Strategy been developed?Under the sponsorship of the HWB, this JHWS has been developed in partnership with a number of stakeholders over several months. In April 2016, Islington’s HWB agreed to maintain a focus on the three priorities from the previous strategy. HWB members have worked together to discuss the areas of focus within this refreshed strategy, drawing on input from strategic partners and stakeholders across Islington, including feeding in input and insights from a range of resident, service user, and voluntary and community sector organisations, groups and engagement activities.

INTRODUCTIONWhat is the role of Islington’s Health and Wellbeing Board?The role of Islington’s Health and Wellbeing Board (HWB) is to improve the health and wellbeing of Islington’s population. It brings together leaders across the health and care system to work together on important cross-cutting issues. There is a statutory duty for the Board to produce a high-level plan for improving the health and wellbeing of people living in Islington. This is our Joint Health and Wellbeing Strategy (JHWS).

The role of the Board is to provide leadership across the whole health and care system and beyond, championing health and wellbeing as everyone’s business, holding ourselves and our partners to account and using the Board’s collective influence to break down any barriers to progress.DRAFT

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What has informed the Joint Health and Wellbeing Strategy?Islington’s most recent Joint Strategic Needs Assessment (JSNA) has formed the basis for Islington’s JHWS. The JSNA and JHWS go hand in hand, with the former detailing Islington’s population health needs, and the latter outlining how we plan to meet those needs. Other current knowledge, evidence and intelligence have shaped the JHWS.

Refreshing Islington’s JHWS has also been an opportunity to ensure the strategy reflects the evolving health and care landscape. Through the Islington and Haringey Wellbeing Partnership, health and care partners across the system in Islington and Haringey are working together to deliver improved health and wellbeing outcomes for our populations. Taking a whole population and place-based approach, Islington and Haringey are working together to address the shared challenges we face across the health and care system and to deliver integrated care and improve outcomes for our residents. We are also working with partners across North Central London to develop a strategic, place-based plan for

transformation of the health and care system over the next five years. Collaboration and joint working on this wider geographical footprint, where it makes sense, can help drive improvements in outcomes, care quality and system sustainability.

Islington’s JHWS does not stand alone. It links into a wide range of strategies and plans that are focused on improving the overall wellbeing of Islington’s residents, and importantly which tackle the underlying determinants of health and inequalities in the borough, including Islington Council’s Corporate Plan and the strategic plans of Islington’s Clinical Commissioning Group (CCG).

We expect this strategy to be a “living document”. We will use data and information to assess our progress, and adapt our approach if we are not on track to deliver our priorities. We want to make sure that our planning stays in touch with the changing needs of Islington’s residents. The Health and Wellbeing Board will monitor progress in the three priority areas every six months. The Board will also review progress on the strategy as a whole after 18 months.

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A healthier, fairer and more resilient populationOur vision for Islington is for a community of healthy, connected and resilient people. We want our residents to live, work and play in places that support and promote health, and for every resident to experience good and secure housing and employment. When people do experience poor health and other problems, we want them to know where to find help and the confidence to seek it - be it from friends or family, the voluntary sector or public services - and that they bounce back and thrive. We will focus on prevention and earlier intervention to prevent or reduce the escalation of problems. Finally, we want our residents to receive timely, quality and joined up public services when they are needed.

We recognise that good health is shaped by numerous factors, from our friends, neighbours and social connections, to our education or opportunities, and through to wider environmental and cultural conditions [see fig.1]. That is why we will continue working in partnership with colleagues across Islington to ensure that making healthier choices and living in healthier environments is easier, and that everyone has the opportunity to reach their potential. We describe our activities on these wider determinants of health in this refreshed JHWS.

Our guiding principles We will put ourselves in the shoes of our residents, ensuring they are at the heart of what we do, and co-design our responses to challenges with our residents, and around their needs.

We will focus on the assets and strengths of our population, and we will build the resilience of individuals and communities to promote independence and reduce dependency.

We will focus on prevention and early intervention to improve outcomes and reduce escalation of need and demand.

We will work across professional, service and organisational boundaries to ensure a coordinated, collective approach to delivering our ambitions and plans, recognising and valuing the contribution of all parts of the system. We will focus on those areas and issues that require us to act in partnership and as system leaders to make the biggest difference.

We will make Islington fairer and will focus on reducing inequalities in all that we do.

We will make every penny count by ensuring that we take an outcomes- and evidence-based approach.

OUR VISION FOR ISLINGTON

Living and workingconditions

Age, sex andhereditary factors

UnemploymentWorkenvironment

Education

Agricultureand food

production

Watersanitation

Healthcare

services

Housing

Indi

vidu

al lifestyle factors

Soci

al an

d community networks

Gen

eral

soc

io-e

conomic, cultural and environmental conditions

Figure 1. The wider determinants of health. Adapted from Dahlgren and Whitehead

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Population segmentation is a way of grouping the population according to similar health and care needs. We have been using the pyramid risk stratification model in Islington, which also underpins the work of the Islington and Haringey Wellbeing Partnership. It divides the population into four broad segments: those who are healthy, those who are at risk of developing long term conditions1, those who have 1-2 long term conditions and those who have 3 or more long term conditions. This helps to understand the needs and health and care experiences of these groups in order to plan and provide better, more integrated health and care, and to ensure a focus on what we can do to help people stay well and further ‘down the pyramid’.

The model is based on anonymous health data relating to individual residents and patients. An ambition going forward is to explore the potential for more sophisticated ways of segmenting and understanding our populations’ health and care needs, including wider determinants and risk factors for health and wellbeing at both the individual, family and household level.

We also recognise that risk and protective factors at the family and/or household level are a key determinant of an individual’s health and wellbeing and a healthy population.

OUR POPULATION IN ISLINGTON

1. Long term conditions included for the purposes of the pyramid: Chronic kidney disease, diabetes, myocardial infarction and coronary artery disease, atrial fibrillation, heart failure, depression, stroke/transient ischaemic attack, chronic obstructive pulmonary disease, cancer, peripheral arterial disease, dementia, serious mental illness, chronic liver disease, and learning disabilities.

75,522 (40%)

74,143 (39%)

3+ long term conditions

33,627(18%)

3,215(2%)

1-2 long termconditions

people putting their healthat risk

mostly healthy

Pyramid of health risks for adults (18+) in Islington

Household and familiesFamily: Almost half of people (44.3%) in Islington live in a family (includes couples with and without children) of which:

23.6% are a couple with dependent children

20.8% are single-parent families with dependent children

36.0% are a couple without children

Everyone else is a single parent or couple with non-dependent children

Living alone: 38.7% of people in in Islington live alone, of which over 1 in 5 (21.0%) people are aged 65 and older.

Shared living: 17.0% of people in Islington are living in a shared house with others, of which almost 1 in 10 (8.1%)

are living with other students

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8

ISLINGTON’S HEALTH AND WELLBEING PRIORITIESIn the following sections of the JHWS, we describe where we are now in relation to each of the priority areas, and what we will do to make further progress and improvements in these areas. We have also defined a number of measures of success in each area.

Although the JHWS is organised around the three broad priority areas of giving every child the best start in life, preventing and managing long-term conditions and improving mental health and wellbeing, each of the priority areas strongly interlinks with one another and do not sit in isolation. For example, parental mental health is a crucial factor determining health and developmental outcomes for children during their early years. People suffering from a range of physical long term conditions are at increased risk of common mental health problems, and improving the physical health of people with severe mental health problems is key to improving life expectancy for this population group. Moreover, a range of common issues and themes are important for health and wellbeing outcomes in all priority areas, including social isolation, resilience, and coordinated and integrated care. A joined up approach to addressing these cross-cutting issues is key to how we will take forward delivering the JHWS. Box 1 gives an example of how we are taking forward work to improve outcomes for residents with complex multiple needs.

BOX 1: Improving outcomes for people with multiple and complex needsThe Council and its partners are committed to working in new ways to reduce the scale of deep social challenges. There are a significant minority of Islington residents who experience multiple disadvantage and a range of health and wider social issues, including substance misuse, mental health and domestic violence, all of which impact negatively on their quality of life and health and wellbeing outcomes. The Council, together with local health partners, other public services, and the voluntary sector is developing a programme of work focused on how we improve outcomes for residents experiencing multiple disadvantage. This includes not only joining up and integrating services and support for this population group, but also taking every opportunity to intervene early to prevent problems escalating and demand increasing. There is a strong recognition that no one partner can solve these complex issues alone but through a strong partnership can and looking beyond our own service lens and organisations, we can respond better through taking a system-wide approach.

The programme brings together commissioners and providers across health and social care, community safety, housing and crimila justice, and service users to better understand the needs and assets of this population group, current responses to these “needs” from the system and challenges and gaps, in order to develop and test out new solutions and approaches.

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Why is this important for Islington?Early experiences have profound and enduring effects on children’s health, wellbeing and learning. In the context of Islington’s commitment to fairness and equality, reducing health and education inequalities to ensure that children have the best possible start in life is vital. We want our children to start school healthy and ready to thrive in every sense. We know that supporting children throughout their childhoods and into adulthood is important, but creating the best foundation for children and their families is essential.

Islington’s pregnancy-to-five vision expresses factors that are key to ensuring all children have the best start in life. It captures a set of stressors, such as domestic violence and poverty, and a set of factors that build resilience, including engagement with high quality early childhood services and supportive relationships and social networks.

All families in Islington engage with early childhood services, many in multiple ways. From maternity services and primary care, through to health visiting and children’s centres, to nurseries and childminders, we have great potential to support families to give their children the best start; providing early, highly effective support to those who need it most, while offering universal services which create a connection with every family and act as a gateway for those who need targeted and specialist services. We also aim to continue working in an integrated way. This involves professionals who work with children and families having an understanding that they have shared aims, goals, data and learning with other professionals, and that closer and more effective work together will be of benefit to children and families and prevent duplication of scarce resources.

PRIORITY 1Ensuring every child has the best start in life

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Where are we now?Where are we now?

In Islington we have a strong commitment to early childhood services, and families use a wide range of services to help children thrive and develop in the first five years. Over the last few years we have seen big improvements in child health and development in the early years. We know our children’s centres are hugely valued by parents, with more than 90 per cent satisfaction reported in our latest parents’ survey and that, at their best, they provide a range of support for families which enables them to develop the resilience they need. But we know we can do more to support children to develop by the end of reception so that they are healthy, happy and ready for school. Furthermore, unprecedented funding pressures mean that we have to reshape our services to make them sustainable.

Over the past two years, the Islington First 21 Months programme focused on developing our understanding of how different services, such as maternity, health visiting and children’s centres could more effectively work together. As a system, we collectively learnt a lot and made important strides forward. However, we now need to build on our successes and our learning to ensure that our collective resources, whether Council, NHS, private or voluntary sector are used as effectively as possible to achieve the best outcomes for children.

Immunisation rates for most of the major immunisation programmes have increased and are above London and national rates

There are approximately

3,000 births in Islington every year, and

13,000 children in Islington are aged 0-4 years

Rates of

Infant deaths have fallenfrom above the London and national averages to below

School readiness has

improved, but 64% of 5 year olds in Islington achieved a “good level of development”, which is below the national level of 66%

33% of children in Islington come from low income families, compared to 18% nationally

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What do we plan to do?Over the next few years we will be transforming early childhood services in Islington. Our context is challenging, with increasingly constrained resources. We will be moving to a locality model to ensure services are organised more effectively around population need. We will also be developing a new early childhood service identity.

Improving outcomes for children and families

We are committed to designing, reviewing and evaluating our early childhood services for Islington families based on what the evidence tells us matters most, keeping a strong and determined focus on these children’s outcomes. We will:

➤➤ Carry out a training needs analysis and develop a programme of training and professional development to ensure all early childhood professionals have the knowledge, confidence and skills in these key areas to support families within their areas of competence and support them to find specialist help where necessary.

Develop specifications which allow us to monitor how effectively commissioned services address the stress and resilience factors which contribute to improvements in children’s outcomes.

Ensuring prevention and early intervention are at the heart of our work

We will measure our success both on the extent that we reach all families and children but also that our services support families with the greatest need most intensively We will:

➤➤ Maintain a strong set of universal early childhood services, organised across three localities in the borough which ensure easy access to all Islington families through our children’s centres as well as other community locations.

➤➤ Improve our reach to the most vulnerable families through collaborative work across health visiting, family support and children’s services.

➤➤ Develop a model based on the concept of parent champions to enable us to work more collaboratively with our disadvantaged families, including the most vulnerable, so as to ensure our services meet their needs.

➤➤ Improve early identification of children’s health and care needs through improvements in the quality and take up of Healthy Child Programme and Early Help assessments and the integrated review at aged 2.

Driving integration across early childhood services

Concrete expressions of our integrated working include Islington’s children’s centres where many of our services co-locate around the needs of families, information sharing and a shared service identity. We will:

➤➤ Build a new early childhood service identity which brings difference services and professionals under a shared banner and where possible a shared roof

➤➤ Ensure clear protocols between agencies are agreed to enhance information sharing to ensure that professionals can effectively work together

➤➤ Build stronger co-location of professionals

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How will we know when we’ve achieved it?


How will we measure it?

Improved school readiness ➤➤ Percentage achieving the good level of development (GLD) and expected level in the prime areas (Foundation Stage Profile (FSP) data)

Improved outcomes at 2 year review

➤➤ We will develop an indicator for measuring our success

Reduced obesity at end of reception

➤➤ Percentage with Body Mass Index (BMI) equating to overweight/obesity measure – National Child Measurement Programme (NCMP)

Reduced oral health decay ➤➤ Percentage with oral health decay at age 3 or 5 (Oral Health epidemiology survey)

Increase in parents going into work

➤➤ Percentage of 3 and 4 year olds eligible and accessing the additional 15 hour entitlement (from Sept 17) (early years data)

Fewer children in care from mothers who have previously had a removal

➤➤ Number of repeat removals of children into care from the same mother (social care data)

Improved uptake of antenatal health visitor visits by women from target groups (to be identified)

➤➤ Percentage of pregnant women from target groups referred by maternity services to health visitor service and receiving a visit by 36 weeks pregnancy (health visitor data)

More women from target groups book early in pregnancy

➤➤ Percentage of pregnant women from target groups (to be agreed) book by end of 12th week of pregnancy (maternity data)

The most vulnerable families are making persistent use of early childhood services

➤➤ Sustained participation rate by children who are Children in Need (CIN), Child Protection (CP), Children Looked After (CLA) (early years data)

Children with specialist needs around social and communication, speech and language and Child and Adolescent Mental Health Services (CAMHS) receive timely intervention

➤➤ Appropriate waiting times for specialist services (Whittington Health data)

Women affected by domestic violence receive appropriate help and support

➤➤ Percentage of women disclosing to health visitor that there is domestic violence (health visitor data)

➤➤ Percentage of women in receipt of health visitor listening visits, Early Help, referred to specialist service (health visitor and early years data)

2 year olds in receipt of an integrated review

➤➤ Percentage of integrated reviews undertaken

Eligible 2 year olds benefit from their 15 hour entitlement

➤➤ Percentage of eligible 2 year olds accessing their entitlement overall and in settings which are good or better (early years data)

Improved access to early childhood services

➤➤ Percentage uptake in 3/4 year olds accessing the universal free entitlement (early years data)

➤➤ Percentage of under 5s registered with a dentist (NHS England)➤➤ Percentage of children with 4 or more healthcare professional assessments

(health visitor data)➤➤ Universal reach to early childhood services (Children Centres) (early years data)

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Reduction in under 5s attending A&E

➤➤ Reduction in number of children attending for preventable accidents (To be confirmed)

➤➤ Reduction in number of children attending when Primary Care is more appropriate (To be confirmed)

Families show increased resilience and escalation to specialist services is avoided

➤➤ Increase in scoring of resilience domain in Family Star➤➤ Track percentage of families in receipt of Early Help, health visitor listening

visits/partnership and partnership plus, Family Nurse Practitioner (FNP) who are not subsequently referred to specialist services (early years family support data)

Families report services are high quality, accessible and focused around their needs

➤➤ Satisfaction rates of services through annual parent survey and Friends and Family Test (early years/Whittington Hospital)

Professionals report strength of integration

➤➤ Professionals experience measures ; integration supporting effective working across boundaries and supporting professionals in their role (data to be confirmed)

Professionals train and learn together

➤➤ Take up of integrated development opportunities by sector (data to be confirmed)

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PRIORITY 2Preventing and managing long term conditions to enhance both length and quality of life and reduce health inequalities

Why is this important?Long term conditions or chronic diseases are conditions for which there is currently no cure and include, for example, diabetes, chronic obstructive pulmonary disease, arthritis and hypertension. Long term conditions account for 50% of GP appointments and are estimated to account for up to around £7 in every £10 of total health and social care expenditure. Long term conditions are often preventable. People can be supported to live well with a long term condition, if diagnosed early and the condition is well managed. Prevention, early diagnosis and proactive management of long term conditions are critical to improving population health in Islington and to the quality of life of our residents. Our environments and lifestyles include a range of risk factors for developing long term conditions, from low levels of physical activity through to our employment opportunities. Preventing long term conditions therefore requires creating healthy environments and tackling a wide range of risk factors, which will also help promote better health and wellbeing for people with existing long term conditions.

The prevalence of long term conditions is set to continue to increase in Islington, with an increasingly ageing population and changing risk factors, such as the increasing prevalence in obesity. Currently, one in six adults aged between 18 and 74 years in Islington has a diagnosed long term condition, which amounts to around 28,000 adults in total. Moreover, one-third of residents with a long term condition in Islington have more than one condition, which underlines the need for and importance of holistic and joined up health and care, in order to improve outcomes and residents’ experience of care.

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Where are we now?Where are we now?

We have made good progress in terms of the prevention, earlier detection and management of long term conditions in Islington. In particular, through a focus on some of the major causes of premature ill health and death, such as cardiovascular disease, respiratory disease and cancer, we have now closed the gap between Islington and England in premature deaths (under 75 years). We have developed a range of innovative approaches to delivering proactive and coordinated care for people with long term conditions. The Integrated Care Pioneer Programme in Islington for example offers co-ordinated case management for adults with the most complex needs. This involves regular meetings with professionals across health, social care, housing and the voluntary sector to help develop plans to support people and carers to remain in the community. To make sure care is personalised, over 9800 local people have shared their preferences by the national Patient Activation Measure to make sure that care is tailored to the support people need. Islington is part of an early adopter of the National Diabetes Prevention Programme that has been rolled out locally in order to identify people at risk of developing diabetes and referring them into a structured programme of support focused on lifestyle changes and reducing the chance of developing diabetes. However, significant challenges remain.

People with

higher levels of deprivationare more likely to have a long term condition

1 in 10 people of working age in Islington are not able to work due to ill health

More people in Islington over the age of 65

experience a fall compared to London and England

203 people per 1000,000 Islington died from preventable causes during 2012-2014

2 in 5 people from manual and routine occupations in Islington smoke, compared to 1 in 5 people from other professions

38% of adults social care users have as much social contact as they would like

Rates of hospital admissions due

to alcohol in Islington

are significantly higher than in London and England

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What do we plan to do?Our approach to promoting healthier longer lives is focused around four key themes – these are listed below along with our planned actions.

Embedding prevention and earlier intervention across the system

We will:

➤➤ Enhance awareness of residents’ needs amongst frontline staff and maximise signposting to relevant services through the implementation of Making Every Contact Count (MECC) across HWB partners and the services that they commission.

➤➤ Work collectively across the Council, the NHS and the voluntary and community sector (VCS) to support and promote campaigns and awareness across our communities, including through estates and community centres.

➤➤ Include increasing ‘social connections’ as a requirement in all services that we commission.

➤➤ Explore approaches for embedding key performance indicators related to healthy lifestyle (such as smoking and alcohol harm reduction) across health and care commissioned services.

Addressing wider causes of health: particularly housing, employment and isolation

We will:

➤➤ Continue to work across the Council, the local NHS and the employment support system to develop and deliver the Wellbeing and Work programme, including.

➤● Providing training to employment practitioners on how they can support people with health conditions into work and refer into appropriate services.

➤● Promoing the importance of workplace wellbeing amongst local employers to ensure people at risk of poor health and with health conditions are supported to stay in appropriate employment.

➤● Developing and testing the effectiveness of Individual Employment Support and job retention services for people with long term conditions as a way to support people back into employment.

➤➤ Redesign Islington’s tenancy management offer to ensure health is integrated holistically in our local approach.

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➤➤ Develop a programme of work focused on tackling loneliness and social isolation, including working with partners across the statutory, voluntary and community sectors to identify residents at risk of social isolation, map out the range of services and community assets that promote social connectivity, and find new ways of connecting residents and at risk groups.

➤➤ Develop an integrated, multi-disciplinary approach to falls prevention, supported by improved local intelligence and data around how and where falls are occurring, and the development of approaches to identify and target those most at risk of falls.

Promoting and enabling healthier lifestyles

We will:

➤➤ Reduce the prevalence of smoking:

➤● Transform our approach to stop smoking services to better meet residents’ needs.

➤● Proactively promote smoke free environments, with a particular focus on protecting children by creating environments where children are not exposed to smoking, including the home, outside schools and in playgrounds.

➤➤ Promoting healthier and more active families

➤● Develop a healthy environment to encourage access to healthy food, physical activity and active travel (including walking) for families in their everyday lives. Make better use of local assets such as parks, leisure facilities and free community groups.

➤● Ensure advice and support on being active and maintaining a healthy lifestyle is part of the care people receive for long term illnesses such as diabetes.

➤➤ Reduce alcohol related harm:

➤● Raise awareness of the harms caused by alcohol, encouraging a healthy approach to alcohol.

➤● Ensure we promote responsible retailing and reduce harmful consumption, including a proactive approach to licensing and enforcement by all responsible authorities.

➤● Reduce long-term harm by improving the identification and support provided to alcohol-

dependent drinkers by strengthening links between primary care, local hospitals and alcohol support services.

➤● Fully understand, identify and address the impact drinking can have on those affected by someone else’s alcohol use, particularly focusing on children.

Providing a collaborative, coordinated, and integrated care offer to residents

We will:

➤➤ Improve case finding, treatment and management of long term conditions and address variation across primary care, with a particular focus on diabetes, hypertension and atrial fibrillation.

➤➤ Address and manage proactively and holistically the complex problems experienced by those with health conditions– making sure the physical health needs of those with mental health conditions are addressed effectively.

➤➤ Ensure self-care and care planning are central to our approach. Services and interventions will be adapted to meet individual needs, with care better targeted and personalised, whilst making use of innovative technology.

➤➤ Improve the holistic care of people with mental health needs who use or misuse substances. Ensure the development and systematic implementation of relevant training and accompanying policies, protocols and pathways.

➤➤ Ensure services continue to be developed focusing on the needs of residents with long term conditions, rather than organisations, services or professionals. Our local approach to service and pathway delivery will be focused on delivering outcomes and value, achieved by different organisations working together to ensure care and support is provided by the most appropriate person and in the most appropriate setting at the right time.

➤➤ Ensure carers are recognised, valued and supported. We will achieve this through strengthening the way we identify carers, supporting people to identify themselves as carers at an early stage, improving the way we support carers to remain mentally and physically well and influencing all partners, service providers and employers to ‘think carer’.

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More people living with long term conditions will report that they feel able and supported to manage their own care

➤➤ Percentage of people with a long term condition who have a care plan (GP Patient Survey)

➤➤ Percentage of people feeling supported to manage their conditions (NHS Outcomes Framework (NHSOF))

➤➤ Percentage decrease in injuries due to falls in people aged 65 and over (Public Health Outcomes Framework (PHOF))

Residents will be more activated: those living with long term conditions will have improved skills, knowledge and confidence to self-manage.

➤➤ Patient Activation Measures (collected by Islington CCG)

Reductions in hospital admissions directly related to alcohol, alcohol related crime and liver disease mortality.

➤➤ A local alcohol dashboard will be developed to monitor and address alcohol related harm

Fewer residents who smoke ➤➤ Smoking prevalence (PHOF)➤➤ Number of people who have quit smoking (Stop Smoking Services)

Fewer residents who are obese or overweight

➤➤ Percentage of adults with excess weight (PHOF)➤➤ Percentage of physically active adults (PHOF)

Reduction in people who report being lonely

➤➤ Percentage of social care users with as much social contact as they would like (PHOF)

➤➤ We will develop local indicators for measuring social isolation

Improved access and awareness of services

➤➤ Percentage of service users who find it easy to get information (Adult Social Care Outcomes Framework)

➤➤ Making Every Contact Count (MECC) indicators: Increase in lifestyle and wider determinants knowledge amongst staff trained, increase in understanding of behaviour change amongst staff trained, and increase in confidence to have healthy and/or difficult conversations

Residents with long term conditions and disabilities are supported to find and keep work

➤➤ Percentage of people with a long term condition who are in employment (NHSOF/PHOF)

➤➤ Percentage of supported adults with a learning disability who are in paid employment (Public Health Profiles/ National Adults Social Care Intelligence Service Short and Long Term (NASCIC-SALT) survey)

➤➤ We will develop specific, measurable outcomes as part of the delivery of an action, taking forward an integrated approach to health and housing.

More patients reporting a positive experience of integrated care, and fewer avoidable emergency admissions to hospitals

➤➤ Average score for health-related quality of life for people with long-term conditions (NHSOF)

➤➤ People's experience of integrated care (NHSOF - Indicator to be launched soon) ➤➤ Patient Activation Measures (collected by the CCG) ➤➤ Frontline staff experience measured by Social Kinetic survey➤➤ Percentage of people who have an avoidable non elective emergency admission ➤➤ Percentage of people who are admitted into care/residential homes

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PRIORITY 3Improving mental health and wellbeing

Why is this important?Our mental health and wellbeing helps us realise our potential to the best of our abilities, builds coping skills and resilience, enables us to work productively and fruitfully, and helps us to make a contribution to the community. It is as fundamental to our health and wellbeing as physical health, and the two are closely linked.

Mental health conditions are major causes of ill health and disability across the population, and the leading cause of poor health among adults of working age. Groups affected by deprivation, disadvantage and discrimination are at higher risk of developing most mental health conditions, but mental health conditions have an important impact across almost all population groups in the borough.

The impacts of poor mental health conditions in Islington are wide-ranging. For instance, it was estimated that the economic impact of mental health conditions in the borough in 2014/15 was at least £650 million, taking into account the treatment and care of people with mental health conditions, lost economic output, the impact on other public services and spending and the human costs of mental health problems.

Where are we now?There are many actions in place already for commissioning and providing services that promote and address mental health and wellbeing in Islington, reflecting the importance that all partners on the HWB place on improving mental health. A three track approach is important, that promotes good mental health, prevents mental ill health, and supports timely access to effective interventions and recovery. Bringing together mental health interventions with other services as part of coordinated and integrated action is important to improve outcomes for groups with complex, multiple needs where mental health conditions can often be a significant factor.

Child and Adolescent Mental Health Services (CAMHS) are delivered in a range of settings across Islington, including health clinics, youth settings, school and children’s centres. Services report that in recent years they are seeing children and young people with a greater degree of complexity or seriousness of conditions. This has had a significant impact on increasing waiting times in some parts of the service. Our local CAMHS Transformation Plan sets out our vision for transforming services locally by 2020. A key focus of this plan for the current year is to increase access to services and improve waiting times to a maximum of 8 weeks – 4 weeks for an initial appointment and a further 4 weeks to commence treatment. Services work in collaboration with a range of stakeholders particularly education and social care colleagues recognising the importance of the ‘think family’ approach, which brings together services for children and adults. Young people aged 16-21 can access counselling in youth settings, and there is increased adult mental health services input into social care services for children and families, such as Children Looked After, Early Help, Families First, Children in Need and the Stronger Families Programme. Specific CAMHS input is also provided locally into the Youth Offending Service and the Integrated Gangs Team recognising the high prevalence of mental health issues in these groups

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Where are we now?

of young people. An innovative new mental health promotion initiative, i-MHARS, has been developed locally and launched in a number of Islington schools.

There has been substantial local focus on achieving parity of esteem for services for people with mental health conditions, and through the Crisis Care Concordat, improving the response across agencies to people with urgent or emergency needs related to their mental health. Perinatal mental health services have also been a focus for improvement, linking into local early years services. Islington’s Improving Access to Psychological Therapies service, i-Cope, for people with depression and anxiety exceeded the national target of seeing 15% of people with these conditions, and recently additional talking therapies have been commissioned to support those groups that have specific vulnerabilities, such as refugees or those who have experienced trauma and abuse. Significant progress has been made on supporting more people with mental health conditions to successfully find and stay in employment. A new ‘value based commissioning’ programme has been developed, which will focus on improving the experience of and outcomes for people with psychosis, with a strong focus on reducing the gap in life expectancy between people with serious mental illness and the general population in Islington. Early Intervention services for psychosis have been extended to those aged 35-65 providing a greater intensity of service to help manage the condition more successfully. Earlier diagnosis with improved support for people with dementia has been a local as well as national priority, and it is estimated that a higher proportion of people with dementia have had their condition diagnosed in Islington than anywhere else in the country. In 2015/16 a total of 750 local staff, volunteers and members of the community have been trained in mental health first aid and mental health awareness programmes.

18% of the total eligible population entered first treatment via Improving Access to Psychological Treatment (IAPT) services in Islington, which is above the 15% target.

There is a

65% gap in employment rate between those in contact with secondary mental health services and the overall employment rate.

1 in 6 adults in Islington have at least one diagnosed mental health condition

Of children with a mental health condition in Islington,

more than half are undiagnosedBetween 2012-2014, there were

55 deaths from suicide in Islington, which is similar to London and national rates

People in contact with specialist mental health services in Islington have a

mortality rate 3.6 times higher than that of the general population in London and England

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What do we plan to do? Increasing focus on mental health and wellbeing for children and families

We will:

➤➤ Continue to develop the ‘think family’ approach between adult and children’s mental health services

➤➤ Further develop the transition for young people and young adults experiencing, or at risk of, longer term mental health conditions.

➤➤ Improve waiting times for CAMHS/counselling.

➤➤ Roll-out of i-MHARS across Islington schools (primary and secondary).

Increasing employment opportunities and workplace health

We will:

➤➤ Give a high priority to supporting people with mental health conditions who are long term workless to return to employment, education and training, and work with employers to promote workplace wellbeing.

Working better as a system

We will:

➤➤ Build on local progress bringing together partners to provide a holistic service to people with multiple complex needs which include mental health problems.

➤➤ Improve long term individual outcomes and support more efficient local services through inclusion of mental health as a parameter within the ‘Adults with Multiple Complex Needs Project’.

Focusing on reducing violence and the harm it causes

We will:

➤➤ Support psychological interventions and access to services designed to reduce violence.

➤➤ Improve understanding of, and response to, the mental health impact on victims and survivors of violence, including domestic violence.

Improving the physical health of people with mental health conditions

We will:

➤➤ Reduce the number of people with serious mental illness who die early from preventable causes, through system-wide action (the Value Based Commissioning programme).

➤➤ Ensure that lifestyle and health behaviour interventions and action to improve early diagnosis, treatment and care of physical long term conditions address and target the needs of people with mental health conditions, and encourage participation and access.

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Supporting social connectedness

We will:

➤➤ Enhance frontline staff’s awareness of residents’ needs and maximise signposting to relevant services, through Implementation of Making Every Contact Count (MECC) across HWB partners and the services they commission.

➤➤ Work collectively across the Council, the NHS and voluntary and community sector to support and promote campaigns and awareness that promote positive mental health, prevent mental ill health and provide timely support and help including through our estates and community centres. We will include increasing ‘social connections’ as a requirement of all local services we commission.

Preventing suicide

We will:

➤➤ Develop and implement the priorities of the local suicide strategy, developing and agreeing new approaches to address risks and support people bereaved or affected by suicide (postvention).

Increasing awareness and understanding

We will:

➤➤ Champion action that promotes understanding, better recognition of signs and symptoms, and positive attitudes about mental health conditions – including within partner organisations and including Islington’s mental health first aid initiatives.

Focusing on dementia

We will:

➤➤ To improve the post diagnosis offer for people diagnosed with dementia.

➤➤ Continue to improve dementia diagnosis rates taking into account increasing prevalence due to an ageing population.

Improving service access

We will:

➤➤ Increase access to IAPT to 19% of the target by 2020.

➤➤ Increase the presence of mental health professionals in primary care settings to support earlier intervention and reduce stigma.

➤➤ Develop a new Health Based Place of Safety to provide safe, comfortable and appropriately resourced settings for individuals in crisis.

➤➤ Review services to support people in crisis to help avoid hospital admissions.

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Healthier lifestyles for people with serious mental illness (SMI)

➤➤ Smoking quits among people with serious mental health conditions (CCG data)

Improved physical health of people with SMI

➤➤ Number of deaths under 75, by cause, among people with serious mental health conditions (PHOF)

➤➤ The number of preventable emergency admissions for long term conditions (NHSOF)

➤➤ The number of premature years of life lost (NHSOF)

Reduction in deaths due to suicide

➤➤ Number of deaths due to suicide or undetermined injury, or reported as suspected suicides. Office for National Statistics (ONS)/PHOF

Multiple / complex needs ➤➤ We will develop local indicators to measure progress in this area

Improved outcomes for people involved with gangs

➤➤ Percentage of gang nominals referred to the Integrated Gangs Team (Information Governance toolkit (IGT)) who have case consultation and mental health screening (IGT data)

➤➤ Number of gang nominals in the IGT requiring mental health support who have a mental health assessment (IGT data)

➤➤ Number who have a positive reduction in psychometric measures of mental health outcomes at end of the intervention e.g. Generalised Anxiety Disorder (GAD) or PHQ (type of patient health questionnaire for depression) or STAXI-III (type of phsychological assessment) (IGT data)

➤➤ Number of individuals who are referred to adult mental health services, who receive a service from the gang psychologist (IGT data)

Improved service access for people with domestic violence

➤➤ Number of people accessing talking therapy services with a history of domestic violence (IAPT data)

➤➤ Number of mental health staff trained on identification and referral of domestic violence (MH team)

➤➤ Number of people accessing drugs and alcohol treatment with a history of domestic violence (Drugs and alcohol provider data)

Increased employment among people with mental health conditions

➤➤ Numbers of people with mental health conditions supported into employment (CCG data)

➤➤ Numbers of people with mental health conditions supported to stay in employment (CCG data)

Improved understanding and ability to respond to mental health conditions

➤➤ Participation in mental health first aid training and related initiatives, evaluated for impact (Public health team)

Improved social connectedness ➤➤ We will develop local indicators to measure progress in this area

Improved service access for people with dementia

➤➤ Ensure children and young people wait no longer than a maximum of 4 weeks for an initial appointment and a further 4 weeks to commence treatment

➤➤ Increase access to CAMH services by 25% by 2020 (CAMHS data)➤➤ Develop out of hours crisis care pathways – working towards 24 / 7 access by

2020➤➤ By 2020 increase access to IAPT to 19% of the target population (IAPT data)

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Appendix 4.4.2

Islington’s Draft Joint Health and Wellbeing Strategy Consultation

What do we want to consult on? Islington's Health and Wellbeing Board (HWB) must set out a clear plan for how we will improve the health and wellbeing of people living in Islington over the coming years. This plan is the Islington Joint Health & Wellbeing Strategy 2017-20 (JHWS), and is jointly owned by the Council, Islington CCG and Islington HealthWatch. Why do we want to engage with you? Everyone has a role to play in improving the health and wellbeing of Islington’s population. Therefore, everybody should be aware of this strategy, and have an opportunity to share their views on it. We want your views This consultation is about helping to shape the actions taken to achieve the three overarching health and wellbeing priorities agreed across Islington. The questions we would like you to think about are detailed at the back of the full document. In general terms we would like to hear your views on:

1. Do you agree that we have identified the right focus for improvement under each priority? Are there other areas of high priority that should also be included, and if so, why?

2. Have we selected the right measures to show improvement? Are there other ways to monitor and evaluate the outcomes that we should consider?

3. What role will you play in contributing to achieving the outcomes set out in this strategy?

4. Are there any other comments that you would like to make? How to respond You can respond to the consultation through an online survey or by completing the form below. The online survey can be found here: [insert link]. This can also be found on the Islington Council website at: http://www.islington.gov.uk/involved/consultation-engagement/consultations Or you can email [email protected] The deadline to make a response to the consultation is: 7 December 2016.

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http://www.islington.gov.uk/involved/consultation-engagement/consultations


Consultation response form for Islington Draft Joint Health & Wellbeing Strategy 2017-20 (JHWS), Name (organisation or individual):

Priority outcome 1: Ensuring every child has the best start in life 1. Do you agree that the actions under the "What do we

plan to do?" section are right for ensuring every child has the best start in life?

2. Are there any actions under the “What do we plan to do?” section that you feel should be included or excluded?

3. Do you think we have selected the right indicators to monitor and evaluate outcomes, under the “How will we know when we’ve achieved it?” section?

Priority outcome 2: Preventing and managing long term conditions to enhance both length and quality of life and reduce health inequalities 4. Do you agree that the actions under the "What do we

plan to do?" section are right for preventing and managing long term conditions?

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Priority outcome 3: Improving mental health and wellbeing 7. Do you agree that the actions under the "What do we

plan to do?" section are right to support improvements in mental health and wellbeing?



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Further questions. 10. What role will you play in contributing to achieving the

priorities set out in this strategy?

11. Are there any gaps in the Islington Joint Health and Wellbeing Strategy? What else should we include and why?

12. Are there any other comments that you would like to make?

Please return your response to the consultation on the draft Joint Health and Wellbeing Strategy to: [email protected] Or HWB consultation Public Health London Borough of Islington 3rd Floor 222 Upper Street London, N1 1XR By: 7 December 2016

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Development of CCG Commissioning Arrangements in North

Central London LEAD COMMITTEE MEMBER:

Dr Jo Sauvage, Chair Alison Blair, Chief Officer


[email protected] 0203 688 2906

Overview: This paper synthesises work to date in respect to transforming the commissioning arrangements in North Central London. It summarises the recommendations detailed in: • Paper 2: Proposal for establishing a Joint Committee of North Central London CCGs;

and, • Paper 3: Management arrangements. 1. Introduction The proposals included in the paper and detailed in the two supporting papers, build on the discussions that have taken place within our CCG and with the other four CCGs in North Central London, as well as with NHS England over the past months. The proposals expand on the papers the Governing Bodies discussed throughout September and October, however, they respond not only to our discussion but also to the governing body discussions that took place within the other four CCGs. During September and October, all five CCG governing bodies discussed an identical set of papers, which built on the work already done by CCGs. These papers outlined the case for changing the way we commission services, a proposed commissioning strategy for North Central London, a proposed financial strategy for North Central London and proposals for revising the management and governance arrangements to strengthen our collective commissioning efforts. In response to these papers, all five CCGs have: agreed the case for change, agreed the commissioning strategy and the financial strategy; and concluded that a shared Accountable Officer and a shared Chief Finance Officer should be appointed in order to align better with the NCL STP. The papers proposed two further shared roles (a Director of Strategy and a Director of Performance). A number of CCG governing bodies wanted further details on the specific roles, as well as on the local structures, in order to conclude on their appropriateness. This work has been progressed by Chief Officers and Chairs and is being presented within the body of these papers. The papers also requested an agreement in principle to establishing a joint governance

Item: 4.5

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structure that would enable decisions to be made collectively as well as a set of next steps to develop the proposition. All CCG governing bodies agreed in principle and significant work has been undertaken to develop the proposals outlined in these papers. All CCGs had governing body representation at a full day workshop on 6 October 2016; to facilitate this effort, legal input has been received from Capsticks. During November, NCL CCG governing bodies will all be reviewing this paper together with its two accompanying papers. They bring forward: 1. A proposal for establishing a Joint Committee of NCL CCGs to make decisions for those

services and functions it is recommended are best resolved collaboratively.

2. Further proposals in respect to management arrangements, specifically recommendations for appointing the shared posts as well as Local Executive Directors.

It is recognised that there is more work to do and that this is an incremental process. However, these proposals are deemed ready for review and are recommended for approval. They will help guide the next steps we need to take in further strengthening our commissioning arrangements. 2. Context and background The NHS Five Year Forward View (FYFV) sets out a clear direction for the NHS – showing why change is needed and what it will look like. To support delivery, areas across the country have been asked to develop 5-year Sustainability and Transformation Plans (STPs) that show how commissioners and providers will come together with local authorities to address three gaps: health and wellbeing; care and quality; finance and efficiency. The five Clinical Commissioning Groups (CCGs) - Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG and Islington CCG - have come together across North Central London (NCL) to articulate and address these gaps together with their main providers and the five local authorities. NCL has a complex health and social care landscape, with a diverse and growing population. Delivering universally for everyone to the best possible standards is not always possible in the current health and care system and there are widespread inequalities across NCL. Health commissioners and providers face a large financial challenge should nothing change. Our aim is to ensure people can get the care they need, when they need it, within the available funding. We have already made great strides in improving health and care both working with local partners and collectively as a group of CCGs. The following illustrate the great work underway or already completed across NCL: • Developing the Sustainability and Transformation Plan itself; • Developing a clear prevention strategy using the community assets in place across

health and care services; • Developing new services as part of the Healthy London Partnership; • Establishing the Islington and Haringey Wellbeing Programme following on from the

Vanguard proposal; • Supporting the emergence of GP Federations in all Boroughs across NCL • Putting Primary Care Networks in place and implementing extended access to general

practice; • Implementing extended health and care teams aligned to general practices offering

proactive care, and for those who need it co-ordinated care (including co-creating health);

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• Delivering Barnet ‘care closer to home’ projects including re-imagining mental health; • Developing new models of care, and a value based commissioning approach, for frail

elders and diabetes and psychosis; and aligning care across primary, community, mental health, social care and hospital services;

• Implementing the Barnet, Enfield and Haringey Clinical Strategy; • Establishing of Whittington Health Integrated Care Organisation; • Supporting the Royal Free Hospitals acquisition of Barnet and Chase Farm (with

supportive pathway work) and hospital chain with North Middlesex; • Agreeing an aligned approach to provider contracts; • Putting an integrated workforce strategy in place with blended training and new roles

(e.g. practice based pharmacists and blended roles in urgent care).

The five CCGs in NCL have extensive experience of commissioning and have been working together for some time, but we have ambitions to do more and are facing collective challenges. The commissioning issues that are facing us include the development of new models of care, the establishment of larger provider organisations, increasing financial risk and stretched capability and capacity. CCG collaboration The CCGs within NCL have come together to consider and respond to these challenges; as part of this process we have been working together to review how best to strengthen our commissioning arrangements, building on work already done (for example, with joint commissioning for primary care). We have agreed that plans for any new commissioning system that will implement the STP will need the following characteristics: • Cover a sufficiently large population to enable commissioning at scale – driving more

ambitious change and productivity improvement • Be clear and as simple as possible – allowing us to speak with one voice when needed • Enable the achievement of consistency in the delivery of standards and thus, deliver a

reduction in the variation in pathways • Facilitate the sharing of scarce commissioning leadership, capacity and capability • Mean that we can manage jointly areas of change that require consultation, and/or

capital/revenue investment • Allow us to take tough decisions when the resources invested do not make the biggest

difference to local patients/residents. Aim of this work We have identified several specific aims for the transformation in commissioning to ensure that the design of new arrangements meets these outcomes including removing complexity, ensuring alignment, maximising use of precious resources, enabling strong commissioning in a shifting provider landscape and protecting local decision making. This work is in line with The NHS Operational Planning and Contracting Guidance 2017-2019, which calls for CCGs to work more collaboratively together, notably for: “CCGs to work together across larger geographical footprints, for example, through joint appointments, integrated management and governance arrangements.” 3. Governing Body recommendations The papers being considered by the Governing Body put forward a series of recommendations. These recommendations build on all the joint work undertaken to date, including the work undertaken by senior executives from all five CCGs and from the governing body workshop held on 6 October 2016. Our CCG has been fully represented in this collaborative work.

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Paper 2: Proposal to establish a Joint Committee of North Central London CCGs This paper sets out a range of proposals relating to how to make collective decisions across the five CCGs. The proposals cover: what decisions should be made collaboratively; the governance arrangements relating to how these decisions be made; how governing bodies should assure the joint committee; and the changes we need to make decisions. Specifically, paper 2 asks the Governing Body to approve: 1) The delegation of responsibility for the commissioning of the following services to an

NCL joint committee: • Acute services including core contracts and other out of sector acute commissioning; • All learning disability contracting associated with the Transforming Care Programme; • All integrated urgent care (including NHS 111/ GP Out-of-Hours services); and • Any specialised services not commissioned by NHS England.

2) That the proposed shared NCL committee will take the form of a joint committee 3) That the membership of the proposed joint committee be as outlined in section 4 of

paper 2

4) The delegation of responsibility for the application of their resources for the commissioning of the delegated areas (acute commissioning, Transforming Care, integrated urgent care and specialised services) to an NCL joint committee

5) That the shared CFO post represents each of the five CCGs, and has the accountability for financial management of the resources to support the acute services commissioned, and equally has accountability to each CCG in line with statutory requirements for the areas delegated.

6) That the shared CFO develops the financial strategy into a set of policies and

procedures, which will require endorsement by the joint committee for operation 7) That the shared CFO represents the five CCGs in finance and performance monitoring

meetings with NHS England 8) The Terms of Reference and Standing Orders for the joint committee as set out as

Appendices 2 and 3 of paper 2 9) The appointment of the independent joint committee members 10) The process assurance of the performance and quality of the proposed Joint Committee

as outlined in section 8 of paper 2 11) The process for assurance of the financial management of the proposed Joint

Committee as outlined in section 8 of paper 2 12) That the Joint Committee complete an annual self-assessment of performance and

develop an action plan to address any issues that arise

13) A three-part escalation process that may be implemented if the joint committee is perceived to be unsuccessful as set out in section 8 paper 2

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14) Amendments to the Scheme of Reservation and Delegation as set out in section 10 of paper 2

Paper 3: Management arrangements This paper sets out a range of proposals relating to proposed changes to CCG management arrangements to support more collaborative working. The paper includes recommendations relating to leadership positions and the impact of this on wider CCG resources as well as proposals for implementation planning and next steps. Specifically, paper 3 asks the Governing Body to approve: 1) The creation of a new Local Executive Director role, to lead the delivery of local

functions, alongside the shared director roles

2) The proposal for a shared Director of Strategy and a shared Director of Performance an Acute Commissioning

3) That all CCG running cost workforce in finance, performance and acute commissioning functions be line managed by the new shared local executive director roles

4) That the management of the core CSU support contracts be reviewed across the five CCGs based on their needs and reflecting the proposals of the new commissioning arrangements.

5) That accountability for the management of the core CSU support contracts be delegated to the new shared Accountable Officer, who would have responsibility for signing the ore contracts on behalf of the five CCGs

6) That the day-to-day management of the CSU support resource where is relates to acute contracting, be undertaken by the proposed Director of Performance and Acute Commissioning

7) That recommendations made by the remuneration committee at 10 November be approved by Chairs Action on behalf of the Governing Body

8) That Islington CCG act as the host employer for any new appointments that are shared across the NCL CCGs

4. Risks In the September and October governing body meetings the risks of this programme were discussed across all CCGs. At the governing body workshop held on the 6 October the Chief Officers discussed the potential risks that the transition to and delivery of the joint commissioning arrangements. From this discussion, a risk register and mitigations were developed and are shown in Figure 1. This risk register will be updated by Chief Officers and is proposed to be discussed at the next CCG Audit Committee. Figure 1: Risk register for joint commissioning arrangements:

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5. Next steps As summarised in section 3 there are a significant number of recommendations outlined to be presented before the governing bodies in November. Implementing these recommendations as well as progressing the appointments of the shared Accountable Officer and the shared Chief Finance Officer requires each of the CCGs to take actions in respect to the development of their local arrangements and, regarding the proposed shared functions, for the five NCL CCGs to work together on a series of next steps. The local circumstances of each CCG in NCL are slightly different. For example, the degree of integration with local government and the approach to delivery of the care closer to home strategy vary between CCGs and are being directed by clinical leadership. This is sensitive to the needs of the local populations and the relationships that exist with, and within, each of the boroughs as this is a key strength of the CCGs. It is therefore not possible or appropriate to have a standardised approach across all CCGs in respect to

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progressing this work. However, there are a core set of next steps all CCGs will need to work through (in Haringey and Islington much of this will be done jointly given the proposal to have a joint team) and a shared set of next steps relating to the shared roles and functions – these are outlined below. The HR implications as a consequence of the proposed shared roles At this stage, the proposals will only impact on Very Senior Manager (VSM-level) posts in the CCGs and specifically just the Accountable Officers and Chief Finance Officers. The draft appointment timeline for the previously agreed shared Accountable Officer and shared Chief Finance Officer (outlined in figure 2, paper 3), will be discussed at the remuneration committee meeting scheduled for 10 November. This meeting will be held in common together with the other four NCL CCG remuneration committees. The proposed timeline means that, at the earliest, offers will be made for these roles in mid-December. Allowing for notice periods we should not expect the positions to be filled until the beginning of the new financial year i.e. week commencing 3 April. In respect to the rest of the executive level structure, if all CCGs in NCL agree with the proposals in these papers, further remuneration committee meetings will be needed in week commencing 5 December 2016. Governing bodies will want to consider if they would like the discussions relating to any shared roles to be held in common, as per the meeting on 10 November. Following this meeting, a process could be initiated for these VSM-level posts. Offers would be made no earlier than January and we should not anticipate roles to be filled before early April. Therefore, we expect it will be mid-April before the new executive arrangements, as outlined in these papers, are in place across NCL. Paper 3 outlines the impact of these proposals on the rest of the CCG workforce. While there are proposed changes in the line management of individuals e.g. those staff working in performance are proposed to report to the Director of Performance and Acute Commissioning, there are currently no changes proposed in respect to what role they are doing or where they are working. Developing our organisational design To date, much work has taken place within each CCG to ensure structures and the use of resources are fit for purpose and aligned to deliver local priorities. We have also worked collectively with the other CCG leaders to map functions and people to the proposed VSM-level structure (as outlined in section 3 of paper 3). However, we recognise there is more work to do both within our CCG and together with the other CCGs in NCL. Once the new VSM-level appointments are in post, we will need them to work with local clinical leaders, teams and governing bodies to review the way we are operating and propose any necessary changes to ensure that our CCG-led efforts (as well as our shared work) is fit for doing all that we intend. With regard to the CCG structure, Accountable Officers are already taking this work forward in recognition that we cannot simply stand still. The outcome of this work may mean delivering functions not currently resourced by all CCGs such as estates. If the proposals resulting from this work impact on individuals there will also be a need to initiate a change process in line with our policies. The work to date has also highlighted the need to work together, across NCL, to determine what of our programme delivery resource would be better shared under the leadership of the proposed Director of Strategy. Examples of this might be our maternity programme and/or our cancer programme, as well as those elements of the STP programme, funded

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by the 16/17 STP budget, that we wish to continue in future years. As we review out approach to delivering the STP we will want to ensure that we are clear about what programmes the Director of Strategy should lead across the whole NCL and what programmes the Local Executive Directors should lead on within each borough. It is anticipated that this will align to the decision-making framework and the commissioning strategy in which we recommend those things best done at an NCL-level (as outlined in section 2 paper 2). However, there is still more work to be done in order to identify and shape the resources required to carry it out. It is understandable that these discussions are causing uncertainty and disruption for our staff. However, we should communicate that this is not an effort to reduce our costs but rather to deploy our resources most effectively, ensuring we best deliver our commissioning responsibilities. However, the leadership changes are in themselves disruptive and bring with them a period of heightened risk due to the transition. It is proposed that a further NCL-wide governing body workshop take place at the beginning of December once these papers have been discussed by all the governing bodies. This workshop should focus on how we manage the transitional period as well as the risks it poses to the day-to-day delivery of business as usual. The Joint Committee The recommendation is that the Joint Committee be established as of 1 April 2017 once the appointments have been made for the proposed independent committee members and the new executive arrangements are in place. However, we suggest that we discuss at the proposed workshop whether we should operate a shadow forum for January to March. Communications and engagement We will want to continue to engage and communicate with our staff and stakeholders about these proposals and the implications of them as they emerge. Chief Officers will work with HR specialists and communications leads to develop a plan for discussion with governing body members. Governing Body members are asked to comment on these next steps and suggest any further actions they think should be taken forward.

This report contributes to: • Delivering high quality, efficient services within the resources available. Prior consideration by Committees and other partners: The Governing Body Seminar held on 12 October 2016, and the Part Two of the Governing Body held on 14 September 2016 provided an opportunity for Governing Body members to comment on earlier drafts of these papers. Patient & Public Involvement (PPI): This report is for information only. Equality Impact Assessment: Not applicable for this report.

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Risks: Risks and mitigations for those risks are included in the cover paper. RECOMMENDED ACTION: The summary paper above has a series of recommendations about the governance of and management structures for commissioning arrangements across North Central London CCGs. For the governance arrangements the Governing Body is asked to APPROVE: 1) The delegation of responsibility for the commissioning of the following services to an

NCL joint committee: • Acute services including core contracts and other out of sector acute commissioning; • All learning disability contracting associated with the Transforming Care Programme; • All integrated urgent care (including NHS 111/ GP Out-of-Hours services); and • Any specialised services not commissioned by NHS England.

2) That the proposed shared NCL committee will take the form of a joint committee 3) That the membership of the proposed joint committee be as outlined in section 4 of

paper 2 4) The delegation of responsibility for the application of their resources for the

commissioning of the delegated areas (acute commissioning, Transforming Care, integrated urgent care and specialised services) to an NCL joint committee

5) That the shared CFO post represents each of the five CCGs, and has the

accountability for financial management of the resources to support the acute services commissioned, and equally has accountability to each CCG in line with statutory requirements for the areas delegated.

6) That the shared CFO develops the financial strategy into a set of policies and

procedures, which will require endorsement by the joint committee for operation 7) That the shared CFO represents the five CCGs in finance and performance monitoring

meetings with NHS England 8) The Terms of Reference and Standing Orders for the joint committee as set out as

Appendices 2 and 3 of paper 2 9) The appointment of the independent joint committee members 10) The process assurance of the performance and quality of the proposed Joint

Committee as outlined in section 8 of paper 2 11) The process for assurance of the financial management of the proposed Joint

Committee as outlined in section 8 of paper 2 12) That the Joint Committee complete an annual self-assessment of performance and

develop an action plan to address any issues that arise 13) A three-part escalation process that may be implemented if the joint committee is

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perceived to be unsuccessful as set out in section 8 paper 2 14) Amendments to the Scheme of Reservation and Delegation as set out in section 10 of

paper 2

For the management arrangements the Governing Body is asked to APPROVE: 1) The creation of a new Local Executive Director role, to lead the delivery of local

functions, alongside the shared director roles 2) The proposal for a shared Director of Strategy and a shared Director of Performance

an Acute Commissioning 3) That all CCG running cost workforce in finance, performance and acute commissioning

functions be line managed by the new shared local executive director roles 4) That the management of the core CSU support contracts be reviewed across the five

CCGs based on their needs and reflecting the proposals of the new commissioning arrangements.

5) That accountability for the management of the core CSU support contracts be

delegated to the new shared Accountable Officer, who would have responsibility for signing the ore contracts on behalf of the five CCGs

6) That the day-to-day management of the CSU support resource where is relates to

acute contracting, be undertaken by the proposed Director of Performance and Acute Commissioning

7) That recommendations made by the remuneration committee at 10 November be

approved by Chairs Action on behalf of the Governing Body 8) That Islington CCG act as the host employer for any new appointments that are shared

across the NCL CCGs

SUPPORTING PAPERS: The summary paper on developing commissioning arrangements in North Central London is supported by more detailed papers that focus on: • Appendix 4.5.1 Governance Arrangements (Paper 2); • Appendix 4.5.2 Management Arrangements (Paper 3).

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Appendix 4.5.1 Paper 2 of 3 Developing the commissioning arrangements in North Central London: Proposal to establish a joint committee of North Central London CCGs

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Contents 1. Introduction .............................................................................................................. 3

2. Proposed decision making framework ....................................................................... 3

3. Statutory form of the proposed committee ................................................................ 9

4. Membership and voting ........................................................................................... 10

5. Financial management implications of the joint committee ..................................... 12

6. Decision making and quoracy of the joint committee ............................................... 13

7. Selection process for the independent members of the proposed joint committee ... 14

8. Assuring the joint committee ................................................................................... 15

9. Implications for CCG sub-committees and other joint forums ................................... 20

10. Proposed amendments to the Scheme of Reservation and Delegation .................. 21 Appendix 1: Levels of commissioning – delegation of functions from governing bodies to joint committee ............................................................................................................................. 25 Appendix 2: North Central London joint commissioning committee Terms of Reference (ToR) . 26 Appendix 3: Standing orders for the North Central London joint commissioning committee ..... 34 Appendix 4: Arrangements for delegating NCL CCG commissioning functions to a joint committee ............................................................................................................................. 38 Appendix 5: Draft job description for the proposed independent Chair of NCL joint committee 49 Appendix 6: Draft job description for the proposed secondary care independent clinical adviser of NCL joint committee ........................................................................................................... 54 Appendix 7: Draft job description for the proposed registered nurse/independent clinical adviser of NCL joint committee ............................................................................................... 58

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1. Introduction In September and October all governing bodies in North Central London confirmed their commitment to joint working and recognised the need for arrangements that would facilitate collective decision making. All CCGs agreed to work together to bring forward proposals for joint governance arrangements. This paper outlines the outcomes of this joint work and proposes the establishment of a Joint Committee of North Central London CCGs. Whatever joint decision making arrangements are in place, it is the individual CCG governing bodies that remain accountable for all statutory duties such as, those relating to quality, safeguarding and the achievement of financial balance. At this stage, no proposals are being brought forward to jointly commission any services across North Central London with either local authorities (there is as yet no legislative framework to allow for this) or with NHS England, beyond the work we are already doing in respect to primary care commissioning. This is done by a joint committee of the five CCGs with NHS England and will continue under the new arrangements. In time, the activities of the Primary Care Joint Committee will need to align with any new arrangements. 2. Proposed decision making framework This section of the paper outlines proposals for the decisions we should, in the future, take jointly with the other CCGs in NCL. However, for clarity and completeness it also covers those services that we should continue to determine locally. This proposed ‘decision making framework’, builds on our agreed NCL commissioning strategy, which outlined the services best commissioned at an NCL-level and those best done locally, within each borough. In developing these proposals commissioning decisions have been thought about in two categories: 1. Where decisions are best taken by individual CCG governing bodies: this could either be

a) independently; or, b) with strategic alignment across the five CCGs

2. Where decisions are best taken collectively by the five NCL CCGs acting together Work has been undertaken by the CCG Accountable Officers, reviewed by the Chair and lay member workshop on 6 October and further developed and considered by CCG Directors of Commissioning on 21 October, to recommend where commissioning decisions would be best determined. These recommendations are outlined in Figure 1 and described in further detail below.

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Figure 1: Proposed commissioning framework reflecting decision-making levels

Commissioning decisions best taken by individual CCG governing bodies There are several services which have a long history of co-commissioning with local authorities and where a detailed understanding of the local population is required to commission them. This proposal ensures decisions about these services will continue to be made locally. Some of these services should continue to be commissioned independently by individual CCGs whilst others would benefit from strategic alignment across NCL but commissioning decisions should continue to be made by individual CCGs. A summary of these services is given in Table 1. Locally determined services that are recommended to benefit from strategic alignment across NCL include: • Care closer to home: a key focus of the Sustainability and Transformation Plan (STP) is

delivering care closer to home, and whilst this theme runs across NCL, it’s delivery will require different actions for each of the CCGs. Therefore, strategic alignment around the strategy for care closer to home will be discussed at an NCL-wide level, but authority for deciding on and overseeing delivery will remain with individual CCG Governing Bodies, with no changes being proposed to the current lead commissioner arrangements. In many cases, this commissioning will be done jointly with the local authority.

• Mental health: whilst there are issues that would benefit from collective commissioning e.g. the commissioning of the two main providers – Camden and Islington NHS Foundation Trust and Barnet, Enfield and Haringey Mental Health NHS Trust, what is needed is a pathway based approach. Much of the commissioning of care is joint with local authorities and it would be detrimental to stop these arrangements. The strategy for mental health should be discussed jointly but decision-making should be determined locally for now; however, the current lead commissioner arrangements would also be maintained. This may be reviewed as strategic commissioning develops across NCL.

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Table 1: Services proposed to continue to be commissioned by individual CCGs

Services proposed to be commissioned independently by individual CCGs

Services proposed to be commissioned by individual CCGs but with strategic alignment across NCL

• Children’s joint commissioning and

children’s services outside of hospital • Primary care development • Primary care prescribing • Sexual health commissioning (within

CCG responsibilities) • Joint commissioning with social care:

− preventative care − complex elderly − Better Care Fund

• Mental health and community contracts

− Barnet, Enfield and Haringey Mental Health NHS Trust

− Camden and Islington NHS Foundation Trust

− South London and Maudsley NHS Foundation Trust

− East London NHS Foundation Trust − Tavistock and Portman NHS

Foundation Trust − Central London Community Healthcare

NHS Trust − Central and North West London NHS

Foundation Trust − Whittington Health NHS Trust

(community only) • Other mental health commissioning • All hospice-based end of life care • Continuing healthcare and funded nursing

care • Day-to-day tactical delivery of A&E

performance

For these services, it is proposed that the individual CCGs will undertake the following commissioning functions: • Approval of business cases and change requests • Needs assessment for the local population • Planning service requirements • Contracting and contract management • Joint working with the local authority • Setting required outcomes for providers and systems • Monitoring outcomes • Approval of decommissioning of services • All engagement including with the public, members and local authorities.

It is recommended that any NCL joint committee will not make any commissioning decisions relating to these services unless explicitly requested by CCG governing bodies. This would only happen on a case by case basis. Where services will benefit from strategic alignment, the committee should support the sharing of best practice, aligning assumptions and

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aligning enablers (for example, joint estates or workforce plans). This is illustrated in Figure 2. Figure 2: Services where it is proposed that there should be strategic alignment across NCL but where commissioning decisions should be made locally

Commissioning decisions proposed to be made by a Joint Committee We recommend that some services are better commissioned jointly across NCL, so that CCGs can: • Successfully negotiate with large providers: the past decade has developed a greater

understanding of how the requirements of high quality care (particularly for the workforce and co-dependency of services) leads to establishing networked acute systems which service large populations (1m+ for stroke, 500k for emergency surgery). Commissioners need to come together to commission several hospital sites that make up an acute system if they are to deliver real strategic change

• Utilise scarce commissioning resources: strategic commissioning requires scarce skills in leadership, cross-organisational working, finance, contracting and performance management. These skills can be better utilised across larger populations.

Services recommended for joint commissioning include most hospital-based acute care and specialist care: • The NCL urgent and emergency care network: several benefits would result from having

joint decision-making on urgent and emergency care; notably a co-ordinated response to providers, unlocking synergies relating to staff, diagnostics, and surge management across the network. Winter resilience funds would be pooled to support the approach. − At NCL level, the model of urgent care will be determined (through the Urgent and

Emergency Care Board), modelling demand and capacity, developing a common approach to standards, and escalation of system resilience.

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− The NHS 111 joint procurement is an example of a recent project that would have been delivered through the NCL joint committee.

• Hospital based elective care: in line with the aim to provide the same, agreed standard

and quality of care for the same need across NCL, authority for specification and contracting of elective hospital services will be conducted at an NCL-wide level. The demand for hospital based elective care will be derived from the care closer to home work being delivered by each CCG (for example, reductions in the number of outpatient appointments).

• Specialised services: any specialised services to be commissioned by NCL CCGs, including any responsibilities which in the future could be delegated by NHS England would be best done jointly.

Services that are proposed to be commissioned by the new NCL shared committee are: • All acute services including core contracts and other out of sector acute

commissioning including contracts with: - Royal Free London NHS Foundation Trust - University College London Hospitals NHS Foundation Trust - The North Middlesex Hospital NHS Trust - Whittington Hospital NHS Trust (acute services) - Royal National Orthopaedic Hospital NHS Trust - Great Ormond Street Hospital for Children Foundation Trust - Moorfields Eye Hospital NHS Foundation Trust

• All learning disabilities contracting associated with the Transforming Care programme

• All integrated urgent care (through the Urgent & Emergency Care Boards including NHS 111/ GP Out-of-Hours services)

• Any specialised services not commissioned by NHS England Whilst responsibility for technical acute contracting would sit with the Joint Committee, the commissioning organisations within the Haringey and Islington Wellbeing Partnership would retain commissioning responsibilities for acute services where this supports the development of an accountable care system. This would not jeopardise the achievement of an NCL wide system control total, but would enable the Haringey and Islington Wellbeing Partnership to work effectively as a local delivery vehicle. For these services, it is proposed that the joint committee will oversee and make decisions on the following commissioning functions: • Approval of business cases and change requests • Needs assessment across NCL as informed by local strategies; • Planning service requirements; • Contracting and contract management; • Developing the provider landscape; • Setting and monitoring outcomes for providers;

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• Aligning incentives across the system; • Engagement with the public and key stakeholders where relevant such as NHS England

and the public; • Approval of decommissioning of services. The recommendation is that each of the five NCL CCGs delegate decision making for acute services to the joint committee. Therefore, each of the individual CCG Governing Bodies would not make commissioning decisions on these services. To ensure that there is a strong link between pan-NCL acute commissioning and individual CCG commissioning, each CCG will feed into the Committee local care strategies and undertake local engagement of the public and key stakeholders where relevant and appropriate. This may include but is not limited to engagement on service change. This is illustrated in Figure 3. Figure 3: Services where there will be joint commissioning across NCL

A detailed breakdown of all the functions that Governing Bodies are being asked to be delegate to the joint committee are shown at Appendix 1.

It is asked that the Governing Body approve the following: 1) The CCG delegates responsibility for the commissioning of the following services to an

NCL joint committee: • Acute services including core contracts and other out of sector acute

commissioning; • All learning disability contracting associated with the Transforming Care

Programme; • All integrated urgent care (including 111/ GP Out-of-Hours services); and • Any specialised services not commissioned by NHS England.

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3. Statutory form of the proposed committee To support the new commissioning arrangements, and to facilitate a more collaborative commissioning approach across NCL, it is recommended that a joint committee be established. This committee will technically be a sub-committee of each of the CCG governing bodies, albeit one they operate jointly. There are two options for the form of the proposed committee: • Committee in common: representatives of the CCGs meet to jointly discharge their

functions but act individually so each member is there as a member of their CCG not as part of a collaborative effort. Any decisions need to be ratified by individual governing bodies. The decisions of Committees in Common need to be unanimous to be binding on constituent members.

• Joint committee: this allows two or more CCGs to form a joint committee and delegate functions to that joint committee. The joint committee can be set up with its own rules about membership and voting, and decisions made are binding on all members of the committee.

Individual CCGs will remain accountable for meeting their statutory duties whatever statutory form is chosen. Joint committees are much more flexible and a less bureaucratic approach than a committee in common. They support implementation as decisions are made collectively and members of the group are jointly responsible for implementing them. Committees in common are particularly unwieldy as they are essentially five governing bodies sitting together as opposed to being true joint decision making forums. As such decisions need to be unanimous to be binding on members. At the full day NCL-wide governing body workshop on October 6, we worked through the detail of the potential new governance arrangements. After deliberating the strengths and weaknesses of the options for statutory form, it was agreed by all representatives from all CCGs that a joint committee would be proposed to governing bodies. The proposed joint committee would be accountable to the five CCG governing bodies, and the process for CCG assurance of this new committee is detailed in section 8.

It is asked that the Governing Bodies approve the following: 2) The proposed shared NCL committee will take the form of a joint committee

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4. Membership and voting There are several factors to consider with regards to the potential membership and voting rights for committee members. These include: • It is useful to draw membership from interested parties and those that can usefully

contribute to discharging the aims of the committee. • Voting rights are usually given to people from organisations that have delegated

responsibilities to the joint committee or who will provide an independent perspective. • The size of the committee is important – it needs to be big enough to include relevant

parties but small enough to be able to make progress. • Consideration also needs to be given to how to engage key stakeholders and make sure

that commissioners discharge their responsibilities around engagement, particularly with the public and local authorities.

With these factors in mind, CCG chairs, chief officers and governing body lay members assessed several options regarding membership of the proposed joint committee at their workshop on 6 October as summarised in Table 2. Table 2: Summary of discussion during workshop regarding membership of the proposed joint committee during 6 October

Proposed member Conclusion Rationale CCG clinical representatives

Chairs from each CCG should be voting members

• The duties of CCGs are being discharged through the committee.

• The committee will make decisions on over 50% of the CCG funding and therefore CCG chairs should be members.

CCG lay member One lay member from each CCG should be a voting member

• The duties of CCGs are being discharged through the committee.

• Lay oversight is important given the size of the budget controlled by the committee.

Chair A non-voting independent chair who is skilled in chairing

• Other members of the committee need the freedom to give their views.

• There will be sufficient clinicians on the committee and a skilled chair would be more helpful in supporting decision-making.

• The chair will be non-voting as their role is to independently chair the committee.

Independent advisors

Two independent clinical advisors who

• This will give perspectives from secondary care and non-medical clinicians who are seen to be independent.

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should be voting members

• Independent lay representation is not necessary as there will be lay representation from each CCG and from HealthWatch.

NCL officers The Accountable Officer and Chief Finance Officer should be voting members, other officers will attend as required

• The CFO and AO have accountability for the management and financial position of each CCG.

• Quality and safety is of key importance in all decisions made.

• Other officers are likely to be required for specific agenda items.

Representatives of local authorities

Each local authority to nominate one non-voting member (of their choosing). Directors of Pulic Health to nominate one non-voting Director of Public Health to give public health input.

• Local authority representation is important but is non-voting as no local authority duties or budgets are being discharged through the committee.

• Local authorities may have different views on who would best represent them at the committee.

• Public health input is of key important to the prevention agenda.

Other HealthWatch to nominate to non-voting one representative of HealthWatch.

• HealthWatch have statutory powers to represent patients.

For the reasons outlined in Table 1, the following membership of the committee is proposed: • Voting members [14]:

- Chair from each CCG [x5] - Lay member from each CCG [x5] - Two independent clinical advisors (appointment process described in section 6) [x2] - NCL Accountable Officer - NCL Chief Financial Officer

• Non-voting members [8]:

- Independent Chair of NCL joint committee (appointment process described in section 6)

- One representative from each local authority (to be nominated by each local authority) [x5]

- Director of Public Health (to be nominated by the Directors of Public Health) - One representative of HealthWatch (to be nominated by HealthWatch)

Other people will be invited to attend the meeting as required for specific agenda items. It will also be possible to amend the membership of the committee over time.

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It is asked that the Governing Body approve the following: 3) That the membership of the proposed joint committee be as outlined in section 4 of

this paper

5. Financial management implications of the joint committee As outlined in Figure 3 above, it is proposed that each of the five NCL CCGs delegate decision making on acute services, learning difficulties and urgent care to the joint committee. Therefore, each of the individual CCG governing bodies would not make commissioning decisions on these services. To ensure that there is a strong link between NCL-level acute commissioning and individual CCG commissioning, each CCG would feed into the joint committee local care strategies, which would form the basis of demand planning. The five governing bodies have agreed a joint financial strategy, which has four components: 1. The creation of an NCL investment pool 2. The creation of an NCL risk reserve 3. The collective management of key contracts 4. The management of legacy financial issues The strategy needs further development to be embedded into an agreed set of principles and processes for effective operation and the expectation is that this will be developed by the new shared CFO, once in post. As a principle, it is recommended that any redistribution of funding formally seeks approval from NHS England to ensure compliance in respect of control totals, and any adjustment required. Part 1 – Investment pool In order to support the implementation of the STP and NCL commissioning strategy in a consistent manner and timeframe, the investment pool is intended to provide funds for pump-priming of priority investments. It is also designed to cover the non-recurrent costs of transformation programmes across NCL. There will need to be a transparent business case process to support allocation of funds from this pool, including the required ‘return on investment’ (ROI) and consideration will be given to determining what non-recurrent costs of transformation can include and what is not covered. Part 2 – Risk reserve The risk reserve will cover unexpected in-year pressures across NCL and the joint committee will need to define what ‘unexpected’ means but the reserve is intended to provide cover against low volume / high cost activity (such as critical care) falling differentially across CCGs

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in the financial year. CCGs would be expected to manage such pressures locally in the first instance, only accessing these funds when other sources have been exhausted. The process for any roll forward or required return of the funds issued under the risk share will be agreed and embedded within the process for release. Part 3 – Collective management of key contracts Commissioning in 2017/18 onwards will follow a more consistent pan-NCL framework. The management of contracts will be in accordance with the NCL commissioning strategy and reflect the proposed delegated responsibilities to the joint committee as well as the CCG responsibilities. The five CCGs will retain legal responsibility for hosting contracts but for the areas agreed, this responsibility will be delegated to the joint committee and joint posts appointed. Part 4 – Legacy financial issues In 2016/17, there is a legacy Resource Accounting and Budgeting (RAB) accumulated deficit in Enfield of £41m. It is proposed that the repayment plan for the accumulated deficit is recognised within the financial challenge for the STP, and the solutions identified include addressing this as well as the overall viability and sustainability of the STP footprint.

It is asked that the Governing Body approve the following: 4) That the five CCGs delegate the responsibility to the proposed joint committee for the

application of their resources for the commissioning of the delegated areas (acute commissioning, Transforming Care, integrated urgent care and specialised services).

5) That the shared CFO, once appointed, represents each of the five CCGs, and has the accountability for financial management of the resources to support the services commissioned, and equally has accountability to each CCG in line with statutory requirements for the areas delegated.

6) That the shared CFO, once appointed, develops the financial strategy into a set of policies and procedures which will require endorsement by the joint committee and each of the governing bodies for operation.

7) That the shared CFO represents the five CCGs in finance and performance monitoring meetings with NHS England.

6. Decision making and quoracy of the joint committee It is proposed that the intention of the joint committee is for decision making to be by unanimous agreement, however, when consensus cannot be reached it is proposed that decisions will be made by the voting members of the joint committee. Attendees at the October 6 workshop proposed that motions should require at least 80% of the votes to be passed. The rationale being that when working collaboratively across NCL, it would not be

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possible for a motion to be blocked by a single CCGs two voting representatives (CCG Chair and lay member). However, it was agreed that the two voting members of a CCG and one other voting member should have the power to block a decision being made. Quoracy sets out who needs to be at the meeting to allow the meeting to make decisions. It is usual to make sure that all the organisations discharging responsibilities through the decision of the meeting are present and that different perspectives are represented (e.g. clinical, lay, officer). It is proposed that, in order for the committee to be quorate, there must be 10 voting members (of whom 50% must be clinicians (CCG Chairs or independent clinical members)), that either the Chair or lay member from each CCG must be present and there must be at least one CCG Chair and one lay member. This will ensure that each CCG is locally represented (i.e. not by one of the pan-NCL posts of Accountable Officer of Chief Finance Officer who sit on each governing Body), that across the committee there is representation from at least one lay member and one CCG Chair and that there will be sufficient clinical representation. The proposed Terms of Reference and Standing Orders for the joint committee is attached at Appendices 2 and 3.

It is asked that the Governing Body approve the following: 8) Agree the Terms of Reference and Standing Orders for the joint committee

7. Selection process for the independent members of the proposed joint committee

It is proposed that the joint committee has three independent members (one non-voting independent chair, and two voting clinical independent advisors). The remuneration for these posts will be proposed at a meeting in common of the CCG Remuneration Committees. Draft job descriptions for these three proposed independent members of the joint committee are attached at Appendices 5, 6 and 7. These are senior roles and typically would be filled by experienced consultants or Medical Directors and, in the case of a nurse, someone who had worked at a strategic level - e.g. as a Director of Nursing in an acute Trust. It would be usual to pay backfill costs for the time required for individuals to undertake the work of the joint committee or, if they are not employees, then an annual rate would be paid. Based on the levels paid in CCGs within London for these roles, an indicative figure of £25-30,000 for the medical adviser and £15-20,000 for the nurse could be expected. An independent chair would cost a similar amount. The remuneration of these position will be covered by the annual saving from the new executive structure, detailed in section 3. of paper 3. Legally, CCG governing bodies are able to approve appointments to each of the committees and sub-committees which it has formally constituted. Where the Governing Body

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determines those persons, who are neither members nor employees, shall be appointed to a committee or sub-committee the terms of such appointment shall be within the powers of the Governing Body. The Governing Body shall define the powers of such appointees.

It is asked that the Governing Body approve the following: 9) The appointment of the independent joint committee members

8. Assuring the joint committee The joint decision making proposed in this paper presents an opportunity to improve performance against key national indicators in respect to acute services, as well as an opportunity to generally improve performance in relation to the commissioning of NCL’s large acute providers. However, alongside this opportunity there is also a risk, both in the transition and in the ongoing arrangements, given that each CCG governing body maintains statutory responsibilities for the population they serve. It is therefore crucial that the CCG governing bodies continue to have oversight of performance and be assured that the joint committee is making progress on the matters delegated to it. Approach to monitoring performance All five CCGs currently review a performance report as part of their governing body meeting. As an example, for acute care these reports cover the operational standards and national quality requirements as stated in the NHS standard contract.1 Given this is how commissioning performance is currently measured across the five CCGs, it is proposed that this remains the same in the new commissioning arrangements. The following process is therefore proposed for ensuring continuity of CCG governing body assurance of performance and quality: 1) At each joint committee meeting, a performance report covering the indicators as set

out in the NHS standard contract will be reviewed against its targets; a draft of this is shown in Figure 4. The final scope of the report will be developed by the NCL Director of Performance and Acute Commissioning and agreed with CCG governing bodies.

2) This report from the joint committee would then be presented back to each of the CCG’s next governing body meetings by an appointed member of both the joint committee and the CCG governing body, in the same way other sub-committees currently report

3) An annual performance report covering all five CCGs will be produced by the joint committee.

1 https://www.england.nhs.uk/nhs-standard-contract/16-17/

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Figure 4: Quality and performance dashboard taken from Barnet CCG Performance and Quality report May 20162

Innovation in performance management It is recognised that joint commissioning also presents an opportunity for innovation in performance management. In addition, to the performance targets already reviewed by CCGs, the increased leverage of the joint committee presents an opportunity to define additional innovative performance targets, for those services delegated to it, to incentivise organisations within the NCL STP to achieve the collective strategic vision. Section 38.8 of the national contract already allows the commissioner and the provider to agree to vary or dis-apply any National Commissioning for Quality and Innovation (CQUIN). Previously CCGs have struggled to incorporate these into contracts with acute providers, however, the increased influence of a joint committee should improve negotiations regarding inclusion of these. These system incentives or penalties could be used as drivers to improve quality of care and address variation experienced with acute providers. Some prospective examples are: Elective • There is scope to enforce sequential further penalties once the 18 week RTT target has

been missed in order to reduce those patients waiting unacceptably long times for treatment.

• It may be possible to introduce top-up payments for new outpatient appointments in tandem with the reduction of payments for follow up appointments, thus incentivising the improvements in patient pathways set out in the STP.

2http://www.barnetccg.nhs.uk/Downloads/boardpapers/20160526/Paper%2010.0%20BCCG%20Performance%20%20Quality%20Report%20May16%20190516%20Draft.pdf

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Non-elective • The increased use of CQUIN based incentives could be implemented to improve quality

provided in the acute settings. • There may be opportunity to introduce top-up payments for the optimised delivery of

care to patients with ambulatory care sensitive conditions.

It is proposed that the detailed design of any additional, innovative acute performance targets is the responsibility of new shared NCL executive team, notably the new Director of Performance and Acute Commissioning, working with the Accountable Officer and Director of Strategy. Detailed design of any targets will be carried out by a working group of patients, clinicians, providers, and commissioning leadership. Financial assurance process All five CCGs currently review a finance report as part of their governing body meeting. These reports outline performance against the control total agreed for each CCG; current monthly, year to date and forecast outturn for both programme and running cost allocations. The finance reports link to the performance reports and identify where actual activity and spend differs from planned, explanation and mitigations to address. This is how financial performance is currently measured across the five CCGs, and it is proposed that this remains the same in the new commissioning arrangements. The five CCGs maintain a duty to adhere to the statutory accounting requirements as outlined in Table 3. Table 3 :Accounting requirements of the CCGs3

Function Power / Duty

Statutory reference Link to legislation

Accounting duties of CCGs

Duty

NHS Act 2006 Schedule 1A Paragraph 17

1) A CCG must keep proper accounts and records relating to the accounts.

2) A CCG must prepare annual accounts for each financial year.

3) Annual accounts must be audited in accordance with the requirements specified in paragraph 17.

4) A copy of a CCG’s annual audited accounts must be sent to the Board no later than the date specified by the Board.

Health and Social Care Act 2012

Schedule 2

http://www.legislation. gov.uk/ukpga/2012/7/ schedule/2

3 https://www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf

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5) The “financial year” for the purposes of paragraph 17 is defined (paragraph 17(9)) as beginning on the day the CCG is established and ending on 31 March.

6) CCGs must also comply with any additional requirements, as directed by the Board in accordance with paragraph 17,

Duty to provide information

Duty

NHS Act 2006 Schedule 1A Paragraph 18

1) If directed, a CCG must provide financial information to the Board

Health and Social Care Act 2012

Schedule 2

http://www.legislation. gov.uk/ukpga/2012/7/ schedule/2

Process for financial monitoring The following process is therefore proposed for ensuring continuity of CCG governing body assurance of financial management: 1) At each joint committee meeting a finance report covering the statutory responsibilities

indicators will be reviewed against its control total, a draft of this is shown in Figure 5. The final scope of the report will be developed by the proposed shared CFO and agreed with CCG governing bodies.

Figure 5 : Financial performance summary as taken from Barnet CCG Annual and Financial Statements 2015-16 4

4 http://www.barnetccg.nhs.uk/Downloads/Publications/Reports/NHS-Barnet-CCG-Annual-report-and-financial-statements-2015-16.pdf

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This report from the joint committee would then be presented back to CCG governing body meetings by an appointed member of both the joint committee and the CCG governing body, in the same way other sub-committees currently report. It is proposed that an annual finance report covering all five CCGs would be produced by the joint committee. Each CCG is required to produce statutory accounts, subject to formal audit and review by the shared audit committee and presented to each of the CCG’s governing body meetings by the CFO as an appointed member of both the joint committee and the CCG governing body, in order to discharge their statutory responsibilities. Measuring the success of the committee As with other sub-committees that CCGs delegate functions or services to, it is recognised that the CCG will want assurance that the proposed joint committee governance is operating effectively. Informally, as each CCG would have two members on the joint committee, it is expected that any managerial issues with this forum would be fed back to governing bodies through this channel. In addition, it suggested that the joint committee should complete a self-assessment of performance in the same way as audit committees do annually. This self-assessment should be provided to each of the governing bodies along with an action plan to resolve any issues. The joint committee will be a sub-committee of each of the CCG governing bodies and the governing bodies will retain the ability to undertake remedial action if required. If the joint committee is perceived to be unsuccessful and/or ineffective and this cannot be resolved through the usual workings of the committee, a three-part escalation process is proposed:

1. Independent Chair action: the independent chair will attempt to resolve issues through negotiation and discussion. A number of remedial actions might be agreed including additional reporting to governing bodies, withdrawal of some responsibilities and amendment to the Terms of Reference.

2. Referral to governing bodies: the joint committee is a sub-committee of the Governing Body and the governing body will retain the right to require the committee to provide information and reassurance as required as to its working. The CCG Chair will lead any effort required to manage the performance of the joint committee.

3. Withdrawal from the committee: As a final resort, the Standing Orders (given as Appendix 3) of the committee allow for withdrawal from the joint committee upon giving 6 months’ notice of termination (paragraph 14).

The Chair of the governing bodies have the power to remove the independent chair of the joint committee if required per the Standing orders of the committee as set out in Appendix 3.

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It is asked that the Governing Body approve the following:

10) The process for the assurance of performance and quality of the proposed Joint Committee is as outlined in section 8

11) The process for assurance of the financial management of the proposed Joint Committee as outlined in section 8

12) The Joint Committee complete an annual self-assessment of performance and

develop an action plan to address any issues that arise

13) A three part escalation process that may be implemented if the joint committee is perceived to be unsuccessful as set out in section 8

9. Implications for CCG sub-committees and other joint forums Each CCG already has a number of sub-committees to which it delegates some powers or responsibilities. CCGs are not allowed to double delegate responsibilities; this means that any joint committee (to which powers have been delegated by the CCG Governing Body) cannot delegate responsibilities to another committee. However, there are ways in which individual CCG sub-committees can work together when it is sensible to do so, for example, where each individual CCG committee is considering a similar agenda with a similar set of people. The existing CCG sub-committee structures are shown in Figure 6.

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Figure 6: Sub-committees of the CCGs5

In the event a joint committee is established as recommended in this paper, there will be a need to review sub-committee arrangements as well as the other joint forums that exist across NCL to ensure that meetings and reporting lines are fit for purpose. For example, this could be particularly relevant for performance, quality and finance sub-committees in respect to acute contracts. In respect to joint forums, it is relevant to the Cancer Commissioning Board. At this stage, there are no specific recommendations for changes, however, if the joint committee is approved for establishment a review will be undertaken. The timing of any potential proposals will additionally be considered so as not to interfere with ongoing contracting.

10. Proposed amendments to the Scheme of Reservation and Delegation There is a requirement to amend some of the technical documents of each of the CCGs once agreement has been reached on the setting up of the joint committee and the delegation of agreed functions. Due to constitutional differences between the CCGs the exact amendments are unique and detailed below.

For Barnet: In order to delegate functions to the Joint Committee, the CCG will need to agree the following amendments:

1. Amend the CCG’s Scheme of Reservation and Delegation at Appendix E to the CCG Constitution to provide for the delegation of functions to the Joint Strategic

5 CCG constitutions available online, accessed October 2016; verified by CCG Directors of Performance, October 2016

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Commissioning Committee under the STRATEGY AND PLANNING and COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES headings, as follows:

“To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.”

2. The column “Committee” will be ticked, and “Joint Strategic Commissioning Committee”

inserted in that column.

3. Add the Terms of Reference of the Joint Strategic Commissioning Committee as an Annex to Appendix C of the Constitution.

The full legal advice as specified by Capsticks Solicitors is provided as Appendix 4. For Camden: In order to delegate functions to the Joint Committee, the CCG will need to agree the following amendments: 1. Amend the CCG’s Scheme of Reservation and Delegation at Schedule 7 to the CCG

Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee as a sub-committee of the Governing Body under the STRATEGY AND PLANNING heading and the COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES heading as follows:

To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.

The full legal advice as specified by Capsticks Solicitors is provided as Appendix 4. For Enfield: In order to delegate functions to the Joint Committee, the CCG will need to agree the following amendment:

Amend the CCG’s Scheme of Reservation and Delegation at Annex 4 to the CCG Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee under the DECISIONS/DUTIES DELEGATED BY THE GOVERNING BODY TO COMMITTEES heading, as follows:


The full legal advice as specified by Capsticks Solicitors is provided as Appendix 4. For Haringey:

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In order to delegate functions to the Joint Committee, the CCG will need to agree the following amendments: 1. Amend paragraph 6.10 of the Constitution to include a description of the Joint

Committee, and provide details of the functions of that Committee, as follows: 6.10.10 NCL Joint Strategic Commissioning Committee - The role of the Joint Committee shall be to exercise on behalf of the Governing Body the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.

2. Amend the CCG’s Scheme of Reservation and Delegation at Appendix 4 to the CCG Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee under the COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES heading, as follows: To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.

3. The column “Committee or Sub-committee” will be ticked, and “Joint Strategic

Commissioning Committee” inserted in that column. The full legal advice as specified by Capsticks Solicitors is provided as Appendix 4. For Islington: In order to delegate functions to the Joint Committee, the CCG will need to agree the following amendments: • Amend the CCG’s Scheme of Reservation and Delegation to provide for the delegation of

functions to the Joint Strategic Commissioning Committee. Insert an additional heading “COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES” and insert the following wording under that heading:


• The column “Committee” will be ticked, and “Joint Strategic Commissioning Committee”

or “JSCC” inserted in that column. The full legal advice as specified by Capsticks Solicitors is provided as Appendix 4.

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It is asked that the Governing Body approve the following: 14) The amendments to the Scheme of Reservation and Delegation for their constitution

as set out in section 10

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Appendix 1: Levels of commissioning – delegation of functions from governing bodies to joint committee Decision making

Commissioned by

Services

Functions

CCG

CCGs

• Children’s joint commissioning and children’s services outside of hospital

• Primary care development • Primary care prescribing • Sexual health commissioning (within CCG responsibilities) • Joint commissioning with social care

- preventative care - complex elderly

• Better Care Fund

• Approval of business cases and change requests • Needs assessment for local population • Planning service requirements • Contracting and contract management • Joint working with the local authority • Setting required outcomes for providers and systems • Monitoring outcomes • Approval of decommissioning of services • Engagement with public, members and local authorities

By exception the joint committee may undertake the following on request from CCG Governing Bodies: • Needs assessment on one-off basis • Planning and procurement:

- Share best practice and align assumptions - Alignment of enablers – estates / IT - One-off procurements (if requested)

• Setting and monitoring outcomes on one-off basis – includes sharing best practice • Engagement with stakeholders (if requested)

Aligned

CCGs

• Mental health and community contracts • Other mental health commissioning • All hospice-based end of life care • Continuing health care and funded nursing care • Day-to-day tactical delivery of A&E performance

Delegated decision-

making from CCGs to Joint Committee

Joint Committee / Central team

• Acute provider contracts • Learning Disabilities Transforming Care • Integrated Urgent Care services (including NHS 111/GP Out-of-Hours) • Specialist care not commissioned by NHS England

• Approval of business cases and change requests • Needs assessment across NCL (informed by local strategies) • Planning service requirements • Contracting and contract management • Developing the provider landscape • Setting and monitoring outcomes for providers • Aligning incentives across the system • Engagement with acute providers, NHSE (for specialist services) and public / other

stakeholders on service changes • Approval of decommissioning of services

To support joint commissioning CCGs will: • Needs assessment - Feed in local needs assessments • Planning and procurement – feed in local plans and ensure alignment • Setting and monitoring outcomes – feed in local agreed outcomes • Engagement with stakeholders- local engagement with public, members and local

authorities

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Appendix 2: North Central London joint commissioning committee Terms of Reference (ToR) 1. Introduction

These Terms of Reference set out the purpose, membership, remit and responsibilities of the North Central London Joint Commissioning Committee (‘Committee’).

2. Background

The National Health Service (‘NHS’) is facing unprecedented financial and clinical challenges including rising demand for services and a significant financial gap. System-wide solutions are required to address these challenges for the benefits of patients.

In this regard the following organisations have agreed to work together to meet these challenges and jointly commission services where it is appropriate to do so:

• NHS Barnet Clinical Commissioning Group (‘Barnet CCG’); • NHS Camden Clinical Commissioning Group (‘Camden CCG’); • NHS Enfield Clinical Commissioning Group (‘Enfield CCG’); • NHS Haringey Clinical Commissioning Group (‘Haringey CCG’); • NHS Islington Clinical Commissioning Group (‘Islington CCG’).

The above Clinical Commissioning Groups are collectively referred to as the ‘NCL CCGs.’ These organisations have an informal history of some collaborative working, however, it is seen that the formation of this committee, as well as work conducted together as the health commissioners in the North Central London STP will formalise this collaborative working.

3. Purpose of the Committee The Committee is a joint committee between Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG and Islington CCG to jointly commission goods and services as set out in section 3. for the people of the London Boroughs of Barnet, Camden, Enfield, Haringey and Islington.

4. Role of the Committee

The role of the Committee is to commission the following:

• All acute services including core contracts and other out of sector acute commissioning;

• All learning disability contracting associated with the Transforming Care programme; • All integrated urgent care (including 111/ GP Out-of-Hours services) • any specialised services not commissioned by NHS England.

For these services the Committee will oversee and make decision on the following commissioning functions: • Approval of Business Cases and change requests

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• Needs assessment across NCL as informed by local strategies; • Planning service requirements; • Contracting and contract management; • Developing the provider landscape; • Setting and monitoring outcomes for providers; • Aligning incentives across the system; • Engagement with the public and key stakeholders where relevant such as NHS

England and the public; • Approval of decommissioning of services.

Each of the five NCL CCGs have delegated decision making on acute services to the Committee. Therefore, each of the individual CCG governing bodies will not make commissioning decisions on these services. To ensure that there is a strong link between pan NCL acute commissioning and individual CCG commissioning each CCG will feed into the Committee local care strategies and undertake local engagement of the public and key stakeholders where relevant and appropriate. This may include but is not limited to engagement on service change. The Committee’s role is supported by a statutory framework contained in section 6 below.

5. Quality and Safety

In performing its role, the Committee shall have due regard to any relevant quality and safety issues which may arise as agreed by Committee members.

6. Statutory Framework

The main statutory instrument is the NHS Act 2006 (as amended) with the key clauses being 13Z, 14Z3 and 14Z9.

Section 13Z provides that: • NHS England’s functions may be exercised jointly with a CCG or CCGs; • Functions exercised jointly in accordance with section 13Z may be exercised by a

joint committee of NHS England and the CCG or CCGs; • Arrangements made under section 13Z may be on such terms and conditions as may

be agreed between NHS England the CCG or CCGs. Section 14Z3 provides that: • Two or more CCGs may exercise any of their commissioning functions jointly

including by a joint committee of those CCGs; • For the purposes of any arrangements made under this section a CCG may make

payments, make the services of its employees or any other resources available to another CCG.

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Section 14Z9 provides that:

• NHS England and one or more CCGs may make arrangements for any of the functions of the CCG under section 3 or 3A of the NHS Act or for any functions of the CCG(s) which are related to the exercise of those functions, to be exercised jointly by NHS England and the CCG(s);

• For functions exercised jointly in accordance with the section to be exercised by a Joint Committee of NHS England and the CCG(s);

• Arrangements under that section may be on such terms and conditions as may be agreed between NHS England and the CCG.

7. Membership

The Committee’s membership shall meet the requirement of each of the NCL CCG’s constitutions. The Committee shall comprise of the following voting members:

• The Chair of Barnet CCG; • The Chair of Camden CCG; • The Chair of Enfield CCG; • The Chair of Haringey CCG; • The Chair of Islington CCG; • A lay representative from Barnet CCG • A lay representative from Camden CCG; • A lay representative from Enfield CCG; • A lay representative from Haringey CCG; • A lay representative from Islington CCG; • The NCL Accountable Officer; • The NCL Chief Financial Officer; • Two independent clinical advisors.

The Committee shall comprise of the following non-voting members; • An independent Chair; • A Healthwatch representative; • One Director of Public Health from one of the NCL London Boroughs; • A representative from London Borough of Barnet Council; • A representative from London Borough of Camden Council; • A representative from London Borough of Enfield Council; • A representative from London Borough of Haringey Council; • A representative from London Borough of Islington Council.

The list of named members and attendees is contained in Schedule 1. Committee members and non-voting attendees may nominate a deputy to represent them in their absence and make decisions on their behalf.

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8. Chair and Vice Chair The Chair of the Committee shall be independent and shall ordinarily not be an officer,

employee or office holder of any of the NCL CCGs except to the extent necessary to hold a contract for the role of independent Chair.

Where the Chair is unable to participate in a meeting or vote due to absence or a conflict

of interest the Vice Chair may chair the meeting. The Vice Chair of the Committee shall be a lay member from an NCL CCG.

Details of the Chair and Vice Chair are contained in Schedule 1.

9. Quorum The quorum of the committee is 10 voting members (of whom 50% must be clinicians)

The Committee must have present a) either the CCG Chair or lay representative from each CCG and b) at least one CCG Chair and one lay representative to be quorate.

If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements. If a clinician is conflicted the person temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements must be a clinician.

If a meeting is not quorate the Chair may adjourn the meeting to permit the appointment or co-option of additional members if necessary. If the conflicted person is a Chair or lay member of a CCG the person temporarily appointed or co-opted onto the Committee must be from the same CCG as the conflicted person. The final decision as to the suitability of any person who is temporarily appointed or co-opted onto the Committee shall be made by the Committee’s Independent Chair.

10. Voting

Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussions, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

In the event of a vote, voting members of the Committee shall have one vote each with decisions being made in accordance with the provisions below.

The Committee shall reach decisions by an 80% majority of votes of voting members

present at a Committee meeting.

11. Decisions Decisions of the Committee shall be binding on each of the NCL CCGs.

12. Conflicts of Interest

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Conflicts of interest shall be dealt with in accordance with the NCL conflicts of interest policy. The NCL conflicts of interest policy is a document which is a master document containing the conflicts of interest policy agreed by all of the NCL CCGs together with a schedule setting out the local variations of each CCG.

13. Frequency of Committee Meetings

The Committee shall meet monthly or as otherwise agreed.

14. Meetings Held in Pubic Meetings of the Committee shall be held in public unless the Committee resolves to

exclude non-voting attendees and/or observers and/or the public from a meeting. In which case the meeting, in whole or part, may be held in private.

Non-voting attendees, observers and the public may be excluded from all or part of a

meeting whenever publicity would be prejudicial to the public interest by reason of:

• The confidential nature of the business to be transacted; or • The matter is commercially sensitive; or • The matter being discussed is part of an on-going investigation; or • Other special reason stated in the resolution and arising from the nature of that

business or of the proceedings; or • Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as

amended or succeeded from time to time; or • General disturbance.

15. Secretary

The Committee shall have secretariat support. The secretariat function will be provided by the office of the NCL Accountable Officer.

16. Standing Orders

The Standing Orders for the Committee are contained in Schedule 2 and form part of these Terms of Reference. The Standing Orders must be adhered to.

17. Sub-Committees

The Committee may not delegate any of its powers to a committee or sub-committee. However, it may appoint committees to advise and assist the Committee in carrying out its role.

18. Standards of Business Conduct

Committee members and any attendees or observers must maintain the highest standards of personal conduct and in this regard must comply with:

18.1.1 The law of England and Wales; 18.1.2 The NHS Constitution; 18.1.3 The Nolan Principles;

18.1.4 The standards of behaviour set out in each NCL CCG Constitution; 18.1.5. Any additional regulations or codes of practice relevant to the Committee.

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19. Review of the Terms of Reference

These Terms of Reference shall be kept under review by the Committee to ensure that they meet the needs of the Committee and the NCL CCGs. Any changes to the Terms of Reference must be agreed by the governing bodies of the NCL CCGs in accordance with their Constitutions.

These Terms of Reference shall be reviewed by the NCL CCGs annually in April of each year following the establishment of the Committee.

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Schedule 1 - List of Members Voting Members The voting members of the Committee are as follows:

Position Name Title CCG Chair - Barnet CCG Debbie Frost CCG Chair - Camden CCG Caz Sayer CCG Chair - Enfield CCG Mo Abedi CCG Chair - Haringey CCG Jo Sauvage CCG Chair -Islington CCG Peter Christian Lay member- Barnet CCG

TBC

Lay member- Camden CCG

TBC

Lay member- Enfield CCG

TBC

Lay member- Haringey CCG

TBC

Lay member- Islington CCG

TBC

NCL Accountable Officer TBC NCL Chief Financial Officer TBC Independent clinician TBC Independent clinician TBC

Non-Voting Members The non-voting members of the Committee are as follows:

Position Name Title Independent Chair

TBC

A Healthwatch representative TBC One Director of Public Health from one of the NCL London Boroughs

TBC

A representative from London Borough of Barnet Council

TBC

A representative from London Borough of Camden Council

TBC

A representative from London Borough of Enfield Council

TBC

A representative from London Borough of Haringey Council

TBC

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A representative from London Borough of Islington Council

TBC

The roles referred to in the list of voting members and non-voting members above describe the members’ and non-voting members’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference. Chair and Vice of the Committee The Chair and Vice Chair of the Committee are as follows:

Position Name Title Independent Chair

TBC

Vice Chair

TBC

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Appendix 3: Standing orders for the North Central London joint commissioning committee 1. Introduction 1.1 These Standing Orders apply to the North Central London Joint Commissioning Committee

(‘Committee’).

1.2 The Committee is a joint committee between the following organisations: 1.2.1 NHS Barnet Clinical Commissioning Group (‘Barnet CCG’); 1.2.2 NHS Camden Clinical Commissioning Group (‘Camden CCG’); 1.2.3 NHS Enfield Clinical Commissioning Group (‘Enfield CCG’); 1.2.4 NHS Haringey Clinical Commissioning Group (‘Haringey CCG’); 1.2.5 NHS Islington Clinical Commissioning Group (‘Islington CCG’).

1.3 In these Standing Orders the Clinical Commissioning Groups referred to at clauses 1.2.1 – 1.2.5 above are referred to as ‘NCL CCGs’.

1.4 The Committee’s purpose is to jointly commission goods and services for the people of

the London Boroughs of Barnet, Camden, Enfield, Haringey and Islington.

2. Terms of Reference 2.1 These Standing Orders form part of the Committee’s Terms of Reference and should be

read in conjunction with the Committee’s Terms of Reference.

3. Notice of Meetings 3.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7

days in advance of the meeting.

3.2 The meeting notice shall contain the date, time and location of the meeting. 3.3 Where Committee meetings are to be held in public the date, times and location of the

meetings will be published on each Committee members’ website.

4. Agendas and Circulation of Papers 4.1 Before each Committee meeting an agenda setting out the business of the meeting will

be sent to every Committee member, and for public meetings made public, no less than 7 days in advance of the meeting.

4.2 Before each Committee meeting the papers of the meeting will be sent to every

Committee member, and for public meetings made public, no less than 7 days in advance of the meeting.

4.3 If a Committee member wishes to include an item on the agenda they must notify the

Chair via the Committee’s Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair but any request to add an item to the agenda must not be unreasonably refused.

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5. Quorum 5.1 The Quorum for the Committee is 10 voting members (of whom 50% must be clinicans) 5.2 The Committee must have present a) either the CCG Chair or lay representative from each

CCG and b) at least one CCG Chair and one lay representative to be quorate. 5.3 If any representative is conflicted on a particular item of business they will not count

towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements. If a clinician is conflicted the person temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements must be a clinician.

5.4 If a meeting is not quorate the Chair may adjourn the meeting to permit the appointment

or co-option of additional members if necessary. If the conflicted person is a Chair or lay member of a CCG the person temporarily appointed or co-opted onto the Committee must be from the same CCG as the conflicted person. The final decision as to the suitability of any person who is temporarily appointed or co-opted onto the Committee shall be made by the Committee’s Independent Chair.

6. Minutes 6.1 The minutes of the proceedings of a meeting shall be prepared by the Committee’s

Secretariat and submitted for agreement at the following Committee meeting. 7. Attendees and Observers 7.1 The Committee may call additional experts to attend meetings on a case by case basis to

inform discussions. 7.2 The Committee may invite or allow additional people to attend Committee meetings as

attendees. Attendees may present at Committee meetings and contribute to relevant Committee discussions but are not allowed to participate in any formal vote.

7.3 The Committee may invite or allow people to attend meetings as observers. Observers

may not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.

7.4 The Committee may invite or allow providers of health care services to attend meetings

as attendees or observers on a case by case basis at the Committee’s absolute discretion. 8. Meetings Held in Public 8.1 Meetings of the Committee shall be held in public unless the Committee resolves to

exclude the public from a meeting. In which case the meeting, in whole or part, may be held in private. The Committee may also exclude non-voting attendees and observers.

8.2 Non-voting attendees, observers and the public may be excluded from all or part of a

meeting at the Committee’s absolute discretion whenever publicity would be prejudicial to the public interest by reason of:

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8.2.1 The confidential nature of the business to be transacted; or 8.2.2 The matter is commercially sensitive; or 8.2.3 The matter being discussed is part of an on-going investigation; or 8.2.4 Other special reason stated in the resolution and arising from the nature of

that business or of the proceedings; or 8.2.5 Any other reason permitted by the Public Bodies (Admission to Meetings) Act

1960 as amended or succeeded from time to time; or 8.2.6 General disturbance.

8.3 It may be necessary for a person other than a member of the Committee to be present at

a private Committee meeting to provide the Committee with expert and/or specialist advice and/or knowledge. The Committee may allow this at its absolute discretion without affecting the validity of any resolution determined in accordance with clauses 8.1 and 8.2 above.

9. Publishing and Reports from the Committee 9.1 Decisions of the Committee will be published by the NCL CCGs save as set out in clause 10

below. 9.2 The Committee will produce an executive summary report which will be presented to the

NCL CCG Governing Bodies for information as required. 10. Confidentiality 10.1 Members of the Committee shall respect confidentiality requirements as set out in these

Standing Orders. 10.2 Committee meetings may in whole or in part be held in private as per clause 8 above.

Any papers relating to these agenda items will also be excluded from the public domain. For any meeting or any part of a meeting held in private all members and/or attendees must treat the contents of the meeting and any relevant papers as strictly private and confidential.

10.3 Decisions of the Committee will be published except when decisions have been made in

private in accordance with clause 8 above. 11. Independent Chair 11.1 The Independent Chair will hold office for a period of three years commencing on the

date of appointment. The Independent Chair is eligible for re-appointment for a further term of three years subject to satisfactory performance.

11.2 The Independent Chair may be removed from office if:

11.2.1 They are not legally eligible to sit on a Governing Body committee; 11.2.2 A motion of no confidence is passed by simple majority of voting members

present at a Committee meeting. The simple majority must include at least one representative from each of the NCL CCGs;

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11.2.3 A motion of no confidence is passed by any NCL CCG Governing Body.

12. Standards of Business Conduct 12.1 Committee members and any attendees or observers must maintain the highest

standards of personal conduct and in this regard must comply with:

12.1.1 The law of England and Wales; 12.1.2 The NHS Constitution; 12.1.3 The Nolan Principles; 12.1.4 The standards of behaviour set out in each NCL CCG Constitution; 12.1.5 Any additional regulations or codes of practice relevant to the Committee.

13. Training and Information 13.1 It is the responsibility of each organisation referred to in section 1.2 above to ensure that

their representatives at the Committee are provided with appropriate training and information to allow them to exercise their responsibilities effectively.

14. Withdrawal 14.1 The Governing Body of a participating Clinical Commissioning Group as listed in clause

1.2 above can decide to terminate their membership of the Committee upon giving 6 months’ written notice to all other organisations listed in clause 1.2 above with termination of their membership taking place on expiry of such notice.

15. Review of Standing Orders 15.1These Standing Orders form part of the Committee’s Terms of Reference. They must be

reviewed in accordance with the provisions for review of the Terms of Reference contained in the Committee’s Terms of Reference.

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Appendix 4: Arrangements for delegating NCL CCG commissioning functions to a joint committee Statutory Framework

• The NHS Act 2006 (as amended) (‘the NHS Act’), was amended through the introduction of a Legislative Reform Order (“LRO”) to allow CCGs to form joint committees. This means that two or more CCGs exercising commissioning functions jointly may form a joint committee as a result of the LRO amendment to s.14Z3 (CCGs working together) of the NHS Act.

• Joint committees are a statutory mechanism which gives CCGs an additional option for undertaking collective strategic decision making.

• The NHS Act which has been amended by LRO 2014/2436, provides at s.14Z3 that where two or more clinical commissioning groups are exercising their commissioning functions jointly, those functions may be exercised by a joint committee of the groups.

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Islington CCG • The CCG has the power to exercise jointly the commissioning functions of the CCG and

another CCG pursuant to Appendix D 1.2 and 1.4 of the Constitution. • Paragraph 6.4 of the Constitution provides that the Governing Body has delegated

responsibility for approving commissioning plans and approving consultation arrangements for Islington CCG’s commissioning plan.

• Insofar as these functions are to be vested in the joint committee, the Governing Body will need to delegate the relevant functions (and any other functions that it is envisaged will be undertaken by the joint committee) to the joint committee.

• Paragraph 6.4.4 of the Constitution provides that the Governing Body of the CCG may, so long as it is in line with CCG regulations, establish or disestablish committees with approved Terms of Reference and delegated functions as it deems fit, including, amongst other things, joint committees with other CCGs.

• Accordingly, in order to delegate functions to the Joint Committee, the Governing Body of the CCG will need to take the following steps: (i) Agree to the establishment of the Joint Committee; (ii) Delegate the agreed functions to the Joint Committee; (iii) Ideally, record in its scheme of reservation and delegation details of the delegation

of the agreed functions to the Joint Committee. However, note that at present the scheme of reservation and delegation does not refer to any functions delegated to the Governing Body and so it is arguably unnecessary to do this.

• In order to delegate functions to the Joint Committee, the Governing Body of the CCG

will need to take the following steps: 1. Amend the CCG’s Scheme of Reservation and Delegation to provide for the delegation

of functions to the Joint Strategic Commissioning Committee. Insert an additional heading “COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES” and insert the following wording under that heading:

‘’To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.’’

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2. The column “Committee” will be ticked, and “Joint Strategic Commissioning Committee” or “JSCC” inserted in that column.

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Haringey CCG • Section 6 of the constitution sets out the governing structure for decision making.

• At 6.1.1 it is stated that HCCG is accountable for exercising the statutory functions of

HCCG and may grant authority to act on its behalf to: - its members; - its governing body; - employees (including officers); - a committee or sub-committee of HCCG.

• Paragraph 6.1.2 of the Constitution states that the extent of the authority to act [of the bodies in 6.1.1] depends on the powers delegated to them by the HCCG as expressed through a) the scheme of reservation and delegation and b) the committees, sub committees and their ToRs

• Paragraph 6.4 provides that the Governing Body of HCCG may, so long as it is in line with CCG regulations, establish or disestablish committees with approved Terms of Reference and delegated functions as it deems fit, including, amongst other things, joint committees with other CCGs.

• Paragraph 6.5 deals with ‘Joint or Collaborative Working Arrangements’ and provides at

6.5.1 that the governing body will be responsible for approving the transfer of existing agreements, the establishment of new agreements… and exit from such agreements.

• Paragraph 6.6 specifically provides for joint commissioning arrangements with other

CCGs. Paragraph 6.6.4 specifically states that a joint committee may be established. • Paragraph 6.6.6 requires that where arrangements are made under 6.6.2 (which

includes a joint committee) an agreement is developed setting out the arrangements for joint working

• Paragraph 6.9 of the Constitution sets out that the Governing body has delegated

responsibility for:

- 6.9.1.5 – approving commissioning plans - 6.9.1.8 – approving consultation arrangements for HCCG’s commissioning plan - 6.9.1.10 – any further functions that are set out in the Scheme of Reservation and

Delegation.

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• Paragraph 4 of Appendix C – NHS HCCG Standing Orders sets out the requirements for

the appointment of committees.

• Appendix D sets out the Scheme of Reservation & Delegation. This provides amongst other things that approval of HCCG’s commissioning plan is ‘reserved and delegated’ to the Governing Body.

• In order to delegate functions to the Joint Committee, the Governing Body of the CCG will need to take the following steps: (i) Agree to the establishment of the Joint Committee; (ii) Delegate the agreed functions of the Governing Body to the Joint Committee; (iii) Amend paragraph 6.10 of the Constitution to include a description of the Joint

Committee, and provide details of the functions of that Committee. We would propose the following wording:

“6.10.10 NCL Joint Strategic Commissioning Committee - The role of the Joint Committee shall be to exercise on behalf of the Governing Body the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.”

(iv) Amend the CCG’s Scheme of Reservation and Delegation at Appendix 4 to the CCG

Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee. We would propose the following wording under the COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES heading:

‘’To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.’’

(v) The column “Committee or Sub-committee” should be ticked, and “Joint Strategic

Commissioning Committee” inserted in that column (vi) The amendments will need to be agreed by the CCG Governing Body

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Camden CCG • Paragraph 14 of the constitution provides for the CCG to grant authority to act on its

behalf to: - Any member(s); - The Governing Body; - Camden CCG employees; or - A Camden CCG committee or sub-committee.

• The extent of the authority to act of the respective bodies and individuals depends on

the powers delegated to them by Camden CCG as expressed through the Scheme of Reservation and Delegation;

• Paragraph 24 of the constitution provides for joint working with other CCGs including, amongst other things, exercising jointly the commissioning functions of Camden CCG and another Clinical Commissioning Group by way of a joint committee. Paragraph 27 provides that for non-primary care joint commissioning the Governing Body shall: - Approve the arrangements for joint commissioning with other Clinical

Commissioning Groups for the exercise of Camden CCG’s commissioning functions; - Approve the arrangements for joint commissioning with other Clinical

Commissioning Groups for the exercise of other Clinical Commissioning Group’s or Groups’ commissioning functions;

• Schedule 7 contains the Scheme of Reservation and Delegation. This provides amongst other things that approval of Camden CCG’s commissioning plan is delegated to the Governing Body. Insofar as this function is to be delegated to the joint committee, the constitution provides at 14.1 that the Governing Body has the authority to delegate any of its functions to either a properly constituted committee or sub-committee, in so far as the creation of those committees complies with the arrangements as set out in the Constitution.

• In order to delegate functions to the Joint Committee, the Governing Body of the CCG will need to take the following steps:

(i) Agree to the establishment of the Joint Committee;

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(ii) Delegate the agreed functions of the Governing Body to the Joint Committee; (iii) Amend the CCG’s Scheme of Reservation and Delegation at Schedule 7 to the

CCG Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee as a sub-committee of the Governing Body. We would propose the following wording under the STRATEGY AND PLANNING heading and/or the COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES heading: ‘’To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.’’

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Barnet CCG • Paragraph 1.4.4 provides that the CCG may enter into collaborative arrangements with

other CCGs and NHS England by the creation of a Joint Committee(s) in the exercise of its commissioning functions.

• Section 6 of the constitution sets out the governing structure for decision making. • Paragraph 6.1.2 states that the CCG may grant authority to act on its behalf to:

- The governing body - Its employees - A committee or sub-committee of the governing body - Any of its member practices in their localities

• Paragraph 6.2 provides for the CCG’s scheme of reservation and delegation. 6.2.1 states that

the extent of the authority to act of the respective bodies and individuals depends on the powers delegated to them by the CCG as expressed through the CCG’s scheme of reservation and delegation (appendix D) and for committees, their terms of reference.

• Paragraph 6.5 provides that the CCG may enter into joint arrangements with other clinical commissioning groups and paragraph 7 deals with joint commissioning arrangements with other CCGs in more detail.

• Paragraph 7.6 states that where the CCG makes arrangements with another CCG they shall develop and agree an agreement setting out the arrangements for joint working.

• Appendix C sets out the standing orders which includes at paragraph 4 detail on the appointment of committees and sub-committees, including that (4.2) the ToRs will have effect as if incorporated into the constitution and shall be annexed to the standing orders.

• Appendix E sets out the Scheme of Reservation & Delegation. This provides amongst other

things that approval of the CCG’s commissioning plan and approval of the arrangements for discharging the CCG’s statutory duties associated with its commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation is reserved to the membership.

• In order to delegate functions to the Joint Committee, the CCG will need to take the

following steps:

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- Agree to the establishment of the Joint Committee; - Delegate the agreed functions to the Joint Committee

• Amend the CCG’s Scheme of Reservation and Delegation at Appendix E to the CCG

Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee. We would propose the following wording under the STRATEGY AND PLANNING and/or COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES headings:

• To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services.

• The column “Committee” should be ticked, and “Joint Strategic Commissioning

Committee” inserted in that column.

• Add the Terms of Reference of the Joint Strategic Commissioning Committee as an Annex to Appendix C of the Constitution.

• These amendments will need to be approved by the Governing Body

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Enfield CCG • Paragraph 10 sets out the rights and responsibilities of members which includes (10.1.1)

“members are entitled to the following benefits: to be informed of all commissioning plans of Enfield CCG where there is a significant effect upon commissioning and budgets”

• Part 5 (paragraph 20) sets out the duties of the governing body. Paragraph 22.1 (listed as 22.3, seemingly because of a typographical error, top of page 21) states the CCG is accountable for exercising its statutory functions and may grant authority to act on its behalf to: - Any member(s) - The governing body - Employees of the CCG - A committee or sub-committee of the CCG

• Paragraph 22.2 sets out that the extent of the authority to act of the respective bodies

and individuals depends on the powers delegated to them by the CCG as expressed through: - The CCG’s scheme of reservation and delegation; and - For committees, their terms of reference

• It also provides that the Governing Body may arrange for any of its functions to be

exercised on its behalf by any committee, sub-committee, employee or individual member provided that they are specified in the constitution and the terms of any such delegation must be recorded in the minutes of the Governing Body.

• Paragraph 22.3 provides that if any function of the Governing Body is being exercised on its behalf by a Member, employee, committee or sub-committee, any reference in this

• Constitution to the exercise by the Governing Body of that function shall be interpreted as if it was a reference to the exercise by the said person or committee or sub-committee.

• Paragraph 22.4 states that any… committee… appointed under paragraph [ 23.3 but query whether this is correct or whether it should refer to 22.3/22.1 as referred to above] shall… abide by any restrictions or conditions imposed by the governing body.

• Paragraph 47 provides that the CCG will be entering into joint arrangements with other clinical commissioning groups to enable collaboration and risk sharing throughout the Area.

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• Section 4 of Annex 3 (Standing Orders) sets out the procedure to appoint committees.

Paragraph 4.2.1 states that the ToRs of any committee and sub-committee shall have effect as if incorporated into the SOs.

• Annex 4 sets out the scheme of reservation and delegation. This provides amongst other things that approval of arrangements for discharging the CCG’s statutory duties associated with its commissioning functions and approving plans in respect of the application of available financial resources to support the agreed commissioning strategy plan are reserved to the governing body.

• In order to delegate functions to the Joint Committee, the Governing Body of the CCG will need to take the following steps:

- Agree to the establishment of the Joint Committee; - Delegate the agreed functions of the Governing Body to the Joint Committee; - Amend the CCG’s Scheme of Reservation and Delegation at Annex 4 to the CCG

Constitution to provide for the delegation of functions to the Joint Strategic Commissioning Committee. We would propose the following wording under the DECISIONS/DUTIES DELEGATED BY THE GOVERNING BODY TO COMMITTEES heading:

To exercise the CCG’s decision-making functions in connection with the commissioning of services in respect of Transforming Care; the NCL urgent and emergency care network; Hospital based acute care and specialised services. Capsticks Solicitors 20th October 2016

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Appendix 5: Draft job description for the proposed independent Chair of NCL joint committee

DRAFT v0.1 (26.10.16)

Role Requirements of the Independent Chair of the Joint Committee Main Purpose: 1. To provide independent leadership of the Joint Committee. 2. To chair the Joint Committee effectively to enable the delegated functions set out above

to be realised and to support the delivery of the Sustainability and Transformation Plan 3. To ensure the Joint Committee fulfils the functions of providing effective leadership and

governance in relation to the delegated functions. Key Responsibilities:

1. Ensure the Joint Committee works effectively, with good collaboration between the CCGs, encouraging and supporting the development of partnership working to ensure the strategic objectives are achieved.

2. Provide assurance that any conflicts of interest are appropriately managed. 3. Develop the Board members’ ability to monitor, scrutinise and constructively challenge

to business of the Joint Committee. 4. Chair programmed meetings of the Joint Committee (?? per year and any extraordinary

meetings as required). 5. Chair the Joint Committee in an effective and professional manner including setting of

agendas, approval of minutes and management of associated business. 6. To hold the CCGs to account regarding the deployment of resources to support the Joint

Committee. 7. To work closely with the CCG Chairs and the Accountable Officer for North Central

London to ensure timely management of the Joint Committee business. 8. To meet with the CCG Chairs as required. 9. To prepare and deliver a Chair’s Annual Report on the Joint Committee’s business. 10. Provide leadership, advice and guidance to Joint Committee members, including the

induction of new members. 11. Ensure that the Joint Committee addresses and incorporates best practice with regard

to relevant legislation and guidance, including equality and diversity in its functioning. 12. To adhere to confidentiality in respect of Joint Committee or CCG business. 13. Undertake any other duties as may be needed from time to time as necessary and

appropriate to the role.

Person Specification

Education and Knowledge • No specific professional qualification but needs to be someone with leadership experience at Board level

• Knowledge of establishing corporate structures and frameworks

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• Knowledge of NHS Governance systems, codes of practice etc.

• Able to comply with requirements of being a CCG Governing Body member (see below)

Experience • Chairing complex professional meetings

at a senior level and ability to chair in an efficient manner.

• Significant experience of working with Boards

• Experience in resolving transactional conflicts to deliver both high quality services and the highest value for money for stakeholders

• Experience of working across agency and professional boundaries and collaborative and partnership working.

• Experience of working with professionals and members of the public in order to improve services and create value for money for stakeholders.

• Experience of managing strategic change in a political context.

Skills • Communication skills: interpersonal,

presenting, media relations, maintaining a positive public and professional profile.

• Ability to influence key stakeholders and decision makers in a multi-agency/partner environment.

• Assertive, clear thinking and able to negotiate.

• Ability to generate and develop good working relations across partnership board member organisations at Board and senior management levels.

• Problem solving skills: ability to identify issues and areas of risk, and lead partners to effective resolution and decision.

• Chairing skills: ability to organise, coordinate and follow through on key

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decisions; manage competing or differing views, and positively challenge to achieve the desired outcome.

• Significant skills in negotiating to assist in managing and resolving conflict.

• Ability to recognise discrimination in its many forms and promote Equal Opportunities policies within the operation of the Joint Committee.

• Ability to ensure high standards of confidentiality in terms of individual cases and sensitive cross-organisational matters.

• Enthusiasm, commitment and a determination to carry forward a complex agenda.

• Commitment to improving health. • Ability to enthuse and gain the

commitment of others. • Commitment to principles of promoting

equality and respecting diversity. • Acting in accordance with accepted

Human Rights principles.

CCG Governing Body Requirements As a member of the CCG‘s governing body each individual will share responsibility as part of the team to ensure that the CCG exercises its functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCG constitution as agreed by its members. Each individual is there to bring their unique perspective, informed by their expertise and experience. This will support decisions made by the governing body as a whole and will help ensure that: • a new culture is developed that ensures the voice of the member practices is heard and

the interests of patients and the community remain at the heart of discussions and decisions;

• the governing body and the wider CCG act in the best interests of the health of the local population at all times; the CCG commissions the highest quality services with a view to securing the best possible outcomes for their patients within their resource allocation and maintains a consistent focus on quality, integration and innovation;

• decisions are taken with regard to securing the best use of public money; • the CCG, when exercising its functions, acts with a view to securing that health services

are provided in a way which promotes the NHS Constitution, that it is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get

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better when we are ill and when we cannot fully recover, to stay as well as we can to the end of our lives;

• the CCG is responsive to the views of local people and promotes self-care and shared decision-making in all aspects of its business; and good governance remains central at all times.

Core attributes and competencies Each individual needs to: • demonstrate commitment to continuously improving outcomes, tackling health

inequalities and delivering the best value for money for the taxpayer; embrace effective governance, accountability and stewardship of public money and demonstrate an understanding of the principles of good scrutiny

• demonstrate commitment to clinical commissioning, the CCG and to the wider interests of the health services;

• be committed to ensuring that the governing body remains ―in tune‖ with the member practices;

• bring a sound understanding of, and a commitment to upholding, the NHS principles and values as set out in the NHS Constitution;

• demonstrate a commitment to upholding The Nolan Principles of Public Life along with an ability to reflect them in his/her leadership role and the culture of the CCG;

• be committed to upholding the proposed Standards for members of NHS Boards and Governing Bodies in England developed by the Council for Healthcare Regulatory Excellence;3

• be committed to ensuring that the organisation values diversity and promotes equality and inclusivity in all aspects of its business;

• consider social care principles and promote health and social care integration where this is in the patients‘ best interest; and

• bring to the governing body, the following leadership qualities:

- creating the vision - effective leadership involves contributing to the creation of a compelling vision for the future and communicating this within and across organisations;

- working with others - effective leadership requires individuals to work with others in teams and networks to commission continually improving services;

- being close to patients - this is about truly engaging and involving patients and communities;

- intellectual capacity and application - able to think conceptually in order to plan flexibly for the longer term and being continually alert to finding ways to improve;

- demonstrating personal qualities - effective leadership requires individuals to draw upon their values, strengths and abilities to commission high standards of service; and

- leadership essence - can best be described as someone who demonstrates presence and engages people by the way they communicate, behave and interact with others.

Core understanding and skills Each individual will have:

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- a general understanding of good governance and of the difference between

governance and management; - a general understanding of health and an appreciation of the broad social, political

and economic trends influencing it; - capability to understand and analyse complex issues, drawing on the breadth of data

that needs to inform CCG deliberations and decision-making, and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions;

- the confidence to question information and explanations supplied by others, who may be experts in their field;

- the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill;

- the ability to take an objective view, seeing issues from all perspectives, especially external and user perspectives;

- the ability to recognise key influencers and the skills in engaging and involving them; - the ability to communicate effectively, listening to others and actively sharing

information; and - the ability to demonstrate how your skills and abilities can actively contribute to the

work of the governing body and how this will enable you to participate effectively as a team member.

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Appendix 6: Draft job description for the proposed secondary care independent clinical adviser of NCL joint committee

DRAFT v0.1 (26.10.16)

Specific Role Requirements as Independent Clinical Adviser As well as sharing responsibility with the other Committee members for those aspects of the CCG governing body business delegated, this clinical member will bring a broader view, on health and care issues to underpin the work of the CCGs. In particular, they will bring to the governing body an understanding of patient care in the secondary care setting. Specific attributes and competencies • Must be a Consultant – either currently employed, or in employment at some time in

the period of 10 years ending with the date of the individual‘s appointment to the Joint Committee of the governing bodies;

• Has a high level of understanding of how care is delivered in a secondary care setting; • Be competent, confident and willing to give an independent strategic clinical view on all

aspects of CCG business; • Be highly regarded as a clinical leader, preferably with experience working as a leader

across more than one clinical discipline and/or specialty with a track record of collaborative working;

• Be able to take a balanced view of the clinical and management agenda, and draw on their in depth understanding of secondary care to add value;

• Be able to contribute a generic view from the perspective of a secondary care doctor whilst putting aside specific issues relating to their own clinical practice or their employing organisation‘s circumstances; and

• Be able to provide an understanding of how secondary care providers work within the health system to bring appropriate insight to discussions regarding service re-design, clinical pathways and system reform.

Whilst the individual may well no longer practise medicine, they will need to demonstrate that they still have a relevant understanding of care in the secondary setting. The secondary care specialist cannot be an employee or member (including shareholder) of, or a partner in, a provider of primary medical services, or a provider with whom the CCG has made commissioning arrangements. The exceptions are where the CCG has made an arrangement with a provider, subsequent to a patient exercising choice, and where the CCG has made an arrangement with a provider in special circumstances to meet the specific needs of a patient (for example, where there is a very limited choice of provider for a highly specialised service). Role Requirements for all Governing Body Members and Joint Committee Members

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As a member of the CCG‘s governing body each individual will share responsibility as part of the team to ensure that the CCG exercises its functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCG constitutions as agreed by its members. Each individual is there to bring their unique perspective, informed by their expertise and experience. This will support decisions made by the governing bodies as a whole and will help ensure that: • a new culture is developed that ensures the voice of the member practices is heard and

the interests of patients and the community remain at the heart of discussions and decisions;

• the governing body and the wider CCG act in the best interests of the health of the local population at all times;

• the CCG commissions the highest quality services with a view to securing the best possible outcomes for their patients within their resource allocation and maintains a consistent focus on quality, integration and innovation; decisions are taken with regard to securing the best use of public money;

• the CCG, when exercising its functions, acts with a view to securing that health services are provided in a way which promotes the NHS Constitution,

• that it is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and when we cannot fully recover, to stay as well as we can to the end of our lives;








• be committed to upholding the proposed Standards for members of NHS Boards and Governing Bodies in England developed by the Council for Healthcare Regulatory Excellence;

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Core understanding and skills Each individual will have: • a general understanding of good governance and of the difference between governance

and management; • a general understanding of health and an appreciation of the broad social, political and

economic trends influencing it; • capability to understand and analyse complex issues, drawing on the breadth of data

that needs to inform CCG deliberations and decision-making, and the wisdom to ensure that it is used ethically to balance competing priorities and make difficult decisions;

• the confidence to question information and explanations supplied by others, who may be experts in their field;

• the ability to influence and persuade others articulating a balanced, not personal, view and to engage in constructive debate without being adversarial or losing respect and goodwill;

• the ability to take an objective view, seeing issues from all perspectives, especially external and user perspectives;

• the ability to recognise key influencers and the skills in engaging and involving them; • the ability to communicate effectively, listening to others and actively sharing

information; and

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• the ability to demonstrate how your skills and abilities can actively contribute to the work of the governing body and how this will enable you to participate effectively as a team member.

Core personal experience • previous experience of working in a collective decision-making group such as a board or

committee, or high-level awareness of ‗board-level‘ working; and • a track record in securing or supporting improvements for patients or the wider public. Based on NHSE Clinical Commissioning Group Governing Body members: Role outlines, attributes and skills (2012)

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Appendix 7: Draft job description for the proposed registered nurse/independent clinical adviser of NCL joint committee

DRAFT v0.1 (26.10.16)

Specific Role Requirements as Independent Clinical Adviser (Nursing) As well as sharing responsibility with the other members for all aspects of the CCG Joint Committee body business delegated by the CCG Governing Bodies, as a registered nurse on the Committee, this person will bring a broader view, from their perspective as a registered nurse, on health and care issues to underpin the work of the CCG especially the contribution of nursing to patient care. Specific attributes and competencies • be a registered nurse who has developed a high level of professional expertise and

knowledge; • be competent, confident and willing to give an independent strategic clinical view on all

aspects of CCG business; • be highly regarded as a clinical leader, probably across more than one clinical discipline

and/or specialty – demonstrably able to think beyond their own professional viewpoint; • be able to take a balanced view of the clinical and management agenda and draw on

their specialist skills to add value; • be able to contribute a generic view from the perspective of a registered nurse whilst

putting aside specific issues relating to their own clinical practice or employing organisation‘s circumstances; and

• be able to bring detailed insights from nursing and perspectives into discussions regarding service re-design, clinical pathways and system reform.

The nurse in this role cannot be an employee or member (including shareholder) of, or a partner in, a provider of primary medical services, or a provider with whom the CCG has made commissioning arrangements. The exceptions are where the CCG has made an arrangement with a provider, subsequent to a patient exercising choice, and where the CCG has made an arrangement with a provider in special circumstances to meet the specific needs of a patient (for example, where there is a very limited choice of provider for a highly specialised service). Role Requirements for all Governing Body Members and Joint Committee Members As a member of the CCG‘s governing body each individual will share responsibility as part of the team to ensure that the CCG exercises its functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCG constitutions as agreed by its members. Each individual is there to bring their unique perspective, informed by their expertise and experience. This will support decisions made by the governing bodies as a whole and will help ensure that:

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• a new culture is developed that ensures the voice of the member practices is heard and the interests of patients and the community remain at the heart of discussions and decisions;

• the governing body and the wider CCG act in the best interests of the health of the local population at all times;

• the CCG commissions the highest quality services with a view to securing the best possible outcomes for their patients within their resource allocation and maintains a consistent focus on quality, integration and innovation; decisions are taken with regard to securing the best use of public money;

• the CCG, when exercising its functions, acts with a view to securing that health services are provided in a way which promotes the NHS Constitution,

• that it is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and when we cannot fully recover, to stay as well as we can to the end of our lives;








• be committed to upholding the proposed Standards for members of NHS Boards and Governing Bodies in England developed by the Council for Healthcare Regulatory Excellence;




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Appendix 4.5.2

Paper 3 of 3 Developing the commissioning arrangements in North Central London: Management arrangements

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Contents

1. Introduction ............................................................................................................. 3

2. Leadership roles ........................................................................................................ 3

3. Impact on resources .................................................................................................. 6

4. Remuneration Committees ..................................................................................... 10

6. Implementation ...................................................................................................... 11 Appendix 1: Overall job purposes for the proposed new executive roles ................................. 15 Appendix 2: Breakdown of current CCG running cost workforce in finance and performance ... 17 Appendix 3: Breakdown of current CCG programmes workforce by function ........................... 18 Appendix 4: CSU service specifications by CCG ........................................................................ 19

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1. Introduction Five Clinical Commissioning Groups (CCGs) have come together across North Central London (NCL) to commission services differently. These CCGs are Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG and Islington CCG. The CCGs have extensive experience of commissioning and have been working together for some time, but we have ambitions to do more and are facing collective challenges. The CCGs have proposed to establish a joint committee to commission the following range of services on behalf of the NCL CCGs:

• Acute services including core contracts and other out of sector acute commissioning; • All learning disability contracting associated with the Transforming Care programme; • All integrated urgent care • Any specialised services not commissioned by NHS England Paper 2 sets out the proposed governance arrangements of this committee. To support these governance arrangements, the current management structures across the CCGs in NCL have been reviewed. The creation of two new shared NCL executive roles was agreed by all five CCG governing bodies at their meetings in September and October with a further two shared roles requiring approval. In addition to this, four proposed local leadership roles are detailed within this paper and require approval from the governing bodies. This paper sets out the proposed new executive structure, the impact of the proposals on current CCG resources and an implementation strategy for these changes. 2. Leadership roles Strong leadership both locally and across NCL will be extremely important in delivering the mission and ambitions of the five CCGs. Four NCL wide leadership roles have been proposed at previous governing body meetings. An additional four Local Director roles are also proposed in this paper to be accountable for local services and functions. The proposed executive structure is shown in Figure 1.

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Figure 1: Proposed management structure for NCL under new commissioning arrangements

NCL leadership roles At the governing body meetings that took place across the NCL CCGs in September and October, it was agreed that the following functions would be best performed at the NCL system-wide level: • Setting a vision for health and social care: Under the STP the vision for health and social

care is shared by all constituent organisations • Financial strategy: As CCGs move toward more integrated budgets, risk-sharing

arrangements and an aspiration for capitated budgets, financial strategy and resource allocation will be driven at the system level. The Governing Bodies of the five CCGs have already agreed a paper outlining this.

• Strategy and overall priorities: The strategy and priorities that will drive delivery of the shared vision are to be set at the system-level under the STP.

• Standards and outcomes: Will be set at an NCL level although there may be different options for delivery, all the population should receive the same standard of care for the same condition. Quality monitoring will be conducted at a system level.

• Assurance: Assuring outcomes across the five CCGs, and working together to ensure providers are meeting standards for good quality, effective and efficient service.

To support these functions, it was agreed that there would be the following NCL-shared executive roles: • An Accountable Officer (AO): with accountability for the executive management of the

NCL system and Accountable Officer for each individual CCG. • A Chief Finance Officer (CFO): with executive accountability for the financial

performance of the NCL CCGs and financial strategy and Finance Director for each individual CCG.

In addition, two further roles were proposed:

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• A Director of Strategy: with accountability for shaping and delivering the strategy of the STP across NCL.

• A Director of Performance and Acute Commissioning: with accountability for assurance and service performance across NCL.

Local leadership roles As detailed in Paper 2, it is proposed that there will still be a substantial amount of commissioning undertaken within the individual CCGs, as follows: • Children’s joint commissioning and children’s services outside of hospital • Primary care development • Primary care prescribing • Sexual health commissioning (within CCG responsibilities) • Joint commissioning with social care:

- preventative care - complex elderly - Better Care Fund

• Mental health and community contracts including the contracts for: - Barnet, Enfield & Haringey Mental Health NHS Trust - Camden & Islington NHS Foundation Trust - South London & Maudsley NHS Foundation Trust - East London NHS Foundation Trust - Tavistock & Portman NHS Foundation Trust - Central London Community Healthcare NHS Trust - Central and North West London NHS Foundation Trust - Whittington Health NHS Trust

• Other mental health commissioning • All hospice-based end of life care • Continuing healthcare and funded nursing care • Day-to-day tactical delivery of A&E performance There is, therefore, a continuing need for strong local executive leadership within each CCG to lead and discharge these functions. Members at the 6 October governing body workshop proposed that executive leadership to discharge these functions was required, and that one Local Executive Director (VSM level) would be employed for each CCG, except in the case of Haringey and Islington where there would be a combined role to support their partnership with each other. An outline of the purpose of this position is attached in Appendix 1 of this paper and a draft job description is available from the Chair prior to its discussion at the remuneration committee. Work is being conducted with CCG Chairs to develop these locally prior to going to advertisement.


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3. Impact on resources The NCL CCGs have a dedicated and experienced workforce committed to providing the best service for local people. It has been, and will be, a priority to retain the talent that is currently in NCL CCGs and create opportunities for people to develop and progress. It has also been a principle of the work that any changes will not increase the managerial resource costs across NCL CCGs, and the proposals have been developed with this principle in mind. Impact on leadership (VSM) roles Currently there are 11 VSM roles across the five NCL CCGs: one AO and one CFO in each CCG (and an additional VSM position in Enfield CCG for the deputy Chief Officer with no change being proposed to this position at this point). It is proposed that under the new NCL executive structure, detailed in section 2 of this paper, there are four shared executive roles and four local executive director roles resulting in nine VSM roles across NCL (including the Deputy Chief Officer role in Enfield). CFOs of all the NCL CCG have calculated that these proposed changes would cost £155,500 per year less than the current structure. This is due to a combination of the increased seniority of the roles and the reduction in numbers of roles by two. Impact on resources and workforce The implications of the changes proposed to the VSM structure in section 2 on the wider NCL CCG resources are considered in this section. This consideration of how these resources are affected is taken in three areas, these are detailed in Table 1. Table 1: Current CCG resources

Resource (i) Running costs (£k)

(ii) Programmes (£k)

(iii) CSU (£k)

(iii) CSU GPIT (£k)

Resource Value

£15,580 (205 WTEs)

£14,211 (225 WTEs) £16,173 £3,800

To ensure business continuity across the five CCGs, it is proposed that there is no immediate change to the CCG workforce or resource allocation of any roles other than VSM roles. However, to support the new executive structure, it is proposed that the reporting accountabilities of some functions be changed. The impact of this is shown on (i) establishment (running cost) workforce, (ii) CCG programme workforce and (iii) CSU resource, which is divided into two contracts. Impact on running cost workforce:

1) The creation of a new Local Executive Director role, as described above, to lead the

delivery of local functions.

2) The proposal for a shared Director of Strategy and a shared Director of Performance and Acute Commissioning.

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Across NCL, there are currently 205 staff in the CCG establishment (running cost workforce) at the cost of £15.6m. The CCG Chief Officers and CCG CFOs have reviewed the function and roles of the staff to establish a proposal of staff that would report into one of the new NCL executive roles and staff that will remain within individual CCG’s, being accountable to the Local Executive Director. This assessment was based on: • Consideration of which functions should be shared across NCL • Understanding of the scope of the new NCL executive posts • The functions that are being delegated to the new joint committee • The current roles and responsibility of members of staff It is proposed the members of staff working within the functions of finance, performance and acute commissioning (of which there is only one person in the running cost resource pool, in Haringey) would work across NCL reporting into the new NCL shared executive roles. This would create a shared workforce of 34 whole time equivalents (WTEs) and a combined budget of £2,241,000, in the sub-VSM running cost workforce resource. This is detailed in Table 2. Table 2: Detailed analysis of staff working across NCL

Function WTEs Budget Accountable Executive Finance 22 £1,588,000 NCL CFO

Performance & acute commissioning

12 £653,000 NCL Director of Performance and Acute Commissioning

Total 34 £2,241,000 A breakdown of staff in these two functions, by CCG is attached in Appendix 2. Aside from the proposed changes to the executive structure, and those employees in establishment roles working in the finance or performance functions, it is proposed that the remaining workforce will, at this point, remain local and their accountability will reside with the proposed Local Executive Director. It is recognised that the proposed shared team, as well as the new joint committee, will need administrative support in order to discharge their functions. Across the five CCGs there are currently 26 WTEs who have these skills (five in the CEO office cost centre and 21 in the admin cost centre). At this stage, there is no change proposed to these functions, however there is recognition that there will be a need for administrative staff to support the shared team and service the joint committee, and that this will become available as some executive posts move from individual CCGs to the shared team. It is proposed that this should be revisited and addressed once appointments to the team are underway. Chief Officers, CFOs, and CCG quality leads have additionally spent time discussing the best way to discharge the “quality” function across NCL: either in a shared way across NCL, or remaining local. It has been recognised that as the changes to the commissioning arrangements progress, there may be a requirement for a shared Director of Quality who would be accountable to all CCGs. There are 25 WTEs across the NCL CCGs that work in a

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quality role, whom under such a proposal would report into this position. At this point it is felt that there was not sufficient evidence to propose this change to governing bodies; however once the new single Accountable Officer is in post it is likely that this work will progress. As such, there is no change being proposed to quality resources at this point. It is recommended that the remaining functions are best to remain being discharged at an individual CCG level.

Impacts on the CCG programmes workforce There are 225 WTEs within the programmes workforce across the five CCGs with a budget of £14m a breakdown of these staff by CCG is given in Table 3. A full breakdown of the five CCG programmes workforce by function is given as Appendix 3. The three largest functions by workforce are continuing healthcare services, medicines management and primary care commissioning with 59, 32.5 and 26 WTEs working within these functions respectively. To support the ongoing programmes in each CCG, it is proposed that there is no change to the programmes workforce and that the staff accountable for discharging these functions remain accountable to their own CCG lead and will report into the proposed Local Executive Director. Table 3: Breakdown of NCL CCG programmes workforce by CCG

CCG Workforce, WTEs Budget, £k Barnet 33 £1,869 Camden 55 £3,752 Enfield 66 £3,655 Haringey 33 £2,396 Islington 38 £2,539 Total 225 £14,211

It is proposed that the shared Director of Strategy is supported by STP programme resource to oversee and deliver the STP. Going forward, it is proposed that the programmes workforce would deliver both local and shared STP programmes of work. There will therefore need to be a determination into the future delegation of this strategic workforce. Implications for the CSU resource

It is asked that the Governing Body approve the following: 3) That all CCG workforce in finance, performance and acute commissioning functions be

line managed by the new shared executive director roles

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The five CCGs all commission a range of support services from the CSU. The support provided is variable across the five CCGs and the detail of current service specifications is included at Appendix 4. Over the next year, all five CCGs will undertake a market testing process for their commissioning support, this will begin with GP IT (apart from Camden who have in-house GP IT services), followed by the wider service specification throughout 2017. It is proposed that the CSU support contracts be reviewed following the outputs of this process, and that the management of the CSU contracts be delegated to the new shared AO. This will enable the CSU resource to support the combined finance and performance functions and the delegated responsibility for the commissioning of: • All acute services including core contracts and other out of sector acute commissioning; • All learning disability contracting associated with the Transforming Care programme; • All integrated urgent care; and • Any specialised services not commissioned by NHS England.

Across NCL, the single largest line item of the current CSU contracts is “contracts” with £6.6m of support procured annually across the five CCGs. The key sub-activities provided within this are: • Support with the negotiation process with providers • Development of a negotiation strategy for each provider • Delivery of a signed contract with each provider • Production of activity, finance and performance reports • Provision of analyses to support provider performance management, contract

negotiations and claims management • Working with providers to ensure delivery to contract and ensuring that issues are

addressed in line with the agreed performance management framework.

It is within this resource base that NCL CCG acute commissioning, as well as some performance functionality, is currently undertaken. In order to support the delegation of services as set out in Paper 1, it is proposed that the resource relating to acute contracting be managed by the new shared Director of Performance and Acute Commissioning. The proposed shared AO would have responsibility for signing the core contracts on behalf of the five CCGs. It is proposed that the commissioning support resource requirement be reviewed every four years to ensure that the contract specification continues to deliver value for money and supports the aims and strategy of the five CCGs and the Joint Committee.

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4. Remuneration Committees A CCG remuneration committee-in-common (all the CCG remuneration committees meeting at the same time in the same place with a shared agenda) will take place on 10 November to formally agree: • Job descriptions and pay for the agreed new shared Accountable Officer and Chief

Financial Officer roles (an outline of the purpose of these roles are attached at Appendix 1 and draft job descriptions are available from the Chair prior to their discussion at the remuneration committee)

• The range of exposure to redundancy costs that may result from the removal of the current CCG AOs and CFOs positions.

Assuming governing bodies approve the contents of these papers, a second meeting of all CCG remuneration committees will be required in early December (following the final November governing body in Haringey on November 30) to agree: • Job descriptions and pay for the new shared Director of Performance and Acute

Commissioning and Director of Strategy roles as well as the Local Executive Director role relevant to each CCG (an outline of the purpose of these roles attached at Appendix 1 and draft job descriptions are available from the Chair prior to their discussion at the remuneration committee)


4) That the management of the core CSU support contracts be reviewed across the five

CCGs based on their needs and reflecting the proposals of the new commissioning arrangements

5) That accountability for the management of the core CSU support contracts be

delegated to the new shared Accountable Officer, who would have responsibility for signing the core contracts on behalf of the five CCGs

6) That the day-to-day management of the CSU support, relating to acute contracting,

be undertaken by the proposed Director of Performance and Acute Commissioning

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The Islington CCG Remuneration Committee has the responsibility to make recommendations to the Governing Body in respect to remuneration matters. These recommendations would normally be reviewed at the following Governing Body meeting. In cases such as these when there is a need to expedite the process it would be normal to utilise the ‘urgent decisions’ process whereby a matter may be decided by the Accountable Officer and the Chair of the Governing Body after having consulted at least two voting non-officer Governing Body members. However, in this circumstance, the Accountable Officer is likely to be conflicted therefore, taking into account guidance within the constitution for managing conflicts, it is proposed that the governing body allows just the Chair of the Governing Body to approve the recommendation made by the remuneration committee.

6. Implementation Chief Officers have been undertaking work on the implementation of the proposed new management structure. An independent HR advisor has been appointed to support this process. Engagement and communication with current members of staff will be extremely important in retaining scarce and experienced commissioning talent. This process has already started and will continue in the coming months. A detailed timeline for the HR process has been developed, alongside a detailed communications and engagement strategy and a risk register. Timeline for implementation A proposed timeline for the HR process is given in Figure 2. This timeline sees the recruitment of the new NCL executive roles during December 2016 and January 2017 with roles appointed to by the end of January 2017. It is anticipated that the successful candidates will start in their new roles from April 2017 permitting notice periods. Figure 2: Draft HR process timeline.

It is asked that the Governing Body approve the following: 7) That recommendations on AO and CFO job descriptions and pay and the range of

exposure to redundancy costs made by the remuneration committee at 10 November committee in common be approved by Chairs Action on behalf of the Governing Body [Islington]

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NOTE: notice periods for appointments in the above are indicative only, and may vary on a case by case basis from zero to six months. a) Communications and engagement A full communications and engagement plan will be developed by Chief Officers supported by HR specialists and communications leads for the changes proposed under the commissioning arrangements programme. This plan will align with the wider NCL communications and engagement plan for the STP. Messages to be delivered to each group of stakeholders should be consistent, however, it will be necessary to tailor these messages for the audience so it is best received. The best engagement channel to deliver these communications will additionally be considered, as well as the time at which messages are delivered. i) Stakeholders Four key stakeholder groups for communication and engagement have been identified. As this programme progresses toward implementation, and beyond, it will be important that

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regular, consistent communications and engagement is undertaken with each of these groups across all five CCGs:

1. CCGs staff 2. CCG members 3. CCG partner organisations (e.g. local councils, providers, etc.) 4. Inter-CCG communication (e.g. ensuring each organisation is aware of what is

happening at the others) b) Headline messages The five NCL CCGs have been reviewing the need for strategic commissioning across NCL to deliver on our STP and the Five Year Forward View. Key to this, is looking at ways of working more closely with other CCGs whilst maintaining and building on joint work with local authorities. The five CCGs have agreed a shared commissioning strategy outlining how they will work together to deliver the NCL STP, as part of this a shared financial strategy has been agreed. These papers also propose a new NCL CCG governance structure to effectively make decisions and commission services. These changes will be managed in accordance with the London Change Management Policy which has recently been updated as well as local CCG change management policies where appropriate. Existing CCG change policies are aligned to the London policy and these will be updated to reflect the new additions on staff engagement. The work that underpins these proposals has been ongoing for several months, and has been to governing bodies of all NCL CCGs in September/October and will continue to be developed in detail by the Governing Body meetings going forward. Currently it is thought that the new executive structure will be in place by April 2017 and all NCL CCG staff will be kept informed as these changes progress. i) Channels For the four stakeholder groups identified above, a number of channels will be used to deliver the key messages going forward. These include: • Regular formal and informal staff briefings • Workshops and/or staff engagement meetings as required • Consistent email messages as process progresses • Public borough meetings • Digital engagement, including:

- CCG internal intranet messaging boards - CCG public websites - Partner digital media channels (as part of wider, ongoing STP communications) - twitter, Facebook, Instagram etc. – which already exist across both health and local

government • Regular CCG meetings with STP leadership

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• Face to face meetings between the STP leadership team and local councilors and MPs along with Ministers in the Department for Health

ii) Timing for delivery of key messages As the commissioning arrangements programme progresses through November and looking forwards towards April 2017, when it is expected that the new executive posts will be filled, the plan for communicating will not be static. However, it is expected that communications to each stakeholder group will need to be issued: • At the end of November to provide update on the outcomes of the five NCL CCG

governing bodies • Following appointments to proposed new executive roles • As formal changes to governance progresses (formal agreement to change; progress of

formation of joint committee; first meeting of joint committee) Going forward, the exact timing for issuing these communications will be agreed depending on when the ‘trigger events’ happen, however these communications will be issued concurrently to stakeholders across CCGs. Proposal for the host employer of shared roles Any new staff joining the CCGs in a shared role need one of the five CCGs to employ them. Legally, these posts need to be hosted by a single CCG. It is proposed that the host employer for any new appointments, which are to be shared, is Islington CCG. As Islington CCG is already the host employer for the Healthier London Partnership, it is felt that they were already well placed to undertake hosting responsibilities. For any existing staff undertaking shared roles, there will be no change to their employing organisation.

It is asked that the Governing Body approve the following: 8) That Islington CCG be the host employer for any new appointments that are shared

across the five NCL CCGs.

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Appendix 1: Overall job purposes for the proposed new executive roles NCL Accountable Officer This new role will act as the Accountable Officer for all the CCGs and will be responsible for bringing together the 5 CCGs to deliver the objectives set out above. 1. To provide leadership and innovation to develop and implement both short and long

term strategies for the five CCGs within the collaboration and ensure that agreed plans are effectively delivered.

2. To ensure that the CCGs within the collaboration exercise their functions effectively, efficiently, economically, with good governance and in accordance with the terms of the CCG constitution as agreed by its members.

3. To enhance and build a culture that ensures the voice of the member practices is heard and the interests of patients and the community remain at the heart of discussions and decisions.

4. The collaborative nature of the role requires the Accountable Officer to influence relationships with multiple key stakeholders across the North Central London Sustainability and Transformation area (STP) and London. Including NHS providers, local authorities (including health and wellbeing boards, social care and public health leads), local Health watch and the voluntary and statutory sector.

5. To manage the delegation of functions from NHS England including those relating to Specialised Commissioning and Primary Care. To ensure effective systems are in place to manage the delegation and ensure objectives are met.

6. Further enhance innovative strategic programs such as those promoting new models of care and continue to drive clinical leadership in NHS Commissioning.

7. To ensure that there is clear strategic direction and vision for the CCG(s) in conjunction with the Governing Board(s) and keep this under regular review.

8. To maintain a strategic overview of individual CCG performance within the collaboration.

NCL Chief Finance Officer 1. To provide strategic advice to the Accountable Officer and Governing Board of the

CCG(s) on all aspects of financial strategy and financial management. 2. Play an active role in the determination and implementation of the NCL strategy 3. To lead on the financial strategy underpinning the Sustainability and Transformation

Plan in North Central London 4. To provide leadership and direction to all finance staff working across the five CCGs in

North Central London. NCL Director of Performance and Acute Commissioning 1. To manage the commissioning and contracting of all acute/secondary/tertiary contracts

in NCL (£1,007M of Acute Contracts) 2. To manage any delegated Specialist commissioning contracts held by NHS England 3. To ensure reporting routines for all aspects of acute performance for the five CCGs and

NHSE are implemented and effective across North Central London CCGs. 4. To lead on the delivery of performance improvement strategies across NCL CCGs

including ensuring recovery plans are put in place and monitored

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5. To ensure the CCGs deliver all Operational Standards and Performance Targets and take appropriate action as soon as possible when there are concerns

6. To managing the performance of all Providers within North Central London 7. To develop an effective performance management and assurance working relationship

with the NHSE Regional Team 8. To manage the CSU contract for Acute Contracting to ensure that the CCG objectives

and commissioning strategy is delivered. 9. To maintain effective relationships with a wide range of senior stakeholders across NCL

and ensure integration and joint working with CCG colleagues NCL Director of Strategy 1. To provide direction and leadership to the overall design, delivery and

implementation of the North Central London’s response to the Five Year Forward View and in particular the Sustainability and Transformation Plan for the area.

2. To co-ordinate the portfolio of transformation programmes across North Central London and ensure strategic alignment across the other programmes within the Sustainability and Transformation Plan portfolio working closely with CCG based staff

3. To manage the delegation of functions from NHS England – in particular in relation to Specialised Commissioning and Primary Care. To set up appropriate commissioning functions and integrate the work into the Sustainability and Transformation Plan for the area

Local Executive Directors This role is part of the NCL Executive Team and has line managed responsibility for XXXX CCG staff. They will be expected to work collaboratively with the NCL-wide team who are leading on the Sustainability and Transformation Plan and Acute Commissioning to deliver the vision and objectives set out above. They will be responsible for leading on services which should be commissioned by individual CCGs or in partnership with Local Authorities – including:

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Appendix 2: Breakdown of current CCG running cost workforce in finance and performance Table 4: Number of Whole Time Equivalent (WTE) CCG staff working in the functions finance and performance by band

Table 5: Number of Whole Time Equivalents (WTE) CCG staff working in the functions Finance and Performance by CCG

CCG Finance function WTEs

Performance function WTEs

Total WTEs

Barnet 5 1 6 Camden 5 2 7.3 Enfield 5 4 9 Haringey 4 1 5 Islington 3 3 6

Function Band 8d WTEs

Band 8c WTEs

Band 8b WTEs

Band 8a WTEs

Band 7 WTEs

Band 6 WTEs

Band 5 WTEs

Band 4 WTEs

Total WTEs

Finance 2 4 2 8 3 1 2 22 Performance 3 2 4 1 1 11

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Appendix 3: Breakdown of current CCG programmes workforce by function Table 6: Number of Whole Time Equivalents (WTE) CCG programmes staff working by function

Function Barnet programmes workforce WTEs

Camden programmes workforce WTEs

Enfield programmes workforce WTEs

Haringey programmes workforce WTEs

Islington programmes workforce WTEs

Total programmes workforce WTEs

Continuing healthcare 20 22 15 2 59

Medicines management 8 8.5 9 7 32.5

Commissioning - primary care 4 13 9 26

Commissioning - other 11 11 22

Admin 17 17

Corporate services 8 8

Transformations 3 3

Safeguarding 4 2 6 2 14

Commissioning - non acute 10 10

Referral Management 8 8

Quality 6 5 11

Comms & PR 3 3

Finance 1.7 1.7

Programmes project 1 3 4

Clinical governance 3 3

Commissioning - maternity 3 3

Total 33 55 66 33 38 225

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Appendix 4: CSU service specifications by CCG Table 7: CSU contract details by CCG (£k)

Service Barnet Spend

Camden Spend

Enfield Spend

Haringey Spend

Islington Spend 5 CCG Total

Contracts £1,778 £1,161 £1,446 £1,295 £1,082 £6,762 Reporting and BI £1,107 £813 £990 £921 £862 £4,693

Finance £307 £273 £307 £235 £281 £1,403 Business Support £296 £376 £347 £220 £138 £1,377

Clinical Services £191 £146 £121 £108 £222 £788

HR £138 £136 £145 £108 £80 £606 DITC (FoI, Comms and DITC pre-bought)

£38 £44 £43 £23 £23 £172

Enhanced surge £23 £23 £23 £23 £23 £113

Cancer commissioning £26 £17 £22 £19 £15 £99

Surge £21 £19 £20 £20 £18 £98 Support and Commissioning £12 £12 £12 £12 £12 £62

Total £3,937 £3,020 £3,476 £2,984 £2,756 £16,173

Table 8: CSU GP IT contract by CCG (£k)

Barnet Spend

Camden Spend

Enfield Spend

Haringey Spend

Islington Spend

Total Spend

GP IT core £901 £0 £728 £675 £528 £2,832 GP IT total spend £1,198 £0 £968 £898 £702 £3,766

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Item: 4.6

MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Primary Care Co-Commissioning LEAD GOVERNING BODY MEMBER:


AUTHOR: Alison Blair, Chief Officer Islington CCG and SRO for Primary Care in North Central London

CONTACT DETAILS:

[email protected]

SUMMARY:

This report provides feedback from the North Central London (NCL) Primary Care Joint Committee who tasked a programme group with the appraisal of the NCL CCGs potential move to Level Three – delegated commissioning of primary care from the current arrangement of co-commissioning primary care contracts with NHS England.

The programme group have coordinated all elements of the review, which has included engagement of stakeholders (Appendix A), governance and due diligence (Appendix B), and support to the NHS England organisational development review of staffing and resourcing.

This paper recommends that Haringey, Islington, Barnet and Enfield CCGs submit an expression of interest for delegated commissioning to NHS England. Should the Governing Bodies accept this recommendation each CCG will need to submit an expression of interest in December 2016 to become Level Three – delegated commissioners of primary care from April 2017.

Following engagement activities carried out across NCL, the Constitution of Camden CCG required the CCG to hold a vote of their membership to support the move to full delegated commissioning. Despite there being ‘a single ‘no’ vote and twenty-four ‘yes’ votes, as there were eight abstentions, the CCG was not able to obtain the required twenty-seven ‘yes’ votes to proceed with an application for delegated commissioning at this stage. Camden CCG will continue to work with member practices on this and intends to continue to collaborate with the other CCGs in NCL on transforming primary care.

Following the Governing Body meeting, the programme team will prepare an expression of interest for delegated commissioning. The application form will be finalised by each CCG and sent to NHS England for regional and national moderation. Prior to submission, the programme team will work with the CCG governance leads to finalise an approach to the governance of the Committee that ensures Camden CCG remain a partner in transforming primary care in NCL.

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Islington CCG has carried out an engagement process on the proposal to move from the current co-commissioning arrangement to full delegated commissioning of primary care services. Section 6 of the report and Appendix A set out a summary of the engagement response for Islington and the other NCL CCGs. The Islington CCG engagement program has included the Health and Wellbeing Board, Local Medical Committee (LMC), Healthwatch, local practices through Board Link Visits and practice forums, and the Islington GP Federation.


• Delivering the NCL vision for primary care as outlined in the Sustainability and Transformation Plan;

• Supporting CCGs to carry out their duty of ensuring continuous improvement in the quality of services provided to our local population.

Prior consideration by Committees and other partners:

• North Central London (NCL) Primary Care Joint Committee; • North Central London (NCL) Primary Care Commissioning Options Steering Group

Patient & Public Involvement (PPI): A summary of patient and public engagement activities can be found in Appendix A. Equality Impact Assessment: The proposal outlined in this paper supports local primary care commissioning based on the needs of local patients and public. Risks: The key identified risks relate to resourcing, the core primary care budget and conflicts of interest. RECOMMENDED ACTION:


• CONSIDER and COMMENT on the items in this report. • APPROVE the recommendation that Haringey, Islington, Barnet and Enfield CCGs

submit an expression of interest to become Primary Care delegated commissioners subject to:

o Satisfactory conclusion of due diligence activities in the take on of delegated commissioning responsibilities;

o A finalised governance arrangement which allows four delegated CCGs (Enfield, Haringey, Barnet and Islington) to meet as Committees-in-Common, alongside one Joint Co-Commissioning CCG (Camden);

SUPPORTING PAPERS:

4.6.1 - Appendix A: Stakeholder Feedback and frequently asked questions (FAQ) summary 4.6.2 - Appendix B: Outline due diligence information

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Appendix 4.6

1. Introduction The North Central London CCGs began primary care co-commissioning with NHS England in October 2015, and formed a Primary Care Joint Committee (PCJC) to oversee this new area of commissioning. In April 2016 the PCJC held a workshop to discuss how it was progressing and to explore the possibility of moving to ‘delegated’ commissioning arrangements for primary care from April 2017. This would mean CCGs would formally take on delegated primary care commissioning responsibilities from NHS England, rather than taking joint responsibility with NHS England.

The PCJC agreed that further consideration be given to requesting delegated commissioning in North Central London. They felt there were potential benefits that needed further exploration, as well as recognition that this is a national direction of travel. The Chairs and Chief Officers of North Central London CCGs agreed to support further work on this.

A programme of work commenced to consider an application to move to delegated commissioning (application to be submitted in December 2016) which included a programme of engagement with a variety of key stakeholders, including GP practice members and other partners. 2. Context Since moving to primary care joint commissioning arrangements with NHS England, the CCGs in North Central London have experienced greater involvement and transparency around primary care contracting decisions. For example, CCGs have been involved in contracting discussions at an earlier stage and this has enabled local knowledge to be used to inform the decision making process and to provide support to practices more quickly. Building on existing joint commissioning arrangements by moving to delegated commissioning of primary care is seen as the direction of travel for all CCGs across London and Nationally. The NHS Five Year Forward View signals a clear and continued shift towards commissioning based on the specific needs of a local area and its patients. For NCL, for example, developing population-based contracts to deliver health outcomes for the local population is a key priority for ensuring that patients are provided with accessible care, proactive care and that they are supported to care for themselves. To do this, NCL will need to be able to commission services across all parts of the health system including primary care. Taking on delegated primary care commissioning functions would enable this. A move to full delegation would ensure that primary care contracting functions can align with the overall strategic direction of the Sustainability and Transformation Plan (STP) as per diagram 1 below. Without moving to full delegation, NCL CCGs would still be able to jointly commission primary care services and influence decision making, however they may not have the full autonomy required to make the whole system changes outlined in the NCL STP.

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Diagram1. Primary Care STP programme structure

3. Opportunities and Risks It is anticipated that moving to delegated primary care commissioning would open up a range of opportunities for Haringey, Islington, Barnet and Enfield CCGs:

• 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 more quickly;

• We would be uniquely placed to take a whole-system approach to commissioning, bringing about the necessary shifts in secondary care utilisation described in the NCL STP;

• 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 Health watch representatives and with local communities to ensure local people are engaged in transforming services in their local area;

• We would be able to forge a collaborative approach to working with CCG constituents 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 design local incentive schemes which align to our NCL STP. 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 work together more effectively across NCL to 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 value based commissioning 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;

• We would be able to more effectively share best practice across NCL; • We would be able to offer greater transparency around decision making.

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Appendix 4.6

However, alongside the opportunities for transformation and improving the quality of primary care through greater alignment of primary care commissioning with the CCG commissioning portfolio for community services, mental health and hospital services, there are some key risks and issues to consider:

Area Identified Risk Mitigation / Comment Resourcing The existing primary care

contracting service provided by NHS England (London region) is already stretched. If NCL CCGs were to deliver a primary care contracting service over and above what is currently provided it will require investment in to the staffing of the team.

There may be opportunities to realise greater efficiency in the way in which the current contracting team operate. NHS England is currently carrying out an organisational review of the primary care contracting function. It is anticipated that CCGs will be allocated a share of existing NHS England staff at NCL level. It is acknowledged that to realise the ambition of the STP the CCGs will likely need to invest resource to ensure we are better able to proactively support improvements in primary care services in NCL. There may be external funding streams to support this such as NHS England’s practice resilience fund and wider STP funding.

Primary Care Budget

No additional funding (over the core primary care budget) will be available to implement improvements in primary care and CCGs would assume responsibility for budgetary pressures, deriving from commissioning primary care, including Quality, Innovation, Productivity and Prevention (QIPP) efficiency savings. CCGs 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. Where financial risks are identified, CCGs 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 ensuring out of area clinician(s) are available in circumstances where NCL CCG clinicians are conflicted and by supporting transparency and benchmarking in decision making as CCGs will make decisions in front of each other. NHS England published new conflicts of interest guidance for CCGs in June 2016 including specific recommendations for primary care commissioning committees. These are being incorporated into the NCL Conflicts of Interest Policy.

There may be a perceived CCGs already have a statutory duty to support

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Area Identified Risk Mitigation / Comment tension between CCGs operating as member organisations performance managing members.

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 by a team employed by NHS England working across North Central London, as is currently the case.

4. Roles and responsibilities The functions identified under each level of Co-Commissioning are identified in table 1 below: Table1. Functions under different levels of Co-Commissioning

Source: NHS England, Next steps towards primary care co-commissioning, November 2014

Under delegated commissioning, operational delivery of the activities related to delegated commissioning remain with the staff currently delivering the function. However, NHS England delegates the responsibilities and accountabilities to CCGs via the delegation agreement which CCGs will need to sign as part of submitting an expression of interest in December 2016 to become delegated commissioners. As delegated commissioners, CCGs carry out their responsibilities via a Primary Care Commissioning Committee established to oversee the function and make all key decisions. See diagram 2 below.

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Appendix 4.6

Diagram 2. Delegated Commissioning roles and responsibilities

4.1. Under level 3 co-commissioning arrangements, CCGs have responsibility for: • Commissioning, procurement and management of Primary Medical Services Contracts

(Enhanced Services, Local Incentive Schemes, decisions to establish new GP practices 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;

• Approval of practice mergers; • Planning primary medical care services including carrying out needs assessments; • Undertaking reviews of primary medical care services; • 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);

• Management of the Delegated Fund Premises Costs Directions functions; • Co-ordinating a common approach to the commissioning of primary care services with

other commissioners in the Area where appropriate; • Such other ancillary activities as are necessary in order to exercise the Delegated

Functions.

4.2. Under level 3 co-commissioning arrangements, NHS England retain responsibility for:

• Management of the national performers list; • Management of the revalidation and appraisal process; • Administration of payments in circumstances where a performer is suspended and related

performers list management activities; • Capital Expenditure functions; • Section 7A functions under the NHS Act (public health functions);

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• Functions in relation to complaints management; • Decisions in relation to the Prime Minister’s Challenge Fund; • Such other ancillary activities that are necessary in order to exercise the Reserved Functions; 5. Governance This section of the report provides a summary of the work of the governance work stream who have prepared information and documentation should the Governing Body accept the recommendation to submit an expression of interest to become delegated commissioners. This governance work has been led by the governance lead from Camden CCG in conjunction with advice provided by all of the North Central London governance leads. It has been verified that none of the five CCGs in North Central London are required to amend their CCG constitution to become delegated commissioners. Therefore, the primary focus on the governance work stream has been to:

• Provide a critical review and recommendation of the most suitable governance structure for North Central London;

• Critically appraise and identify issues related to the documentation by which CCGs will sign up to when becoming delegated commissioners (delegation template and delegation agreement template);

• Lead a review of the North Central London Conflicts of Interest guidance and make the necessary changes to adhere to national policy; and to

• Provide all supporting documents which allow the CCGs in NCL to become delegated commissioners (Terms of Reference, Information Governance Toolkit etc.).

5.1. Governance structure The governance work stream has reviewed a number of governance options before recommending the preferred choice of committees-in-common. The committees-in-common structure enables each of the four CCGs to have its own primary care commissioning committee and therefore ensure local decision making, however the four CCG committees would meet at the same time and in the same place i.e. as ‘committees-in-common’. Each CCG would vote separately on any decisions, but by meeting in common, this structure will promote integrated working, information sharing and benchmarking, support management of conflicts of interest by creating more transparency and supporting non-conflicted clinical input and helping to identify areas for collaborative working. How Camden CCG collaborates with the other four CCGs whilst remaining as Joint Commissioners is unclear at this stage. Following November Governing Body meetings further work will be carried out to finalise arrangements before submitting an expression of interest in December. 5.2. Conflicts of Interest Policy The Conflicts of Interest Policy for NCL has been updated and will be presented to November 2016 Governing Body meetings, see table 2 below which outlines the key changes specifically relating to Primary Care Commissioning Committees.

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Appendix 4.6

Table 2. NCL Conflicts of Interest Policy Changes

6. Feedback from stakeholder engagement Engagement activities have been carried out throughout the period from May to August 2016. The engagement period provided an opportunity for stakeholders to share their views and identify those areas where further information will be required through the due diligence process. Table 3 below summarises the feedback received by each CCG area. Table 3. Summary CCG feedback for delegated commissioning

CCG Summary feedback received Islington Islington clinicians were positive towards a move to delegated commissioning.

Clinicians noted the benefit of having greater control of primary care contracting and the ability to bring about shifts from secondary to primary care. Healthwatch were also supportive, albeit asked that great care and thought be given to the relationship between the CCG and practices and the need for transparency and management of conflicts of interest. The LMC felt that they needed more information to inform their feedback, however their initial feedback suggested concerns regarding the resource/ capacity to deliver the function.

Barnet Information shared with stakeholders, no specific concerns or feedback raised by GP practices, or the Scrutiny Committee. The LMC and practice managers’ forum expressed the need to ensure there is enough resource/ capacity to deliver the function. The last meeting of the GB members were interested to better understand the rationale for choosing the Committee in Common governance structure.

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Enfield

Enfield’s LMC and Locality events both felt strongly that the Primary Care Commissioning Committee needed to not lose the Enfield voice in discussions about improving primary care. The practice managers and nurses forums welcomed the changes, however flagged the need to ensure there is enough resource/ capacity to deliver the function.

Haringey Similar to other areas, concerns focused on the resource/ capacity to deliver the function. Haringey practices and practice staff welcomed the opportunity to gain greater control, particularly over the primary care budget. As with Enfield, there was a concern that Haringey needed not to lose its voice in discussions about primary care across NCL. The LMC discussion noted the benefit of greater local autonomy, however flagged a concern with any pooling or spreading of funds originally allocated for Haringey CCG.

See Appendix A for more detailed information on frequently asked questions and feedback provided by stakeholders.

6.1. Outcome of CCG votes As is mentioned earlier in the report, in two of the five CCGs in North Central London, a membership vote has taken place. In Haringey the vote concluded that the CCG should take part in delegated commissioning. In Camden the ballot opened on 21st July 2016 and was extended (beyond its original cut-off date of 25th August 2016). Of thirty five practices in Camden, thirty three practices took part in the ballot. Twenty four practices voted yes and a single practice voted no. Therefore, as members in favour of Level three – delegated commissioning did not reach 75% of responses received, the CCG will remain as Level two Joint Commissioners with NHS England. Camden CCG will continue to work with member practices and the other four CCGs in NCL on a proposed way forward.

7. Next steps Should the Governing Body accept the recommendation to move to Level three – delegated commissioning the programme team will:

• Identify the governance approach which allows collaboration between the level three delegated commissioning CCGs and Camden CCG;

• Conclude due diligence activities; • Develop an application pack, which will highlight any outstanding issues for resolution, for

submission in December 2016; • Work alongside NHS England to ensure that staffs aligning from NHS England are inducted

by North Central London prior to April 2017; • The programme team will work alongside the primary care contracting organisational

development review team to ensure processes which transfer to North Central London are documented and are as efficient as possible within the resources available;

• Work towards mobilising the Primary Care Commissioning Committee, which will mean the recruitment to key posts on the Committee-in-Common.

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Summary of Stakeholder Feedback & Frequently Asked Questions relating to NCL Primary Care Co-Commissioning

Options for Delegated Authority

May – August 2016

Barnet Clinical Commissioning Group

Camden Clinical Commissioning Group

Enfield Clinical Commissioning Group

Haringey Clinical Commissioning Group

Islington Clinical Commissioning Group

Appendix 4.6.1

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Apr 20164 11 18 25

May 20162 9 16 23 30

Jun 20166 13 20 27

Jul 20164 11 18 25

Aug 20161 8 15 22 29

Sep 20165 12 19 26

Oct 20163 10 17 24 31

Barnet

Camden

Enfield

Haringey

Islington

KeyHealth & Wellbeing BoardGP Practice eventsHealthwatchScrutiny CommitteeProvider Transformation BoardPublic ForumsCollaborative meetings

Other stakeholder meetings:LMCCCG Primary Care Strategy BoardCCG Strategy & Finance GroupPractice Manager/ Nurse ForumGoverning BodyGeneral / NCL wide meetingsCCG Executive / Staff

21 1227

6

4

?

5 7 872010 1 6 717

1418

13 14

14

1615

2121

151816

26 30 28 25

13

13151617

21

22 11

11

11

1520

29

29

14

1230

21

30

5

1310

2119

28

21

151720

21

2

2822

1214

1814

18

1115

Membership vote

14

22

Summary of NCL primary care co-commissioning engagement activities

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Health and Wellbeing Board

Practices,Practice staff and

Constituents

Public Forums Healthwatch Scrutiny Committee*

LMC

Barnet

Camden

Enfield

Haringey

Islington

*The Scrutiny Committee meetings for Barnet & Enfield CCGs take place after the September CCG Governing Body meetings.

Key stakeholder engagement

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Constituents

Public Forums Healthwatch Scrutiny Committee

LMC

Supported application.

Keen that patients are kept advised of the impact of moving to level 3

Practice Managers Forum were supportive of delegation, only concerned about NCL/CCG’s ability to manage the additional workload.

The CCG has not received any feedback/questions from individual GP practices.

Barnet GB meeting –expressed concerns relating to the governance structure and that only1 Option was being considered. Would like examples of how level 2 has improved the commissioning of primary care services.

Sharingengagement pack with their patient forum.

Email sent waitingfor a response

Concerns around CCG’s ability to manage additional workload, and proposed governance structure.

Key stakeholder feedback: Barnet CCG

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Practices,Practice staff

and Constituents


LMC

No specific feedback.

Questions from members have focused on how we would manage conflicts of interest and what our approach to performance managing practices would be.

No major concerns expressed. Questions asked about financial and staff resourcing impacts of delegation on CCG.

No specific feedback but present for Governing Body and patient engagement group discussions.

Interested in exploring risks at strategic and operational levels and how they may be mitigated.

Expressed concerns about level of detail available to members to inform their decision and the length of the ballot period.

Key stakeholder feedback: Camden CCG

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Practices, Practice staff and Constituents

Public Forums

Healthwatch Scrutiny Committee

LMC

Feedback from the Health & Wellbeing Board meeting on 12/07/16 noted the direction of travel

Feedback from the Practice Managers’ Forum 18/07/16 welcomed the closer relationship between the practice and contract holder, but had some concerns about whether sufficient resources were identified to deliver this.

Feedback from the Practice Nurses’ Forum 14/07/16 hoped for improvement of services based on local priorities;

Feedback from the 4 locality practice meetings included the above and the need to ensure that Enfield’s priorities were understood/addressed across NCL.

Feedback from the PPE event 20/07/16 noted the proposal.

Aware of the general direction of travel and context from its representation on other groups (Governing Body, etc). Scrutiny Committee –direction of travel noted

Not meeting until September 2016.

Feedback from LMC meeting 09/06/2016 raisedthe concern of a local Enfield voice being further diluted within a wider STP.

Key stakeholder feedback: Enfield CCG

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Practices,Practice staff

and Constituents


LMC

Yet to have meeting

Generallypositive, feel like it will happen anyway. Think having more local autonomy good and greater transparency over the money. Concerns about:Performance management –GPs knowing about concerns re another practice, financial transparency and ring fencing of money – across boroughs and with other CCG monies. Also some concern whether there will be enough money.

No significant feedback

Haringey Healthwatch Board is considering the proposal at their meeting on 15th September 2016.

No concerns about this, consider it positive that Haringey gets to influence decision making more easily.

Concern over whether funds would be spread across boroughs and that if this occurs it should be clear that some boroughs started in a much better position than others. Query about whether this would lead to greater autonomy (which was considered positive) or greater top down control which limits making local decisions that are best for the local population.

Key stakeholder feedback: Haringey CCG

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Constituents


LMC

No feedback received (deadline 12th August).

Feedback from clinical leads: If this is the direction of travel then better not to be behind. Potential for more joined up work across NCL. It will be good to bring primary care contracting closer. Could be an opportunity to move money from secondary to primary care. Concerns about being able to do the job within the budget.

No public forums visited (althoughhave put Governing Body feedback here):

Sought assurance that the CCG would be able to support practices on the ground, that there would be equity of service and asked for clarity on how this would impact practices specifically.

Visiting Healthwatchevening of 16th

August.

Support for general direction of travel. Felt that more thought was needed on relationship between practices and the CCG.Important that governance structure manages conflicts of interest without being bureaucratic. Need to ensure we secure primary care contract skills and knowledgeresource to manage contracts well.

Visiting Scrutiny5th Sept

Felt that engagement pack did not identify risks or challengesand not enough information about implications of not moving to delegated authority. Concern about workload to CCG and loss of local decision making. Also felt dealing with local performance issues could be difficult. Queried how this links to wider STP collaboration. Felt there may not be enough control of budgets.

Key stakeholder feedback: Islington CCG

8234 of 344

Summary of questions from the NCL Local Medical Committees (LMC)

1. Level Three clearly direction of travel; if not a real choice should we be having an open conversation about making Level Three work, rather than calling this an options appraisal.2. Concern re NHS E handing over deficits to CCGs as part of delegating functions.3. Concern that NHS E can change the rules, and delegate further functions.4. CCGS are already stretched, people and budgets; expecting them to take on significant additional functions is unrealistic, and will impact on current workload/staff.5. Likely that limited numbers of staff, with no additional funding, will be transferred from NHS E to CCGs.6. Concern that as CCGs work at NCL level as is the clear direction, individual CCG ability to prioritise, make local decisions, and autonomy will be removed.7. Timescale and process (i.e. lack of a membership vote) for decision making does not support sufficient consultation.8. Not enough information for members to make informed decision, and/or to discuss issues.9. Concern re role of over-arching NCL Joint Committee.10. Consultation pack is strong on benefits, with very limited coverage of risks.11. Message based on assumed Level Three benefits; doesn’t reflect real position in existing level Three CCGs where little has been achieved; it’s rhetoric rather than reality.12. Concern re risk sharing and budgets being used across NCL to bail out CCGs in deficit.13. Concern re CCGs moving money from Primary Care to other budgets.14. Concern about CCGs involved in detailed contract management/performance management.15. Impact of STP and new governance structures largely ignored.16. Changes to CCG constitutions need to be discussed with CCG members; not included in process.

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Frequently Asked Questions (1 of 3)

10

# Question Answer

1What happens if our members vote ‘no’ to the move to delegated commissioning?

We would expect the other CCGs to continue as per local decisions to do so.

2What are the implications for CCG categorised as ‘under directions’ (i.e. Enfield)?

Being under directions does not prohibit a CCG from becoming level 3 Delegated commissioners.

3 Where will the resource come from? Resources to support delegated commissioning will migrate from the existing NHS England Contracting Team on a fair shares basis with the rest of London.

4 Will we have more control over our primary care budgets?

Yes, we will make all decisions regarding the budget where there is budgetary discretion.

5Why is the proposed governance structure to have a 'committee in common'?

This structure enables each CCG to have its own primary care committee and therefore control over local decision making, however the 4 CCG committees would meet at the same time and in the same place i.e. as a ‘committee in common’. Each CCG would vote separately on any decisions, but by meeting in common, this structure will promote information sharing and benchmarking across NCL, support management of conflicts of interest by creating more transparency and supporting non-conflicted clinical input and helping to identify areas for collaborative working. This approach would be very similar to how the current primary care Joint Committee functions.

6

How would CCGs deal with local performance issues between the CCG and contractors under delegated commissioning?

The current process will remain, where by the staff at NHS England manage performance issues, the CCG will not intervene in this as performance management is determined based on performance against contracts already in place.

7 Will CCGs be able to make decisions locally? Yes, this will be possible under the Committee in Common governance model proposed

These frequently asked questions have been collated throughout the CCG engagement activities. The questions are not listed in any particular order other than that in which they were received. In some cases there is an element of duplication where stakeholders asked similar questions.

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11

# Question Answer

8 What would happen if 1 CCG voted out and the rest voted in?

We would expect the other CCGs to continue as per local decisions to do so.

9 When will the due diligence on the finance be complete?

We have received information from NHS England, contained in the Co-Commissioning Governing Body report for November 2016 and would expect this to be complete by December 2016.

10 It is vital that there is transparency around the process of who is making decisions about what.

CCGs will be responsible for making decisions relating to individual CCG issues. The proposed Primary Care Committee will meet in public and minutes will be available on CCG websites. Decisions that are made under part 2 of the meeting will be documented and shared with CCG representatives.

11 Will Primary Care monies be ring fenced from other CCG monies? How will you assure that? CCGs would have to spend primary care monies on primary care services.

12 Would NCL would have sufficient staff to manage the increased workload?

Resources to support delegated commissioning will migrate from the existing NHS England Contracting Team on a fair shares basis with the rest of London.

13Would current funding spent on GMS/PMS practices be ring fenced when moved to CCG and not used for secondary care or overspends?

CCGs would have to spend primary care monies on primary care services. There is no intention to pool budgets between CCGs or other portfolio areas

14Who will be responsible for performance management under level 3 - will this be someone independent of the CCG's clinical commissioners?

The current process will remain, where by the medical directorate staff at NHS England manage individual practitioner performance issues.

15

How will the GP member on the primary care committee be selected - will this automatically be members of the Governing Body? Or can this representative be voted in by the membership?

It is expected that each CCG will decide how GP representatives on the Primary Care Committee will be nominated.

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12

# Question Answer

16 Will CCGs hold the contracts with practices or will it continue to sit with NHSE?

From a legal perspective the contract is between NHSE (NCB) and the practice.

17How could a level 3 Committee be responsible for IT & Estates but not for capital expenditure? Could this be negotiated?

NHS England have indicated that these responsibilities only relate to management and administration as required in executing the delegated functions.

18 How are complaints managed at level 3? There is no change to how complaints are managed.

19 Are there currently plans for delegating ophthalmology, pharmacy and dentistry?

No plans currently but there is potential for further involvement by level 3 CCGs.

20 What resources will follow level 3 delegation? Existing staff will be assigned to SPGs on a fair shares basis.

21 How would we ensure resource to do delegation well?

Existing staff will be assigned to SPGs on a fair shares basis and an assessment will be made of any gaps in staffing as part of the NHS England Primary Care OD review

22 Would we need to consider a dedicated team across NCL?

The form of the team to support delegated commissioning has not as yet been determined and will be discussed as part of the NHS England OD review.

23 How would conflicts of interest be managed?

NCL CCGs have a conflicts of interest policy in place which was approved by all NCL CCG Governing Bodies. In June 2016 NHS England published revised guidance on managing conflicts of interest. This includes guidance specifically aimed towards primary care commissioning committees. The NCL conflicts of interest policy has been updated to reflect this revised guidance and will be presented to November 2016 GB meetings

24

What learning is there from other areas already at level 3? e.g. committee structure, primary care resourcing, e.g. to be able to develop better quality reports.

The steering group overseeing the potential move to level 3 delegated commissioning has reviewed lessons learned and has incorporated the learning in to the governance approach being proposed as part of NCL engagement activities.

25 What are other level 2 CCGs are thinking of doing?

CCGs across London are being encouraged to take on greater powers for Co-Commissioning, this includes the remaining level 2 CCGs in South East London and North West London.

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Appendix 4.6.2

APPENDIX B – OUTLINE DUE DILIGENCE INFORMATION DATE: 14th October 2016 TITLE: Primary Care Co-Commissioning – Due Diligence LEAD COMMITTEE MEMBER:

Ahmet Koray, Chief Finance Officer (Islington CCG)

AUTHOR: Daniel Morgan, Primary Care Lead

SUMMARY: This report provides due diligence information on Primary Care Commissioning. The objective of this due diligence exercise has been to gain greater clarity on the contractual and financial risks associated with primary care contracts. It is important to note that NHS England and the CCGs have for 2016/17, and will continue to, work collaboratively together. Whilst it is acknowledged there are challenges associated with the current Primary Care Commissioning model, both parties are committed to working through any new challenges or unexpected situations together. NHS England also commissioned an Organisation Development review in early 2016 to look at how the Primary Care Commissioning function operates in London, and to provide options for how this can be improved for staff and other stakeholders, as well as what the model might look like in the future. The CCGs in North Central London (NCL) are working with NHS England to align staff to NCL, with an expectation that staff will align from the start of 2017/18. Should the four CCGs decide to become delegated commissioners for Primary Care, the CCGs will have delegated budgets and decision making powers for Primary Medical Services commissioning, therefore NHS England will act to support, rather than participate in, matters of day to day Primary Care Commissioning.

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Appendix 4.6.2

1. Summary 2016/17 financial position

1.1. An annual plan has been set across NCL across the four categories of expenditure as follows:

2016/17

Plan

£’000

Personal Medical Services (PMS) 90,670

General Medical Services (GMS) 88,340

Alternative Provider Medical Services (APMS 7,806

Other Medical Services 104

Total Primary Care Medical Services 186,921

1.2. The £186,921k plan includes a QIPP target of £939k. Separately set aside is also the 1% non-recurrent reserve (£1,909k) and 0.5% contingency (£955k). The reserve and contingency have been funded through the allocation balance that is available to NCL. In summary, the allocation across NCL has been applied as follows:

2016/17

£’000

NCL CCG allocation (as notified) 190,918

Expenditure Plans:

Primary medical services plan (as above and including QIPP) 186,921 1% Non-recurrent reserve 1,909 0.5% Contingency 955

Total expenditure plan 189,784

Surplus against allocation 1,134

1.3. At month 5, the period to 31 August 2016, the overall financial position for North

Central London Primary Medical services is reporting an under-spend of £96k against plan. The full-year forecast is consistent and there is expected to be £256k underspend by 31 March 2017.

1.4. The most significant variance within the position is the difference between the QIPP

values and the beneficial impact from the reversal of 2015/16 accruals that are no longer considered necessary. This difference between QIPP and accrual reversals is the reason why both the year-to-date and forecast positions are underspent.

1.5. A risk to note is that the 2016/17 plan has been set with a QIPP target that is

being achieved through non-recurrent measures. This may have implications on future planning if the QIPP requirement cannot be identified recurrently and potentially grows. Mitigation is currently available with the allocation surplus

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Appendix 4.6.2

(£1,134k as above) and the 1% non-recurrent reserve and 0.5% contingency, which would cover any gap in the short-term, but could not be considered a longer term solution.

2. 2016/17 NCL budget plans and performance

2.1. The average growth in London medical allocations for 2016/17 was 4.78%.

However this has not fallen evenly across CCGs due to their differing distance from target allocation assessments. Furthermore, the requirement to deliver a QIPP target as well as set aside the 1% non-recurrent reserve and 0.5% contingency, has meant that financial plans across NCL CCG’s is very different with a range that includes Islington CCG with a significant surplus, two CCGs with deficits and the remaining two with break-even plans.

£'000 NCL Barnet Camden Enfield Haringey Islington 2016/17 CCG allocations 190,918 46,640 35,897 39,126 37,568 31,687 Expenditure plans: Primary medical service plans 186,921 45,846 35,955 38,760 36,983 29,377 1% Non-recurrent reserve 1,909 466 359 391 376 317 0.5% Contingency 955 233 179 196 188 158 Total expenditure plan 189,784 46,546 36,493 39,347 37,546 29,852 Surplus / (Deficit) 1,134 94 (596) (221) 22 1,835

2.2. For the purposes of monthly reporting, NHSE uses budget plans that reflect

contractual commitments along with an assessment of costs that are likely to materialise over and above these. Therefore allocation values, reserves and contingencies are excluded for monthly reporting purposes.

2.3. Future NCL co-commissioning arrangements will require budgetary information to

reflect all items and as a result, the NCL position will immediately improve (depending on the value of QIPP) by the value of the net surplus, which for 2016/17 is £1,134k.

2.4. Expenditure summaries for the first five months of 2016/17 (to 31 August 2016) are

set out in the six tables below. After each CCG, a brief narrative is provided of performance issues:

Table 1 - NCL Total Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 90,670 37,778 37,739 (39) 90,571 (99) (0.1)%

87,314

GMS 88,340 36,806 36,739 (67) 88,169 (170) (0.2)%

86,612 APMS 7,806 3,252 3,221 (31) 7,729 (77) (1.0)%

5,760

Other 104 43 84 41 195 91 87%

168

NCL Total 186,921 77,879 77,783 (96) 186,665 (256) (0.1)%

179,854 (Brackets denote underspend)

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Appendix 4.6.2

Table 2 - Barnet CCG

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 21,857 9,107 9,078 (29) 21,787 (69) (0.3)%

21,222

GMS 23,660 9,858 9,823 (34) 23,528 (132) (0.6)%

22,904 APMS 297 124 132 8 303 6 2%

505

Other 32 13 19 6 48 16 49%

82

Total Barnet 45,846 19,101 19,052 (50) 45,666 (180) (0.4)%

44,713

2.5. Barnet - five months results to 31 August are showing an underspend of £50k (-

0.3%), which comprises the net benefit of unidentified QIPP (£96k) offset by the non-recurrent benefit from 2015/16 accruals (£157k). Refunds in relation to prior year business rates are expected to contribute towards the QIPP savings target later in the year.

2.6. The £180k forecast year end underspend includes the non-recurrent benefit of prior

year accruals (£376k).

2.7. Barnet’s weighted population has increased by 2% from April 2015 to April 2016. In absolute terms, this equates to an increase of 7,306 in its normalised weighted population. For the 2016/17, growth rates are currently 1% (3,743 weighted population).

Table 3 - Camden CCG

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 19,490 8,120 8,147 27 19,544 55 0%

19,069

GMS 13,492 5,621 5,650 28 13,617 125 1%

13,245 APMS 2,958 1,233 1,222 (11) 2,940 (19) (0.6)%

2,392

Other 15 6 33 27 52 37 247%

9

Total Camden 35,955 14,981 15,052 71 36,153 198 1%

34,716

2.8. Camden is overspent by £71k (0.5%) for the first five months of 2016/17. This is

almost entirely a result of premises related cost pressures and whilst some saving is expected from a revaluation exercise, this is unlikely to cover the underlying cost pressure.

2.9. Camden’s weighted population has grown by 3.1% from April 2015 to April 2016.

However, there has been a year to date reduction of -0.5% (1,268 weighted population) for the period to 1 July 2016.

Table 4 - Enfield CCG

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 25,315 10,548 10,508 (39) 25,223 (93) (0.4)%

24,522

GMS 11,523 4,801 4,757 (44) 11,411 (112) (1.0)%

11,529 APMS 1,900 792 795 4 1,898 (2) (0.1)%

1,026

Other 22 9 13 4 36 14 64%

10

Total Enfield 38,760 16,149 16,074 (75) 38,568 (192) (0.5)%

37,087

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Appendix 4.6.2

2.10. Five months results show an underspend of £75k (-0.5%), due in part to a GMS practice closure and the costs no longer being incurred. The remaining benefit is the net effect of QIPP (£81k) and 2015/16 accrual reversals (£140k). The forecast includes the extrapolated values for these items, i.e. practice closure budget released (£65k) and prior year accruals (£336k).

2.11. Enfield’s weighted population has increased by 1.9% (5,528) from April 2015

to April 2016. 2016/17 year-to-date growth currently stands at 0.4% (1,185 weighted population).

Table 5 - Haringey CCG

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 22,649 9,437 9,432 (5) 22,638 (11) 0%

21,150

GMS 13,236 5,515 5,496 (18) 13,179 (56) (0.4)%

13,114 APMS 1,078 449 418 (32) 1,018 (61) (5.6)%

689

Other 20 8 11 3 33 13 65%

44

Total Haringey 36,983 15,409 15,357 (51) 36,868 (115) (0.3)%

34,997

2.12. The delayed start of an APMS practice and the closure of another (GMS) are

the main contributory factors in reported £51k underspend. The QIPP and 2015/16 accrual release virtually balance themselves although the net benefit increases to £17k in the forecast. The balance of the full year forecast underspend (£115k) relates to the APMS and GMS practice changes.

2.13. Haringey’s weighted population has seen the largest increase across NCL,

with growth of 3.2% (7,254) from April 2015 to April 2016. This is expected to continue into 2016/17, where figures to date are already at 1.5% (4,295).

Table 6 - Islington CCG

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

2015/16 Outturn

£000's £000's £000's £000's £000's £000's %

£000's PMS 1,360 567 573 7 1,379 19 1%

1,351

GMS 26,429 11,012 11,013 1 26,434 5 0%

25,820 APMS 1,572 655 655 0 1,571 (1) (0.1)%

1,148

Other 15 6 7 1 26 11 73%

22

Total Islington 29,377 12,240 12,248 9 29,410 34 0%

28,341

2.14. Five months results are showing a breakeven position, managed through

2015/16 accrual reversals (£55k) offsetting QIPP (£62k). Unplanned PMS seniority payments (£7k to date and £19k for the year) are the only significant cost pressure.

2.15. Islington’s weighted population increased by 3% (7,254) from April 2015 to

April 2016, but has not shown the same level of growth in 2016/17. Current figures indicate an increase of 0.9% (2,250) for the period to 1 July 2016.

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Appendix 4.6.2

3. Summary capitation position

CCG

Normalised weighted list as at

01/04/2015


01/04/2016

Year on Year %

Movement


01/07/2016

YTD Movement

(to 01/07/16)

% YTD Movement

Barnet 362,566 369,872 2.00% 371,857 3,743 1.00% Camden 259,074 266,994 3.10% 266,701 (1,268) (0.50)%

Enfield 295,562 301,090 1.90% 300,661 1,185 0.40% Haringey 284,076 293,292 3.20% 294,768 4,295 1.50% Islington 244,719 251,973 3.00% 253,046 2,250 0.90%

Total NCL 1,445,997 1,483,221 2.60% 1,487,032 10,206 0.70%

3.1. The capitation table above captures the growth in list sizes from April 2015 to April

2016. There is variation across CCGs ranging from a 1.9% increase to 3.2%. On average, NCL as a whole has seen a 2.6% increase between April 2015 and April 2016. This however is not the case in 2016/17, where the increases are much forecast to be much lower at 0.7%, with Camden retracting by 0.5%.

3.2. The implications of this are on funding formulas and allocation of growth in future

years and the impact this will have on any future QIPP requirements. A savings programme will need to be developed to ensure that a robust recurrent position can be maintaining going forward.

4. Feedback from NHS England on known risks and issues to consider

4.1. NHS England has provided information as part of the NCL CCGs due diligence exercise for Primary Care Commissioning. There is a very limited financial and contractual risk identified by NHS England for North Central London. The current position on specific areas is set out below.

4.2. Contracts under caretaking arrangements - Haringey CCG have two contracts

under caretaking arrangements. Both contracts end in spring 2017. Camden CCG have a caretaking arrangements for one practice which also ends in spring 2017

4.3. Zero list contracts - There is one identified zero list contract for NCL in Barnet. The

CCG are aware of the population profile estimates for the practice which have been reported by NHS England and shared with the CCG

4.4. Locum payments disputes - There are no known legal disputes to report in regard

to locum payments.

4.5. Contract disputes - There are no legal claims to report in regard to contract disputes

4.6. Estates and Technology Transformation Fund (ETTF) - ETTF information will

follow post December 2016. ETTF schemes will require CCG agreement of the revenue consequences before being approved for the pipeline. CCGs are expected to have undertaken their own due diligence exercise on ETTF schemes. ETTF costs

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Appendix 4.6.2

will be a call on the CCG primary care medical allocations in future years, so this needs to be considered carefully.

4.7. Rent reviews - rent review liabilities relate to over-due reviews that may result in

historic premises payment adjustments and costs. NHS England will confirm in writing that they will meet these historic costs up to the point of full delegation. NHS England will review this arrangement at the end of 2016/17 following any updated information from the District Valuer.

5. General assurances on financial liabilities

• NHS England and the CCGs have for 2016/17, and will continue to, work collaboratively together. Whilst it is acknowledged there are challenges associated with the current Primary Care Commissioning model, both parties are committed to working through any new challenges or unexpected situations together;

• Where appropriate NHS England will ensure sufficient provisions are made in 2016/17 to cover the financial risks of liabilities that the CCGs may incur that have not been planned or provided for in previous periods;

• NHS England will accrue all known and expected pre April 2017 costs relating to rent reviews and aim to identify as accurately as possible through District Valuer reviews. Such pre-April 2017 rent costs will be charged back to NHS England by the CCG;

• Quality Outcomes Framework (QOF) and extended access payments will be provided for by NHS England as part of year end payments.

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MEETING: Islington Clinical Commissioning Group Governing Body Meeting DATE: 9th November 2016 TITLE: North Central London (NCL)

Conflicts of Interest Policy LEAD GOVERNING BODY MEMBER:

Melanie Rogers, Director of Quality and Integrated Governance

AUTHOR: Karl Thompson, Head of Corporate Affairs CONTACT DETAILS:

[email protected]

SUMMARY: In June 2016, NHS England published revised statutory guidance on managing conflicts of interest for CCGs. The guidance was strengthened to improve conflicts of interest management across the NHS and to increase public confidence in the propriety of decision-making. The revised guidance introduced a number of key changes which are:

• Introduction of more stringent requirements to the management of conflicts of interest in all areas of the CCG’s business and procurement cycle;

• Greater openness and scrutiny of declarations of interest with all staff having to agree a plan for managing any of their conflicts of interest with their manager;

• Greater scrutiny by NHS England with new compliance requirements with the NHS England CCG Assurance Framework;

• The recommendation for CCGs to have a minimum of three lay members on the Governing Body in order to support conflicts of interest management with an additional recommendation of adding a fourth;

• The introduction of a conflicts of interest guardian in CCGs with a recommendation that CCG audit chairs undertake this role;

• The requirement for CCGs to include a robust process within their conflict of interest policy for managing any breaches and for anonymised details of any breach to be published on the CCG’s website for learning and development purposes;

• Strengthened provisions around decision-making when a member of the Governing Body, or a committee or sub-committee is conflicted;

• Strengthened provisions around the management of gifts and hospitality, including the need for a publicly accessible register of gifts and hospitality;

• A requirement for CCGs to include an annual audit of conflicts of interest management within their internal audit plans and to include the findings of this audit within their annual end-of-year governance statement;

• A requirement for all CCG employees, Governing Body and committee members and practice staff within involvement in CCG business to complete mandatory online conflicts of interest training which will be provided by NHS England.

It should be noted that Islington CCG have not yet decided if they will opt for a third lay member given the amount of change currently underway in respect to NCL collaborative arrangements and that this will be further discussed in early 2017. To ensure compliance with the revised guidance a simple action plan is being developed to

Item: 5.1

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ensure we implement the required changes. One of the key actions is to update the generic North Central London (NCL) Conflicts of Interest Policy which was approved by the Governing Body in May 2015. The policy has been revised in the light of the new statutory guidance in agreement by the NCL Governance Leads Working Group. The policy was considered by the NCL Governance Leads Working Group in September 2016 from which a final agreed draft was circulated to the Working Group members on 21 October for consideration and approval. The approval of the attached policy is one of the required steps in the submission of the expression of interest in December 2016 to become Level Three delegated commissioners of primary care from Barnet, Enfield, Haringey and Islington CCGs. The Governing Body is asked to approve the revised NCL Conflicts of Interest Policy which mirrors the statutory guidance. The policy will be shared with our internal auditors but it is anticipated that further changes will be minimal. Subject to Governing Body approval, we will inform NHS England of the approved policy and implementation of the conflicts of interest action plan. This report contributes to:

• Ensuring every child has the best start in life, • Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities, • Improving mental health and wellbeing, and • Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: The new statutory guidance was considered by the Executive Team in August 2016 and by the Audit Committee in September 2016. Patient & Public Involvement (PPI): NHS England conducted a consultation period before the revised guidance was finalised. As part of this the five North Central London CCGs submitted a joint response. Equality Impact Assessment: The Equality Impact Analysis identified no adverse equality issues. Risks: Failure to adopt the guidance could potentially impact on Islington CCG’s ability to adequately manage perceived and actual conflicts of interests in the event of co-commissioning services with other CCGs in the NCL Cluster. RECOMMENDED ACTION:

The Governing Body is asked to note the changes to the NHS England statutory guidance and to APPROVE the revised North Central London Conflicts of Interest Policy. In the event of further material changes to the policy, the Governing Body is asked to DELEGATE responsibility to the Audit Committee for final approval.

SUPPORTING PAPERS: • Appendix 5.1.1 - Revised Conflicts of Interest Policy

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1

Appendix – 5.1.1

Draft NHS NORTH CENTRAL LONDON CLINICAL COMMISSIONING GROUPS’ CONFLICT OF INTEREST POLICY

Policy updated to take into account NHS England’s revised statutory guidance for CCG’s on the management of conflicts of interests published June 2016.

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2

V3 TL 31/10/2016

Contents

1 Introduction

2 Scope

3 Purpose

4 Roles and Responsibilities

5 Definition of a Conflict of Interest

6 Register of Interests

7 Managing and Declaring Interests

8 Designing Services and Conflicts of Interest

9 General Guidance

10 Breaches of this policy

11 Criminal Implications

12 Related Documents

13 Dissemination

14 Advice

15 Review

Appendices

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3

1. Introduction

Managing conflicts of interest appropriately is essential for protecting the integrity of NHS North Central London CCGs from perceptions of wrongdoing. The CCG must meet the highest level of transparency to demonstrate that conflicts of interest are managed in a way that does not undermine the probity and accountability of the CCG.

This policy sets out how the CCG will identify, manage and record any potential or actual conflicts of interests that may arise as part of the commissioning of healthcare for [local authority area].

This policy is issued in accordance with statutory guidance under Sections 14O and 14Z8 of the National Health Service Act 2006 (as amended by the Health and Social care Act 2012). The act sets out clear requirements for CCGs to make arrangements for managing actual and potential conflicts of interests, to ensure they do not affect, or appear to affect, the integrity of the CCGs decision making processes. These requirements are supplemented by procurement-specific requirements in the National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013.

This policy was adopted in August 2015 and has now been updated to take into account NHS England’s statutory guidance on the management of conflicts of interest published in June 2016.

CCG policies set out the organisation’s standards and intentions, and are written with the aim of being as clear and comprehensive as possible. However, we operate in a dynamic and evolving work environment and attention should be paid to the spirit of the policy as well as the letter. Policies by themselves cannot guarantee effective behaviour or the delivery of key objectives. Therefore thought must be given to good practice when applying or interpreting any of the CCG’s policies, and you should read any guidance or supporting documentation that relates to this policy to help you do this.

This policy should be read in conjunction with the CCG’s Constitution, with particular reference to the following policies (or their equivalent(s)) Conflicts of Interest section, the Gifts, Hospitality and Sponsorship Policy, Whistleblowing, Anti-Fraud & Bribery Policy, Disciplinary Policy as well as the Equality & Diversity Policy. In addition NHS England has produced a number of summary guides for managing conflicts of interest, for various professional groups which are appended to this policy. This policy should also work in accordance with national and local guidance on child and adult safeguarding as applicable.

In the event of a conflict of interpretation between policies in the area of conflicts of interest the provisions of this policy shall prevail to the fullest extent applicable law and NHS guidance allows.

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2. Scope

This policy applies to all CCG members, staff (including students, trainees, agency staff, seconded staff and joint appointments), self-employed consultants, contractors, officers, and office holders.

It also applies to Governing Body members and members of its committees and sub committees (and attendees) including all groups relating to commissioning, contracting and procurement processes and where decision making is required by those members.

This includes

• Co-opted members; • Appointed deputies; and • Any members of committees/groups from other organisations.

Where the CCG is participating in a joint committee alongside other CCGs, any interests which are declared by the committee members should be recorded on the register(s) of interest of each participating CCG.

In addition this policy is applicable to all member practices of the CCG as listed in the CCG’s Constitution, and as far as possible the scope extends as far as is possible to all GP partners and any individual directly involved in the business of the CCG.

The CCG will ensure that North and East London Commissioning Support Unit (CSU) and other Contractors are aware of the contents of this policy if applicable.

Where an individual fails to comply with this policy disciplinary action may be taken in accordance with the CCG’s Disciplinary Policy. The CCG’s disciplinary policy is located on the staff intranet and on the CCG’s website.

3. Purpose

The aim of this policy is to protect both the organisation and individuals involved from impropriety or any appearance of impropriety by setting out how the CCG will manage conflicts of interest to ensure there is confidence in the commissioning decisions made and to ensure the integrity of the clinicians involved with the work of the CCG.

Conflicts of interest may arise where an individual’s personal interests, loyalties or those of a connected person (a relative or close friend) conflict with those of the CCG, or might be perceived to conflict with those of the CCG. Such conflicts may create problems such as inhibiting free discussion which could result in decisions or actions being made that are not in the interests of the CCG, and risk giving the impression that the CCG has acted improperly.

The CCG Governing Body’s responsibility includes the stewardship of significant public resources and the commissioning of health and social care services to the population of the CCG area. The Governing Body is therefore determined to ensure the organisation inspires confidence and trust amongst its members, officers, office holders, staff, stakeholders, suppliers and the public by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decision-making of the CCG.

This policy reflects the Appointment Commission’s Code of Accountability and Code of Conduct for NHS Boards and the ‘Seven Principles of Public Life’ from the Nolan Committee included in Appendix 1.

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4. Roles and Responsibilities

4.1 All CCG staff, officers, office holders and the Governing Body

It is the responsibility of all CCG staff, officers, office holders and Governing Body members to:

• Familiarise themselves and comply with this policy • Declare any relevant interests or complete nil returns on their appointment within the

CCG and every six months thereafter. In addition, it is the responsibility of each member of the CCG to notify the Governance Team of any changes in between this time frame

• Declare their interests as a standing agenda item for every governing body, committee, sub-committee or working group meeting, before the item is discussed. Even if an interest has been recorded in the register of interests, it should still be declared in meetings where matters relating to that interest are discussed. Declarations of interest should be recorded in minutes of meetings

• Complete when required online conflicts of interest training, and take part in any face to face training sessions as required.

• Avoid undertaking duties, remunerated or otherwise, outside of his / her employment with the CCG if there is any actual or potential conflict with, or prejudice of, the standards set out in this document;

• Take account of the CCG’s Policies and practice regard to gifts and hospitality and whistleblowing procedures.

Line Managers must ensure that employees are aware of the policy and processes to be followed for declaring interests. Line managers must consider any declarations of interest made by their employees and put in place mitigating arrangements in accordance with the instructions of the Chief Officer where appropriate. Where this is not clear, they should consult the Governance Team;

4.2 Head of Governance (or equivalent)

It is the responsibility of the Head of Governance or the equivalent post holder to:

• Support the Conflicts of Interest Guardian, including briefing them on conflicts of interests matters and issues arising.

• Assure the Accountable Officer that appropriate arrangements for the management of conflicts of interests are in place (see also section 4.4, below).

• Oversee the arrangements for the management of conflict of interest and advise the Governing Body as required.

• Ensure all CCG employees, Governing Body Members and members of CCG committees and sub committees, undertake online conflicts of interest training at least once in each period running from 1 February to 31 January.

• Review this policy every two years, or in light of changes in legislation / guidance published in relation to conflicts of interest and make recommendations to the Governing Body for any required changes.

• Ensure that the Register of Interests and Register of Procurement decisions is reviewed regularly, updated and published as necessary.

• Ensure that for every interest declared, arrangements are in place to manage the conflicts of interests or potential conflict of interest, to ensure the integrity of the group’s decisions making process.

• Ensure any breaches of the CCG’s policies and procedures for the management of conflicts of interest are identified and managed, including:

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o The reporting of any breaches as part of statutory returns to NHS England; o The publication of anonymised details of any breaches on the CCG’s website.

• Ensure that the CCG makes its self-certification return to NHS England on the management of conflicts of interest as required e.g. quarterly reporting for self-certification purposes, and that this includes an explanation for any non-compliance with NHS England’s guidance on the management of conflicts of interests.

4.3 Commissioning Lead and Procurement Leads

• The Director of Commissioning and any staff leading on any relevant procurements within the CCG must ensure that bidders, contractors and direct service providers adhere to this policy, and that the service re-design and procurement processes used by the CCG reflect the procedures set out in this policy.

• This includes ensuring: o Declarations are made a part of any contract meeting; o Interests are recorded and managed; o There are arrangements for the identification and management of conflicts of

interest through the management and delivery of the contract.

4.4 The Accountable Officer

• The CCG’s Accountable Officer has overall responsibility for the CCG’s management of conflicts of interest and ensuring that there are arrangements for:

o The day-to day management of conflicts of interest matters and queries; o Maintaining the CCG’s register(s) of interest and the other registers referred to in

this Guidance; o Supporting the Conflicts of Interest Guardian to enable them to carry out the role

effectively1; o Providing advice, support, and guidance on how conflicts of interest should be

managed; and o Ensuring that appropriate administrative processes are put in place.

4.5 Chair of Audit Committee

• The Chair of the Audit Committee, who is the Lay Member for Governance and Audit will assist the Governing Body on conflict of interest matters and will also provide direct formal attestation to NHS England alongside the Chief Officer. In addition they will provide a view of the working of the CCG with a strategic and impartial focus.

• The Chair of the Audit Committee will be the CCG’s Conflicts of Interest Guardian, provided they have no provider interests as they already have a lead role in conflicts of interest management, and ensuring that the Governing Body and the wider CCG behaves with the utmost probity at all times..

• As part of this The Chair of the Audit Committee will:

1 See Paragraph 67 of NHS England’s statutory guidance on the management of Conflicts of Interests, version 6.1, published 28 June 2016,

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o Ensure an audit of the management of conflicts of interest is undertaken annually as part of the internal audit programme

o Decide the level of information to be included in the CCG’s Register of

Interests (see section 6.4 onward) and about any individual included on the register

o Be consulted where necessary on the management of conflicts where the Chair and Deputy Chair of a meeting at which CCG business is conducted are conflicted.

4.6 Primary Care Commissioning Committee Chair

The primary care commissioning committee must have a lay chair and lay vice chair. To ensure appropriate oversight and assurance, and to ensure the CCG audit chair’s position as Conflicts of Interest Guardian is not compromised, the audit chair should not hold the position of chair of the primary care commissioning committee. This is because CCG audit chairs would conceivably be conflicted in this role due to the requirement that they attest annually to the NHS England Board that the CCG has:

• Had due regard to the statutory guidance on managing conflicts of interest; and • Implemented and maintained sufficient safeguards for the commissioning of primary

care.

CCG audit chairs can however serve on the primary care commissioning committee provided appropriate safeguards are put in place to avoid compromising their role as Conflicts of Interest Guardian. Ideally the CCG audit chair would also not serve as vice chair of the primary care commissioning committee. However, if this is required due to specific local circumstances (for example where there is a lack of other suitable lay candidates for the role), this will need to be clearly recorded and appropriate further safeguards may need to be put in place to maintain the integrity of their role as Conflicts of Interest Guardian in circumstances where they chair all or part of any meetings in the absence of the primary care commissioning committee chair

4.6.1 The Primary Care Commissioning Committee should:

• For joint commissioning take the form of a joint committee established between one or more CCGs and NHS England and;

• In the case of delegated commissioning, be a committee established by the CCG.

As a general rule, meetings of the primary care commissioning committee, including the decision-making and deliberations leading up to the decision, should be held in public unless the CCG has concluded it is appropriate to exclude the public where it would be prejudicial to the public interest to hold that part of the meeting in public. Examples of where it may be appropriate to exclude the public include:

• Information about individual patients or other individuals which includes sensitive personal data is to be discussed;

• Commercially confidential information is to be discussed, for example the detailed contents of a provider’s tender submission;

• Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings is to be discussed;

• To allow the meeting to proceed without interruption and disruption.

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The primary care commissioning committee is a decision-making committee, which is established to exercise the discharge of the primary medical services functions.

The quorum requirements for primary care commissioning committee meetings must include a majority of lay and executive members in attendance with eligibility to vote.

In the interest of minimising the risks of conflicts of interest, 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.

Whilst sub-committees or sub-groups of the primary care commissioning committee can be established e.g., to develop business cases and options appraisals, ultimate decision-making responsibility for the primary medical services functions must rest with the primary care commissioning committee.

For example, whilst a sub-group could develop an options appraisal, it should take the options to the primary care commissioning committee for their review and decision-making. CCGs should carefully consider the membership of subgroups.

They should also consider appointing a lay member as the chair of the group.

It is important that conflicts of interests are managed appropriately within sub-committees and sub-groups. As an additional safeguard, it is recommended that sub-groups submit their minutes to the primary care commissioning committee, detailing any conflicts and how they have been managed. The primary care commissioning committee should be satisfied that conflicts of interest have been managed appropriately in its sub-committees and take action where there are concerns.

4.7 Conflicts of Interests Guardian

To further strengthen scrutiny and transparency of CCGs’ decision-making processes, the CCG will appoint a Conflicts of Interest Guardian, who will usually by the Chair of the Audit Committee. The Conflicts of Interests Guardian will have responsibility for the day-to-day management of conflicts of interest matters and queries. The CCG Head of Governance (or equivalent) should keep the Conflicts of Interest Guardian well briefed on conflicts of interest matters and issues arising.

The Conflicts of Interest Guardian should, in collaboration with the CCG’s governance lead:

• Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest;

• Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy;

• Support the rigorous application of conflict of interest principles and policies; • Provide independent advice and judgment where there is any doubt about how to

apply conflicts of interest policies and principles in an individual situation; • Provide advice on minimising the risks of conflicts of interest.

4.8 The Chair of CCG Meetings

4.8.1 The Chair of a meeting of the CCG, including but not limited to the Governing Body and its Committees, is responsible for:

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• Identifying as far as possible in advance of meetings where one or more members have a conflict of interests.

• Ensuring interests are declared at the start of a meeting, and any declared interests are recorded in the minutes of the meeting.

• Ensuring there are arrangements for the management of the meeting’s business in the event the Chair has a conflict of interests

• Ensuring that where members of a meeting have conflicts of interests the meeting remains quorate and if not to follow the processes set out in this Policy (see section 7, below), in the meeting’s terms of reference, and in the CCG’s Constitution.

4.8.2 The chair should ask at the beginning of each meeting if anyone has any conflicts of interest to declare in relation to the business to be transacted at the meeting. Each member of the group should declare any interests which are relevant to the business of the meeting whether or not those interests have previously been declared. Any new interests which are declared at a meeting must be included on the CCG’s relevant register of interests to ensure it is up-to-date.

4.8.3 Any new offers of gifts or hospitality (whether accepted or not) which are declared at a meeting must be included on the CCG’s register of gifts and hospitality to ensure it is up-to-date.

4.8.4 It is the responsibility of each individual member of the meeting to declare any relevant interests which they may have. However, should the chair or any other member of the meeting be aware of facts or circumstances which may give rise to a conflict of interests but which have not been declared then they should bring this to the attention of the chair who will decide whether there is a conflict of interest and the appropriate course of action to take in order to manage the conflict of interest.

4.8.5 When a member of the meeting (including the chair or vice chair) has a conflict of interest in relation to one or more items of business to be transacted at the meeting, the chair (or vice chair or remaining non-conflicted members where relevant as described above) must decide how to manage the conflict. The appropriate course of action will depend on the particular circumstances, but could include one or more of the following:

• Where the chair has a conflict of interest, deciding that the vice chair (or another non-conflicted member of the meeting if the vice chair is also conflicted) should chair all or part of the meeting;

• Requiring the individual who has a conflict of interest (including the chair or vice chair if necessary) not to attend the meeting;

• Ensuring that the individual concerned does not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict;

• Requiring the individual to leave the discussion when the relevant matter(s) are being discussed and when any decisions are being taken in relation to those matter(s). In private meetings, this could include requiring the individual to leave the room and in public meetings to either leave the room or join the audience in the public gallery;

• Allowing the individual to participate in some or all of the discussion when the relevant matter(s) are being discussed but requiring them to leave the meeting when any decisions are being taken in relation to those matter(s). This may be appropriate where, for example, the conflicted individual has important relevant knowledge and experience of the matter(s) under discussion, which it would be of benefit for the meeting to hear, but this will depend on the nature and extent of the interest which has been declared;

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• Noting the interest and ensuring that all attendees are aware of the nature and extent of the interest, but allowing the individual to remain and participate in both the discussion and in any decisions. This is only likely to be the appropriate course of action where it is decided that the interest which has been declared is either immaterial or not relevant to the matter(s) under discussion

4.9 Secretariat to CCG Meetings

The Secretariat to CCG meetings has a vital role in ensuring, where a meeting member has a conflict of interests that has been identified in advance, that member does not receive any papers or other information relating to that conflict of interest.

They must also ensure any declared conflicts and how they are managed are accurately and faithfully recorded in the meeting’s minutes.

It is imperative that the CCG ensures complete transparency in its decision making processes through robust record keeping. If any conflicts of interest are declare or otherwise arise in a meeting the following must be recorded in the minutes:

• Who has the interest; • The nature of the interest and why it gives rise to a conflict • The items on the agenda to which the interest relates • How the conflict will be managed • Evidence that the conflict was managed as intended (e.g. recording when an

individual left and returned to a meeting).

4.9.1 Meeting Preparation

The CCG should consider conflicts of interests in advance of meetings. It is good practice for the chair, with support of the CCG’s Head of Governance or equivalent and, if required, the Conflicts of Interest Guardian, to proactively consider ahead of meetings what conflicts are likely to arise and how they should be managed, including taking steps to ensure that supporting papers for particular agenda items of private sessions/meetings are not sent to conflicted individuals in advance of the meeting where relevant.

To support chairs in their role, they should have access to a declaration of interest checklist prior to meetings, which should include details of any declarations of conflicts which have already been made by members of the group.

4.10 General Practitioners (GPs)

Following guidance from The General Medical Council (GMC) the CCG will ensure that any GPs with a responsibility for or involvement in commissioning of services must:

• Satisfy themselves that all decisions made are open, fair and transparent and comply with legislation.

• Keep up to date and follow the guidance and codes of practice that govern the commissioning of services.

• Formally declare any and all relevant interests that they, or someone close to them, including their GP or business partners and employees, or their employer/GP practice has.

• Take steps to manage any conflict between their duties as a GP and their commissioning responsibilities, for example by excluding themselves from the decision making process and any subsequent monitoring arrangements.

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5 Definition of a Conflict of Interest

A conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it could be reasonably considered that a conflict exists even when there is no actual conflict. In these cases it is important to still manage these perceived conflicts in order to maintain public trust.

Conflicts of interest can arise in many situations, environments and forms of commissioning, with an increased risk in primary care commissioning, out-of-hours commissioning and involvement with integrated care organisations, as clinical commissioners may here find themselves in a position of being at once commissioner and provider of services. Conflicts of interest can arise throughout the whole commissioning cycle from needs assessment, to procurement exercises, to contract monitoring.

Conflicts can arise from personal or professional relationships with others, e.g. where the role or interest of a family member, friend or acquaintance may influence an individual’s judgement or actions, or could be perceived to do so.

For a commissioner, a conflict of interest may therefore arise when their judgements as a commissioner could be, or be perceived to be, unduly influenced and impaired by their own concerns and obligations as a provider. In the case of a GP involved in commissioning, an obvious example is the awareness of a new contract with a provider in which the individual GP has a financial stake. However, the same considerations and the approaches set out in this guidance apply when deciding whether to extend a contract.

Important things to remember are that:

• A perception of wrongdoing, impaired judgement or undue influence can be as detrimental as any of them actually occurring;

• If in doubt, it is better to assume a conflict of interest and manage it appropriately, rather than ignore it;

• For a conflict to exist, financial gain is not necessary.

It is acknowledged that the above text in this section is taken from the NHS England Guidance on Co-Commissioning.

5.1 Privileged Information

An individual must not use confidential information acquired in the pursuit of their role within the CCG to benefit them or another connected person.

Members of the CCG, staff , Governing Body members, committee members and individuals involved in the CCG’s decision making processes should take care not to provide any third party with a possible advantage by sharing privileged, personal or commercial information, or by providing information that may be commercially useful in advance of that information being made available publically (such as informing a potential supplier of an up procurement in advance of other potential bidders), or any other information that is not otherwise available and in the public domain.

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5.2 Identifying Conflicts of Interests

Conflicts of interests can be split into four different categories.

5.2.1 Financial Interests

A financial interest is where an individual may financially benefit from the consequences of a commissioning decision (for example, as a provider of services). Examples include:

• Having a role in a company or other organisation which is doing, is likely to be doing, or is seeking to do business with health and social care organisations;

• Being a shareholder or having a similar ownership interests in a private or not-for-profit company, business partnership or consultancy which is doing, or which is likely to be doing, or is seeking to do business with health and social care organisations;

• Being a management consultant for a provider; • Being in secondary employment or in receipt of another income or grant from a

provider; • Being in receipt of any payments such as honoraria, allowances, travel or

subsistence, or other one-off payments from a provider; • Being in receipt of research funding including grants received by an individual or any

organisation in which they have an interest of role; • Having a pension that is funded by a provider, and the value of the pension may be

affected by the success or failure of the provider.

5.2.2 Non-financial Professional Interests

This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

• An advocate for a particular group of patients; • A GP with special interests e.g. in dermatology, acupuncture etc. • A member of a particular specialist professional body (although routine GP

membership of the RCGP, British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);

• An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE);

• A medical researcher.

GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices.

5.2.3 Non-financial Personal Interests

This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

• A voluntary sector champion for a provider; • A volunteer for a provider;

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• A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;

• Suffering from a particular condition requiring individually funded treatment; • A member of a lobby or pressure group with an interest in health.

5.2.4 Indirect Interests

This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above) for example, a:

• Spouse / partner • Close relative e.g., parent, grandparent, child, grandchild or sibling; • Close friend; • Business partner.

A declaration of interest for a “business partner” in a GP partnership should include all relevant collective interests of the partnership, and all interests of their fellow practice partners (which could be done by cross referring to the separate declarations made by those practice partners, rather than by repeating the same information verbatim). Whether an interest held by another person gives rise to a conflict of interests will depend upon the nature of the relationship between that person and the individual, and the role of the individual within the CCG.

5.2.5 It is not possible to define all instances in which an interest may be a real or perceived conflict. However, if an individual is unsure as to whether an interest should be declared then advice should be sought from the Head of Governance (or equivalent), who will co-ordinate advice from the Chief Officer, the Chair and the Conflicts of Interest Guardian. If in doubt, the individual concerned should assume that a potential conflict of interest exists.

5.3 Secondary Employment

5.3.1 All CCG members, staff, Governing Body members and members of the CCG’s committees and sub committees must ensure that secondary employment is declared to prevent a conflict from arising, or to allow the management of a conflict of interests where this is identified.

5.3.2 Additional work or employment is considered as ‘secondary’ even where the CCG may not be considered by an individual as their main or ‘primary’ employment or work. Individuals are not precluded from having secondary employment - however the CCG must be informed of such employment.

Secondary employment is defined as:

• Paid employment or work outside of the CCG • Voluntary employment or work outside of the CCG • Self-employment / private work • Reservist occupations • Bank/locum/agency work outside of the CCG.

The CCG is aware that they may be in some instances a secondary employer for GPs.

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6 Register of Interests

6.1 The CCG will maintain a register of interests which will be published on the CCG’s website alongside the CCG’s Register of Gifts and Hospitality; and will be included in the CCG’s Annual Report and Annual Governance Statement.

6.2 The CCG will record all nil returns on the register of interests.

6.3 When conflicts are entered onto the register sufficient information about the nature of the interest and the details of those holding the interest will be recorded, as will details of deliberations and subsequent decisions about how to manage these conflicts. The CCG will ensure that, when members declare interests, this includes the interests of all relevant individuals within their own organisations (e.g. partners in a GP Practice), who have a relationship with the CCG and who would potentially be in a position to benefit from decisions made by the CCG.

6.4 In keeping with statue and guidance on information governance, only the minimum necessary information about an individual will be included on the register. However, further information may be requested by anyone under the provisions of the Freedom of Information Act and each such request will be considered on its own merits in line with the CCG’s Freedom of Information Policy.

6.5 Notwithstanding sections 6.3 and 6.4 above, where in exceptional circumstances the public disclosure of information could give rise to a real risk of harm or distress the details of an individual’s declaration of interests or other information may be redacted from the publicly available register(s). Decisions not to publish information must be made by the Conflicts of Interest Guardian for the CCG, who may seek guidance if required. The CCG will retain a confidential un-redacted version of the register(s).

6.6 The CCG will ensure that declarations of interest are made and regularly confirmed or updated. This includes the following:

• On appointment: applicants for any appointment to the CCG or its Governing Body should be asked to declare any relevant interests as part of the election/recruitment process. When an appointment is made, a formal declaration of interests should be made and recorded.

• Every six months, including any nil returns. • At meetings: all attendees should be asked under a standing item on the agenda of the

meeting, to declare any interest they have in any agenda item before it is discussed or as soon as it becomes apparent. Declarations of interest made should be recorded in the minutes of the meeting.

• On changing role or responsibility: Where an individual changes role or responsibility within the CCG or its Governing Body, any change to the individual’s interests should be declared.

• On any other change of circumstances: wherever an individual’s circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside the CCG or sets up a new business or relationship), a further declaration should be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising.

6.6.1 In keeping with regulations, individuals who have a conflict should declare these as soon as they become aware of any actual or potential conflict.

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6.6.2 The declaration of interest form (Appendix 2) should be completed and sent to the Board Secretary including a signature.

6.6.3 Where an individual is unable to provide a declaration in writing, e.g. if a conflict becomes apparent in the course of a meeting, they will make an oral declaration before witnesses, which will be recorded in the minutes of the meeting, and complete a written declaration form as soon as possible thereafter but no later than 28 days. If the individual, for any reason, has difficulty making a declaration in writing then they should contact the Governance Team for further guidance.

6.6.4 If an individual fails to declare an interest or the full details of an interest, this may result in disciplinary action being undertaken. Please see the CCG’s Disciplinary Policy for more information.

6.7 Register of Procurement Decisions

6.7.1 The CCG recognises that particular care must be exercised when procuring services including the commissioning of services from GP practices. For that reason, this policy incorporates the Procurement Template developed by NHS England which must be completed in each case where GP practices, consortia or organisations in which GPs have a financial interest are, or may be a tenderer (See Appendix 3).

6.7.2 The CCG is prohibited by law from awarding any contract where the integrity of the procurement process or the award has been, or appears to have been, affected by a conflict of interest. Further information can be found in section 7.4.

6.7.3 The CCG’s register of procurement decisions will include;

• Details of any decisions made; • Who was involved in the decision making process (i.e. Governing Body or Committee

members and others with decision-making responsibility); and • A summary of any conflicts of interest in relation to the decision and how this was

managed.

6.7.4 The Register will be updated whenever a procurement decision is made.

6.7.5 The Register will form part of the CCG’s annual accounts and will thus be reviewed by external auditors.

7 Managing and Declaring Interests

7.1 Managing Conflicts of Interests during Meetings

7.1.1 Where an individual, employee or person providing services to the CCG attending a meeting is aware of an interest which has not been declared, he or she will declare this immediately at the start of the meeting.

7.1.2 Where an individual, employee or person providing services to the CCG is attending a meeting is aware of an interest that has previously been declared in relation to the scheduled or likely business of the meeting, the individual will bring this to the attention of the Chair of the meeting, together with details of arrangements which have been confirmed for the management of the conflict of interest or potential conflict of interest.

7.1.3 The Chair of the meeting will determine how the conflict should be managed, and will inform the individual of the decision. Where no arrangements have been confirmed, the

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Chair of the meeting may require the individual to withdraw from the meeting or part of it. The individual will then comply with these arrangements, which must be formally recorded in the minutes of the meeting.

7.1.4 Where the Chair of any meeting of any group including committees or subcommittees of the Governing Body has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, he or she must make a declaration and the deputy or vice Chair of the Governing Body or the Committee will act as Chair for the relevant part of the meeting. Where arrangements have been confirmed for the management of the conflict of interest or potential conflict of interest in relation to the Chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the Deputy Chair may require the Chair to withdraw from the full meeting or part of it.

If both the Chair and Deputy Chair are conflicted the voting members of the meeting who are not conflicted, provided the meeting then remains quorate, shall decide and agree how to manage the conflict(s), where necessary in consultation with the Conflicts of Interests Guardian.

Where there is no Deputy Chair, the members of the meeting will select one.

Declarations of interests, and the arrangements agreed to manage them, will be recorded formally in the minutes of the meeting.

7.1.5 If more than 50% of the members of a meeting are required to withdraw from a meeting or part of it, owing to the arrangements agreed for the management of conflicts of interests or potential conflicts of interests, the Chair (or Deputy Chair) will determine whether or not the discussion can proceed. In making this decision, the Chair will consider whether the meeting is quorate.

7.1.6 Where the meeting is not quorate, discussions may take place but any decisions will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the meeting, owing to the arrangements for managing conflicts of interest or potential conflicts of interests the Chair may adjourn the meeting to permit the co-option of additional members.

Where this is not possible the matter shall be referred to the Procurement Committee or its equivalent committee. The Procurement Committee or its equivalent committee shall decide whether to:

• Make the decision on the matter under consideration on behalf of the Governing Body or an authorised relevant committee; or

• Make a recommendation to the Governing Body or an authorised relevant committee on the matter under consideration.

7.1.7 The Governing Body or a relevant committee may choose to refer a matter to the Procurement Committee or its equivalent committee when there is a conflict of interest or a potential conflict of interest but the conflict of interest is such that it does not render a meeting inquorate. Unless the Governing Body or committee specifically reserves the decisions on the matter to itself the Procurement Committee or its equivalent Committee shall decide whether to:

• Make a decision on the matter under consideration on behalf of the Governing Body; or • Make a recommendation to the Governing Body or the relevant committee on the matter

under consideration.

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7.2 Managing conflicts of interest where all / or most of the GPs have an interest

7.2.1 Where certain members of the CCG have a material interest, they will either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision-making itself (i.e. not have a vote).

7.2.2 In many cases, for example, where a limited number of GPs have an interest, it will probably be straightforward for relevant individuals to be excluded from decision-making.

7.2.3 In cases where all of the GPs or other practice representatives on a decision making body could have a material interest in a decision, particularly where the CCG is proposing to commission services on a single tender basis from all GP practices in the area, or where it is likely that all or most practices would wish to be qualified providers for a service under Any Qualified Practitioner (AQP) framework, the CCG:

• May refer the decision to the Governing Body and exclude all GPs or other practice representatives with an interest from the decision-making process, i.e. so that the decision is made only by the non-GP members of the Governing Body including the lay members and the registered nurse and secondary care doctor;

• Shall consider co-opting individuals from a Health and Wellbeing Board or from another CCG onto the Governing Body, or inviting the Health and Wellbeing Board or another CCG to review the proposal, to provide additional scrutiny, although such individuals would only have authority to participate in decision-making if provided for in the CCG’s constitution;

• May Co-opt other relevant non conflicted members; • Refer the matter to the Procurement Committee or its equivalent committee. The

Procurement Committee or its equivalent committee shall decide whether to: o Make the decision on the matter under consideration on behalf of the Governing

Body; or o Make a recommendation to the Governing on the matter under consideration.

7.3 Managing conflicts of interest for GPs that are potential providers of CCG-commissioned services

7.3.1 The CCG may commission primary care services, including local incentive schemes, from General Practices. If a practice, or group of practices, provides a service, the CCG will need to demonstrate to the appropriate Committee of the Governing Body (and to the external and internal auditors) that the service:

• Clearly meets local health needs, and has been planned appropriately; • goes beyond the scope of the General Medical Services (GMS)/Personal Medical

Services (PMS) contract; • offers best value for money; and • has been commissioned via the appropriate procurement process as set out in the

CCG’s Procurement Policy.

7.3.2 Any breach of the above must be reported to the Audit Committee.

7.3.3 A General Practice or group of practices may belong to a provider consortium in which GPs have a financial interest. Where General Practices including provider consortia or organisations in which GPs have a financial interest are potential providers of CCG-commissioned services, the CCG will seek to assure itself of the factors set out in and to use the NHS England’s Code of Conduct for managing conflicts of interest and the procurement should be approved by the Procurement Committee or its equivalent committee.

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7.4 Managing Conflicts of Interest during Procurement

7.4.1 The CCG recognises the importance in making decisions about the services it procures in a way that does not call into question the motives behind the procurement decisions that have been made. The CCG will ensure that they recognise and manage conflicts or potential conflicts of interest that may arise in relation to procurement.

7.4.2 Anyone participating in the procurement, or otherwise engaging with the CCG, in relation to the provision of services or facilities, will be required to make a declaration of interest which will include nil returns. This includes those who will take part in any tender evaluation or decision making with regards to the award of a contract. Where these functions are undertaken by the CSU, declarations from CSU employees involved in the process should also be obtained and made available to the CCG.

7.4.3 The Procurement, Patient Choice and Competition Regulations place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour that is against the interest of patients, and protect the rights of patients to make choices about their healthcare.

The Regulations set out that commissioners must:

• Manage conflicts or potential conflicts of interest when awarding a contract by prohibiting the award of a contract where the integrity of the award has been or appears to have been affected by a conflict; and

• Keep appropriate records of how they have managed any conflicts in individual cases.

7.4.4 Potential conflicts will vary to some degree depending on the way in which a service is being commissioned e.g.:

• Competitive Tender - Where a CCG is commissioning a service through Competitive Tender (i.e., seeking to identify the best provider or set of providers for a service) a conflict of interest may arise where GP practices or other providers in which CCG members have an interest are amongst those bidding.

• Any Qualified Provider - Where the CCG is commissioning a service through an AQP contract, a conflict could arise where one or more GP practices (or other providers in which CCG members have an interest) are amongst the qualified providers from whom patients can choose.

• Single tender - Where the CCG is procuring services from a GP practice where there are no other capable providers, i.e. this is the appropriate procurement route and the proposed service goes beyond the scope of the services provided by GP practices under their GP contract.

7.4.5 The CCGs will ensure that details of all contracts, including the contract value, are published on its website as soon as possible after contracts are agreed. Where the CCG decides to commission services through Any Qualified Provider (AQP), it should publish on its website the type of services they are commissioning and the agreed price for each service. Further, the CCG will ensure that such details are also set out in its annual report.

Further information can be obtained from the CCG’s Procurement Policy or applicable equivalent policy which is located on the staff intranet and on the CCG’s website.

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7.5 Declarations on changing role / responsibility, or any other change of circumstances

7.5.1 When an individual changes role or responsibility within the CCG, or its Governing Body, such changes to the individual’s interests should be declared immediately.

7.5.2 Whenever an individual’s circumstances change in a way that affects the CCG or sets up a new business or relationship, a further declaration would need to be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising.

8 Designing Services and Conflicts of Interest

8.1.1 The CCG recognises the benefits to be gained from engagement with relevant providers, especially clinicians, in confirming the design of service specifications. However, the CCG also recognises that conflicts of interest can occur if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid for in a competitive process.

8.1.2 The same difficulty could arise in developing a specification for a service that is to be commissioned using the ‘Any Qualified Provider’ process, for example where there is not a competitive procurement but patients can instead choose from any qualified provider that wishes to provide the service and can meet NHS standards and prices.

8.1.3 The CCG will seek, as far as possible, to specify the outcomes that they wish to see delivered through a new service, rather than the way in which these outcomes are to be achieved. As well as supporting innovation, this helps prevent bias towards particular providers in the specification of services.

8.1.4 The CCG will seek to follow the principles set out in the Office of Government Commerce (OGC) guidance on pre-procurement engagement with potential bidders, in engaging with potential providers when designing service specifications.

8.1.5 The CCG will consider the following points when engaging with potential service providers:

• Use engagement to help shape the requirement but take care not to gear the requirement in favour of any particular provider(s).

• Ensure at all stages that potential providers are aware of how the service will be commissioned, e.g. through competitive procurement or through the ‘Any qualified provider’ process.

• Work with participants on an equal basis, e.g. ensure openness of access to employees and information.

• Be transparent about procedures. • Maintain commercial confidentiality of information received from providers.

8.1.6 The CCG shall use engagement with potential providers to:

• Frame the requirement; • Focus on desired outcomes rather than specific solutions; and • Consider a range of options for how a service is specified.

8.1.7 Other practical steps the CCG may also consider using include:

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• Advertising the fact that a service design/re-design exercise is taking place widely (e.g. on Contracts Finder) and inviting comments from any potential providers and other interested parties (ensuring a record is kept of all interactions) – i.e. do not be selective in who works on the service specifications unless it is clear conflicts will not occur.

• As the service design develops, engaging with a wide range of providers on an ongoing basis to seek comments on the proposed design, e.g. via the CCG’s website or workshops with interested parties.

• If appropriate, engaging the advice of an independent clinical adviser on the design of the service.

• When specifying the service, specifying desired (clinical and other) outcomes instead of specific inputs.

• Where an individual has declared a relevant and material interest or position in the context of the specification for, or award of, a contract the individual concerned will be expected to act in accordance with the arrangements for the management of conflicts of interest outlined in this policy and may be excluded from the decision making process in relation to the relevant specification or award.

9 Declarations of Interests on Application for Appointment or Election/Appointment to the CCG

9.1 General Guidance

9.1.1 Individuals will be required to declare any relevant interests. This includes:

• Lay member appointments to the Governing Body; • Other appointments of external individuals to the Governing Body, its committees,

and other working or project groups; • Professional medical practitioners, practice nurses and practice managers standing

for election to the Governing Body; • All employees and individuals contracted to work for the CCG, especially those

operating at senior level or Governing Body level.

9.1.2 The purpose of such declarations will be to enable the Governing Body and its committees to determine on a case by case basis, whether any of the declared interests are such that they could not be managed under this policy and mean that the individual should be excluded from being appointed to the Governing Body or to a committee or sub-committee of the CCG as the declared interest is so related to a significant area of the business that the individual would be prevented from making a full and proper contribution to the CCG. In so doing they will take into consideration the materiality of the declared interest and the extent to which the individual (or a family member) could benefit from any decision that the Governing Body might make.

9.1.3 Any individual who has a material interest in an organisation that provides or is likely to provide substantial business to the CCG (either as a provider of healthcare or commissioning support services) shall not be appointed as an appointed voting member of the Governing Body.

9.2 Additional Guidance for Appointees to the Governing Body, Committees, and Senior Management Positions

9.2.1 On appointing governing body, committee or sub-committee members and senior staff, the CCG will consider whether conflicts of interest should exclude individuals from being appointed to the relevant role.

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9.2.2. The CCG will assess the materiality of any declared interest, in particular whether the individual (or any person with whom they have a close association) could benefit (whether financially or otherwise) from any decision the CCG might make.

9.2.3 The CCG will also need to determine the extent to which an interest impacts on the nature of the appointee’s proposed role within the CCG. If the interest is related to an area of business significant enough that the individual would be unable to operate effectively and make a full and proper contribution in the proposed role, then that individual should not be appointed to the role.

9.2.4 The CCG’s Constitution sets out the conduct expected of individuals involved in the CCG, e.g. members of the governing body, members of committees, and employees, which reflect the expectations set out in the Standards for Members of NHS Boards and Clinical Commissioning Groups.

10 Breaches of this Policy and/or national guidance

10.1 Failure to Disclose or Declare

10.1.1 The CCG takes the failure to disclose such information as required by this policy seriously.

10.1.2 It is an offence under the Fraud Act 2006 for personnel to fail to disclose information to the CCG in order to make a gain for themselves or another, or to cause a loss or expose the organisation to a loss. Therefore, if an individual becomes aware that someone has failed to disclose relevant and material information, they should raise the matter with their line manager or senior manager in the first instance. The Anti-Fraud and Bribery Policy will be consulted and an appropriate referral made to the Local Counter Fraud Specialist where applicable.

10.1.3 Breaches of this policy may result in a Governing Body member being removed from office in line with the CCG’s Constitution. A contractor may be prevented from obtaining further work with the CCG or an employee may face disciplinary action and dismissal.

10.2 Reporting Breaches

The CCG will ensure that employees, governing body members, committee or sub-committee members and GP practice members are aware of how they can report suspected or known breaches of the CCG’s conflicts of interest policies, including ensuring that all such individuals are made aware that they should generally contact the CCG’s designated Conflicts of Interest Guardian in the first instance to raise any concerns. They should also be advised of the arrangements in place to ensure that they are able to contact the Conflicts of Interest Guardian on a strictly confidential basis.

11 Criminal Implications

11.1.1 Failure to manage conflicts of interest could lead to criminal proceedings including for offences such as fraud, bribery and corruption. This could have implications for the CCG and any linked organisations, and the individuals who are engaged by them. 11.1.2 The Fraud Act 2006 created a criminal offences of fraud, and defines three ways of committing it:

• Fraud by false representation; • Fraud by failing to disclose information and; • Fraud by abuse of position.

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11.1.3 An essential ingredient of the offences is that, the offender’s conduct must be dishonest and their intention must be to make a gain, or cause a loss (or the risk of a loss) to another. Fraud carries a maximum sentence of 10 years imprisonment and /or a fine if convicted in the Crown Court or 6 months imprisonment and/or a fine in the Magistrates’ Court. The offences can be committed by a body corporate.

11.2 Bribery Act 2010

11.2.1 The Bribery Act 2010 came into force on 1st July 2011 and repeals, in their entirety, the Prevention of Corruption Acts 1906 to 1916 and the common law offence of Bribery. It creates three relevant offences of bribing another person, being bribed and the failure of commercial organisations to prevent bribery.

11.2.2 Office holders, officers, Staff, members, committee and sub-committee members of the CCG and members of the Governing Body (and its committees) should be aware that in committing an act of bribery they may be subject to a penalty of up to ten years’ imprisonment, a fine, or both. They may also expose the organisation to a conviction punishable with an unlimited fine.

11.2.3 They should also be aware that a breach of this Act, or of this guidance, renders them liable to disciplinary action by the CCG whether or not the breach leads to prosecution. Where a material breach of this guidance is found to have occurred, the likely sanction will be dismissal.

11.2.4 In short, the offences cover the offering, promising or giving of a financial or other advantage and the requesting, agreeing to receive or accepting of a financial or other advantage where the overall intention of such an action is to bring about an improper performance or a relevant function or activity. The organisation may be liable where a person associated with it commits an act of bribery.

12 Related Documents

The following documents contain information that relates to this policy:

• Anti-Fraud and Bribery Policy; • Clinical Procurement Policy; • The Clinical Commissioning Group Constitution.

13 Dissemination

13.1 This policy will be published on the CCG’s staff intranet and website for access by all CCG Employees and other relevant individuals.

13.2 A copy of this policy will be emailed to Governing Body members by the Governance Team to highlight the new policy and ask for any amended interests to be declared in a timely manner.

14 Advice

Advice on declaration of interests can be sought from the Governance Team.

The Governance Team can be contacted at the following e-mail address:

[insert local information]

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15 Review and Compliance Monitoring

15.1 Review

A bi-annual review of the policy will be undertaken by the Audit Committee.

15.2 Compliance Monitoring

The Audit Committee will require assurance annually on compliance with the policy as part of its assurance programme.

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Appendix 1

The Nolan Principles

Selflessness – holders of public office should act solely in terms of the public interest.

They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

Integrity – holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

Objectivity – in carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

Accountability – holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

Openness – holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

Honesty – holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

Leadership – holders of public office should promote and support these principles by leadership and example.

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Appendix 2

Declarations of Interest form for members / employees

This form (whether in paper form or electronic/digital form) is required to be completed in accordance with the CCG’s Constitution, Conflicts of Interests Policy, and section 14O of The National Health Service Act 2006, the NHS (Procurement, Patient Choice and Competition) regulations 2013 and the Substantive guidance on the Procurement, Patient Choice and Competition Regulations

Notes:

• Each CCG must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and/or NHS England and the public for whom they commission services in relation to a decision to be made by the CCG and/or NHS England or which may affect or appear to affect the integrity of the award of any contract by the CCG and/or NHS England.

• A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days.

• If any assistance is required in order to complete this form, then the individual should contact either the Board Secretary or Governance Lead at the following email address:

[local email]

• The completed form should be sent by email or in hard copy to the Board Secretary, at [email]

• Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form.

• The register will be published on the CCG’s website. • Any individual – and in particular members and employees of the CCG and/or NHS

England- must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and/or NHS England and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered.

• If there is any doubt as to whether or not a conflict of interests could arise, a declaration of the interest must be made.

Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include:

• Roles and responsibilities held within member practices; • Directorships, including non-executive directorships, held in private companies or PLCs; • Ownership or part-ownership of private companies, businesses or consultancies likely or

possibly seeking to do business with the CCG and /or with NHS England; • Shareholdings (more than 5%) of companies in the field of health and social care; • A position of authority in an organisation (e.g. charity or voluntary organisation) in the

field of health and social care; • Any connection with a voluntary or other organisation (public or private) contracting for

NHS services; • Research funding/grants that may be received by the individual or any organisation in

which they have an interest or role;

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• Any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgment or actions in their role within the CCG.

If there is any doubt as to whether or not an interest is relevant, a declaration of the interest must be made.

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Declarations of Interest Form for CCG Staff and Members

See over for guidance. You should also refer to the CCG’s Conflicts of Interest Policy.

About You Name

Position within the CCG

Do you have any interests to declare? Yes No

Interests Roles and responsibilities in CCG member practices.

Directorships including non-executive directorships held in private companies or PLCs.

Shareholdings of more than five per cent in companies in the field of health and/or social care.

Positions of authority in a charity or social organisation in the field of health and/or social care.

Any connection with a voluntary or other organisation contracting for NHS services.

Research funds or grants received by the individual or any connected organisation.

Other specific interests.

Any other roles or relationships which the public could perceive as impairing or influencing your judgement of actions in your role with the CCG.

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information provided and to review the accuracy of the information provided regularly and no longer than annually. I give my consent for the information to be used for the purposes described in the CCG’s Constitution and published accordingly.

Signed: Date:

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Guidance:

• All staff need to complete this form and either declare their interests or confirm they have no interests.

• Staff for this purpose means anyone who works at the CCG in any capacity; employees, interims, Governing Body members, etc. If in doubt if this applies, do ask.

• Members means practice partners and any individual from a practice directly involved with the business or decision making of the CCG.

• Complete and return the form in hard copy or email a scanned copy to [tbc]

• Remember an interest is anything that could influence your judgement or actions; or that could be perceived to influence your judgement or actions.

• Relevant interests include those of your family, friends and acquaintances, and means anything actual, potential or perceived.

• If you are in doubt, declare it.

• When completing the form you must go into enough detail that a lay person or member of the public would understand the implications and why the interest needs to be registered.

• You will need to complete a new form:

o at least once every six months and/or; o if you start a new role within the CCG and/or; o if you become aware of an interest that you need to declare.

• You will also need to declare any and all interests at the start of meetings you are

part of if there is, or you feel there may be, a related agenda item for discussion. We will also be asking regular attendees at committee meetings to complete a form.

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Appendix 3

Procurement Decision Register

*To be used when commissioning services from GP practices, including provider consortia, or organisations in which GPs have a financial interest

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Appendix 4

Declaration of Interests for Bidders / Contractors

This form is required to be completed in accordance with s140 of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and the NHS (Procurement, Patient Choice and Competition) (No2) Regulations 2013 and related guidance Notes:

All potential bidders/contractors/service providers, including sub-contractors, members of a consortium, advisers or other associated parties (Relevant Organisation) are required to identify any potential conflicts of interest that could arise if the Relevant Organisation were to take part in any procurement process and/or provide services under, or otherwise enter into any contract with, the CCG, or with NHS England in circumstances where the CCG is jointly commissioning the service with, or acting under a delegation from, NHS England. If any assistance is required in order to complete this form, then the Relevant Organisation should contact

• The completed form should be sent to the Governance Team.

• Any changes to interests declared either during the procurement process or during the term of any contract subsequently entered into by the Relevant Organisation and the CCG must notified to the CCG by completing a new declaration form and submitting it to the Governance Team.

• Relevant Organisations completing this declaration form must provide sufficient detail of each interest so that the CCG, NHS England and also a member of the public would be able to understand clearly the sort of financial or other interest the person concerned has and the circumstances in which a conflict of interest with the business or running of the CCG or NHS England (including the award of a contract) might arise.

If in doubt as to whether a conflict of interests could arise, a declaration of the interest should be made.

• Interests that must be declared (whether such interests are those of the Relevant Person themselves or of a family member, close friend or other acquaintance of the Relevant Person), include the following:

• the Relevant Organisation or any person employed or engaged by or otherwise connected with a Relevant Organisation (Relevant Person) has provided or is providing services or other work for the CCG or NHS England;

• a Relevant Organisation or Relevant Person is providing services or other work for any other potential bidder in respect of this project or procurement process;

• the Relevant Organisation or any Relevant Person has any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions.

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[DECLARATIONS OF INTERESTS FORM FOR BIDDERS AND CONTRACTORS]

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Appendix 5

[DECLARATIONS OF INTEREST FLOW CHART]

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Corporate Assurance Framework and Risk Report LEAD GOVERNING BODY MEMBER:

Melanie Rogers, Director of Quality and Integrated Governance

AUTHOR: Frazer Tams, Interim Corporate Affairs Manager CONTACT DETAILS:

[email protected]

SUMMARY: The CCG risk management process and reporting structure has been reviewed with a view to enhancing the process further. The key change resulting from this review is the development of a new Corporate Assurance Framework (CAF) designed to focus the attention of the Governing Body on the principal risks likely to impact on the achievement of our objectives. Attached are three papers included for review and approval:

1) Corporate Assurance Framework (CAF) Development Paper - this highlights the work undertaken and changes proposed;

2) Risk Management Flow Chart 3) New CAF structure – this documents the revised structure for the CAF as defined in

the development paper This report contributes to:

• Ensuring every child has the best start in life, • Preventing and managing long term conditions to extend both length and quality of

life and reduce health inequalities, • Improving mental health and wellbeing, and • Delivering high quality, efficient services within the resources available.

Prior consideration by Committees and other partners: Specific elements of the risk register was considered by the Strategy and Finance Committee on 27 October 2016 and the Quality and Performance Committee on 25 October 2016. Patient & Public Involvement (PPI): This paper will be available on the CCG website for consideration by patients and the public. Equality Impact Assessment: none. Risks: N/A RECOMMENDED ACTION: The Governing Body is asked to:

1) NOTE the revised risk management process introduced;

Item: 5.2

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2) APPROVE the new Corporate Assurance Framework (CAF) document format SUPPORTING PAPERS:

• Appendix 5.2.1 Corporate Assurance Framework Development Paper; • Appendix 5.2.2 Risk Management Flow Chart; • Appendix 5.2.3 New CAF Format.

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Appendix: 5.2.1

Risk Management and Corporate Assurance Framework Development

Following on from previous work completed around the risk register and taking in to consideration feedback from Internal Audit reviews, the risk management system has undergone further development to streamline the risk management function and enhance the way that risk is managed and reported.

Existing Risk Management System

The CCG has historically had a structured risk management system that had embedded processes in place for identifying risk through the routine consideration of the risk register at each committee of the Governing Body but also reflecting risk within each report presented. This Executive Management Team also considered any risks arising from the work taking place within the CCG and also by way of horizon scanning. It was however recognised that there were areas for improvement within this system and these included:

• There was no clearly defined Corporate Assurance Framework as all risks werepresented to the Governing Body in what was considered a very large and difficultto understand document;

• The CCG had not formally identified its principal risks to the achievement of thestrategic objectives and therefore the risk reporting was not specifically structuredtowards the key risk that needed close scrutiny;

• The structure of reports made the mapping of risks, controls and assurances difficultthus limiting the extent to which the Committees could scrutinise the informationprovided;

• There was no clearly defined basis for the operational review of risk that ensuredthe risk status was appropriately updated.

These points therefore formed the basis for the work that has been completed.

New Corporate Assurance Framework (CAF) Structure

A completely new structure for the Corporate Assurance Framework has been developed that has defined the principal risks and subsequently reduced the number of risks presented to the Governing Body. The structure presents each risk on a separate page and in a format that makes mapping controls and assurances far easier.

It should be noted that all identified CCG risks remain within the risk registers and continue to be mitigated and reviewed through the CCG committees. The Governing Body will no longer see the full risk register but will concentrate on the principal risks as detailed in the CAF document.

The key elements changes/developments with the document are as follows:

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Appendix: 5.2.1

Principal Risks

The CAF document focuses on the principal risks to the achievement of our strategic objectives, by this we are referring to risks that if not managed, effectively will result in our failure to deliver against each objective. Principal risks therefore should be defined as those with an inherent risk score (before mitigation) of 15+ (red risks).

(See appendix A for 5x5 matrix used for assessing CCG risks)

It can be assumed that risks with inherent risk scores lower than this are not on their own likely to result in our failure to achieve the objective. These risks are still important though and will be managed through our risks register but will not feature in the CAF.

High Residual Risks

There may be instances where risks not initially scored as high escalate due to further events/circumstances arising. Once these risks are reassessed as high risk, they are to be brought in to the CAF for consideration by the Governing Body.

The following two examples demonstrate how specific risks are managed within the risk framework.

Example1

Risk 322 related to the achievement of the QIPP target for 2016/17 of £9m. Initially the risk was assessed as a medium risk scoring 12. This resulted from a likelihood score of 4 and an impact score of 3. The score of 12 was not considered to be of a magnitude that required bringing to the attention of the Governing Body so initially this risk was being managed through the risk register and reviewed by the Strategy and Finance Committee. In June the risk around the QIPP was felt to be escalating due to a sizeable gap in identifying QIPP saving schemes. The net impact was that the impact on the CCG of not achieving the risk was increased to 4 resulting in the risk being scored as high (3X4=16).

The risk was therefore brought in to the CAF in order for the Governing Body to have sight of the escalating concern.

By Month 5 the QIPP gap had significantly reduced to the extent of reassessing the score back to 12 (3x4). Due to the risk no longer being classified as high and the fact that its inherent score was only medium, this risk was removed from the CAF.

284 of 344

Appendix: 5.2.1

Controls and Assurances

The new structured CAF places greater emphasis on controls and assurances as these are the basis by which the Governing Body will take comfort over how effectively we are managing the risks that directly impact on our objectives. You will see from the new document that assurances and controls are mapped by row rather than collated. This enables a clearer assessment as to which controls listed we have received assurances against and therefore makes it easier to identify where we have gaps in assurances.

This CAF structure includes a RAG rating for each control and assurance which helps us classify the relative strength of each one listed.

Controls will be assessed based on:

• How it directly impacts on the risks score; • How frequent and reliable to the control is; • The outcome of any assurance against the control.

Assurances will be assessed based on:

• The accuracy and timeliness of the data received; • The frequency of the assurance; • Whether the assurance has come from an internal source or from an independent

external body.

Summary Risk Sheet

This page enables Governing Body members to have an overview of the risk position against each objective and view the movement in risk for each quarter throughout a rolling 12 month period.

Example 2

Risk 205 relates to pressure on mental health acute beds and the impact on the CCG’s ability to meet the health needs of residents if demand increases.

This risk was initially scored as high (5X4=20) with a likelihood of 5, suggesting that if not controlled it would materialise. It was also given an impact score of 4 suggesting there would be a significant impact on the CCGs ability to meet its commissioning obligations and deliver effective services to residents if action was not taken to manage this.

Through consideration of a series of controls that were subsequently implemented and also assurances received against those controls the risk was reassessed as medium with the score significantly reduced to 9 (3x3).

This risk though should remain on the CAF due to its initial risk rating which clearly identified it as a principal risk. Although the current risk level is a borderline medium/low risk the consequences of a sudden failure or loss of control will instantly escalate this risk back to high. The Governing Body therefore need to continue to feel suitably assured that the controls and assurances in place for this risk remain effective.

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Appendix: 5.2.1

Review of Risks

The risk register and BAF are live documents that continue to move as changes and developments take place within the CCG. It is therefore vital that information remains up to date and consistent to provide useful and timely information to management. The risk register continues to be reviewed to ensure that risks, controls, assurances and actions are correctly defined and worded in addition to recording additional assurances and controls as they are identified/received. Risk scores are also revisited where changes to the risk status has been identified in order to provide clarity around the impact controls and assurances are having on reducing the level of risk.

It was acknowledged that reviewing each risk on a monthly basis was not feasible but there was a need to maintain control over the regularity of review for each risk. In light of this risks will be reviewed based on their current residual risk score: High risks (15+) – reviewed monthly; Medium risks (6-14) – reviewed bi-monthly; Low risks (5 or less) – reviewed quarterly. This is a maximum timeframe for review and it is recognised that where known changes to the risk position have occurred the risk will be updated regardless of whether a review is due.

NEXT STEPS

Risk Appetite and Tolerance

A further element of developing this process is to define the risk appetite of the CCG and then attribute risk tolerance levels to the principal risks in order to gain an understanding of how effective risk mitigation has been. This is achieved by defining the point at which the CCG feels comfortable with accepting each risk. This will vary based on the nature of each risk and the CCGs appetite to take on risk in certain areas.

It is proposed that a Governing Body seminar in the New Year will be used to consider the development of the CAF and also agree risk tolerance scores for each of the risks detailed in the CAF.

To date, the following proposed risk appetite statement has been compiled that aims to capture the Governing Body’s current view of risk:

We are open to the acceptance of some risk in our desire to commission high quality services of good value for our population. We therefore, accept the possibility of some limited financial loss whilst remaining aware of the current restrictions in place around our financial resources. We will continue to encourage innovation in the pursuit of quality improvements whilst recognising the need for commensurate improvements in management control. We accept that decisions made in this regard may potentially expose the CCG to additional scrutiny, yet through adopting a proactive approach to the management of risk and retaining effective and transparent systems of governance, these decisions should act to further enhance the reputation of the CCG.

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Appendix: 5.2.1

Appendix A – Risk Assessment Table

Risk Rating = Likelihood x Impact Li

kelih

ood

Impact 1 2 3 4 5

5 5 10 15 20 25

4 4 8 12 16 20

3 3 6 9 12 15

2 2 4 6 8 10

1 1 2 3 4 5

Low risk (green) = less than 5 Medium risk (amber) = between 6-14 High risk (red) = 15 and over

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RISK

APP

ROVA

L/SI

GN

OFF

RISK MANAMGEMENT FLOW CHART

The CAF document sits at the heart of the work of the Governing Body. The document itself is reviewed at each meeting in line with current concerns and commitments to ensure the CAF reflects the core business issues of the CCG and subsequently provides members with adequate assurance over the management of risks most likely to impact on the achievement of corporate objectives.

Corporate Assurance Framework (CAF)

Executive Management Team

Audit Committee

Governing Body

RISK

IDEN

TIFI

CATI

ON

AN

D A

NAL

YSIS

RISK

REV

IEW

The EMT meets on a fortnightly basis and will review the Risk Register in its entirety and CAF on alternative meetings to ensure risks are complete, up to date and scores are appropriate. The Risk register is reviewed after the round of committees and the CAF is reviewed prior to the Governing Body meetings.

RISK

SCR

UTI

NY

The Audit Committee meets a minimum of 4 times a year and provides independent scrutiny of the CAF as part of its core work. The CAF and Risks Register form a key part of developing the Internal Audit work plan for the year.

Narrative

ID Potential Risk

All risks on the Risk Register are subject to review by their assigned committee as a standing agenda item. This includes consideration of how accurate and complete the information presented is and the relevance of the current scoring. Consideration is also given to further action and mitigation that can be taken to reduce the risk scores.

Patient and Public Involvement Committee

For risks assesseed as having an inherrent (initial) risk score of 15+ these are incorporated in to the CAF.

Quality and Performance Committee

Strategy and Finance Committee

Once assessed the details are added to the CCG Risk Register and assigned a review committee.

CCG Risk Register

Score risk

Potential risks are identified from a number of sources including committees, internal meetings, external meetings/reports

Potential risks are assessed to establish the extent of the risk to the CCG, who owns the risk and who will lead on mitigation. The risk is then scored using the likelihood and impact matrix.

Assess Risk

As part of the risk assessment consideration is given to the controls and assurances in place or planned to be implemented to control the risk. These will subsequently impact on the risk score.

Controls Assurances

Appendix 5.2.2

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15/16Q4 Q1 Q2 Q3

Ensuring every child has the best start in life

Statutory Obligations and Core Business

406 Strategy & FinanceThere is a financial risk amounting to £500,000 (based on current activity) this financial year resulting from the Department of Health directive to increase by 40% weekly rates paid to nursing homes towards the care of people eligible for funbded nursing care. The directive confirmed that payments will have to be back dated to April 2016.

25 25 25

409 Strategy & Finance The STP does not address the health, wellbeing or financial gap in Haringey and Islington over the next five years. 20 12 12

Delivery of High Quality, Efficient Services Within Available Resources

105 Quality & Performance

Oversight of quality and safety issuesAn undetected and unaddressed failure in a commissioned service due to poor performance or quality of services could result in • poor patient experience • potential patient harm• missed targetsResulting in • Failure to meet our statutory and strategic obligations• Damage to CCG’s reputationThe CCG is the lead commissioner for the Whittington, Moorfields, Camden and Islington Foundation Trust (for mental health), Care UK GP out of hours services, and the local NHS 111 service.

15 0 10 8 8 8

205 Strategy & Finance

Pressure on mental health acute bedsIf pressure/demand exceeds the current bed base provided by our commissioned services then The CCG may not be able to meet its obligation to commission effectively to meet the health needs of our residents in terms of• safety – through delayed admission and risk of stay on an excessively high occupancy ward• Clinical effectiveness: care not based on health need or poor continuity of care• Poor patient experience.This could also adversely affect the CCG’s reputation.

20 0 9 9 9 9

208 Quality & Performance

Mental Capacity and Deprivation of LibertyIf the CCG fails to meet its responsibilities under the Mental Capacity ActMental capacity assessments and deprivation of liberty assessments may be undertaken inconsistently across commissioned services because of insufficient understandingThe consequence of this could be clinical failings in terms of safeguarding vulnerable people and the law may be broken due to unlawful deprivation of libertyThis could mean the CCG could experience damage to its reputation and possible legal action and cost.

16 0 12 9 9 9

215 Quality & PerformanceWorkforce and succession planningIf the CCG does not effectively recruit, retain or plan for succession for its workforce it may not deliver on its local leadership role, key projects, overall strategy and statutory obligations

15 0 10 8 8 8

407 Strategy & FinanceSTP doesn't recognise or support the work of Haringey and Islington Partnership as the agreed direction of travel across all partners and so benefits to the population and sustainable services are not realised.

20 9 9

408 Strategy & Finance The implementation of new NCL commissioning arrangement could result in a lack of focus and continuity in Islington leading to a decline in performance or deteriating relationships. 16 9 9

Preventing and Managing Long Term Conditions

Risk Movement since last Qtr

CORPORATE ASSURANCE FRAMEWORK

SUMMARY

Risk ToleranceInherent Risk

Score16/17

Risk RefReview

Committee Description

No principal risks have currently been identified for this objecitve based on the criteria defined (15+ risk score)

Objective 4

Objective 1

Objective 2

Objective 3


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No principal risks have currently been identified for this objecitve based on the criteria defined (15+ risk score)Objective 1 Ensuring every child has the best start in life

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Impact Likelihood Total Impact Likelihood Total Impact Likelihood Total

CAF Ref:406 5 5 25 5 5 25 0 0 0

Control Ref:

Strength1=red2=amber3=green Date

Strength1=red2=amber3=green

Internal / External

C1 2 Monthly 2 Internal


Cross Ref:Delivery Date Owner Ref:

C1 31/01/2017

Senior Commissioning Manager - Older People services

Objective 2 Statutory Obligations and Core Business

A new national framework is planned for that will address the way assessments are completed potentially moving some patient out of FNC/CHC (discharge to assess)

Assurance

Risk:

There is a financial risk amounting to £500,000 (based oncurrent activity) this financial year resulting from theDepartment of Health directive to increase by 40% weeklyrates paid to nursing homes towards the care of peopleeligible for funbded nursing care. The directive confirmedthat payments will have to be back dated to April 2016.

Risk Owner

Director of CommissioningInherent risk score

before we consider any mitigation

Business Case submitted for additional resource.Case review assessor on long term sick. Part time cover being recruited. Update report to S&F Committee. Internal report

Residual Risk scoreRisk after consideration of controls

Risk Tolerance The level of risk the CCG will tolerate in

line with the risk appetite

Risk LeadSenior Commissioning

Manager - Older People services

Actionsactions taken to directly improve the effectiveness of controls or assurances

received TypeGaps In Control / Assurance

Aread requiring improvement where we lack control or assurance

Recruitment of Nurse assessor for CHC/FNC and Fast Track cases has been agreed in principle but awaiting financial approval.

Latest reports show that fast track patients moved in to nursing homes and looked after in own homes has increased significantly.

Fast Track patients are living longer than the anticipated 3 months resulting in increased costs.

Internal report

ControlsSpecific tasks and measure implemented to mitigate the effect of the pricipal

risks.

AssurancesReports/information received that confirms controls listed are working effectively

Evidencewhat was received and where

was it presented

Date Risk Added:

17/8/2016

Strategy and Finance Committee Date 27/10/2016

Committee Feedback S&F Committee acknowledged the current risk level standing at £550k and the need to improve the fast track assessment process and ongoing resourcing issue.

Review Committee

Risk Conclusion Further mitigation of risk is required to bring In line with the defined risk appetite.

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Objective 2 Statutory Obligations and Core Business


CAF Ref:409 5 4 20 3 4 12 0 0 0

Control Ref:



Internal / External

C1 1 1


C1

Date Risk Added:

Risk:

The STP does not address the health, wellbeing or financialgap in Haringey and Islington over the next five years.

Risk Owner

Chief OfficerInherent risk score

before we consider any mitigationResidual Risk score

Risk after consideration of controls



Risk LeadDirector of Commissioning

ControlsSpecific tasks and measure implemented to mitigate the effect of the pricipal

risks.


Evidencewhat was received and where

was it presented

The STP risks will be fully populated following the Governing Body Meeting in November.


Actionsactions taken to directly improve the effectiveness of controls or assurances Type

Gaps In Control / AssuranceAread requiring improvement where we lack control or assurance

To be populated

Committee Feedback Risk to be considered in more detail once fully populated.


Review Committee Strategy and Finance Committee Date 27/10/2016

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CAF Ref:105

5 3 15 4 2 8 0 0 0

Control Ref:



Internal / External

C1 2 2 Internal

C2 2 3 External

C3 3 Internal

C4 2 2 Internal

C5 2 Internal

Additional intelligence from the bi-monthly NHS England London quality Surveillance Group meeting.

Internal and external audit, and regular assurance

provided to NHS England.


Evidencewhat was received and where was

it presented

Regular quality review and contract meetings with providers. CQC and other alertsDirect feedback from patients, Healthwatch, GPs and voluntary organisations

CCG quality team reports on providers to the CCG Quality

and Performance Committee.Minutes of contract meetings

with providers

CSU Contracting and quality team and reportsInternal audit report on CCG clinical governance RAG rated us green. There has been a self-review of the Terms of Reference of the Quality and Performance Committee and its effectiveness in the last year.

Minutes of the CCG Quality and Performance committee

Quality and performance reports to Governing body.

service failure addressed via CSU Performance Management Framework B12

Objective 3

Date Risk Added:

Risk:Inherent risk score




Oversight of quality and safety issuesAn undetected and unaddressed failure in a commissioned service due to poor performance or quality of services could result in • poor patient experience • potential patient harm• missed targetsResulting in • Failure to meet our statutory and strategic obligations• Damage to CCG’s reputationThe CCG is the lead commissioner for the Whittington, Moorfields, Camden and Islington Foundation Trust (for mental health), Care UK GP out of hours services, and the local NHS 111 service.

Risk Owner


Risk LeadHead of Quality



ControlsSpecific tasks and measure implemented to mitigate the effect of the

pricipal risks.

Appointment of Head of quality and quality Assurance Manager

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Objective 3




received Type


No actions identified for this risk None stated

Risk Conclusion Risk currently being managed within agreed tolerance levels

Review Committee Quality and Performance Committee Date 25/10/2016Committee Feedback

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Objective 3



CAF Ref:205

4 5 20 3 3 9 0 0 0

Control Ref:



Internal / External

C1 1 Oct-16 2 Internal



Additional beds are now available as part of a risk share agreement with Camden and Islington Foundation Trust (CIFT)

STP work on overall capacity including development of St Anne's

Quarterly reports to Quality & performance committeeReadmission rates are reported to Contract review group

The National Crisis Concordat has led to a local action plan to enhance admission avoidance capability





Risk LeadSenior Commissioning

Manager Mental Health and Continuing Healthcare


pricipal risks.



it presented

Date Risk Added:

Risk:Pressure on mental health acute bedsIf pressure/demand exceeds the current bed base provided by our commissioned services then The CCG may not be able to meet its obligation to commission effectively to meet the health needs of our residents in terms of• safety – through delayed admission and risk of stay on an excessively high occupancy ward• Clinical effectiveness: care not based on health need or poor continuity of care• Poor patient experience.This could also adversely affect the CCG’s reputation.

Risk OwnerDirector of Commissioning

Inherent risk scorebefore we consider any mitigation

Risk share arrangement includes monthly meeting with CIFT to monitor bed occupancy, identify issues and solve problems

STP, through Healthy London Partnerships, created service specification for mental health place of safety outside of A&E.


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Objective 3



Senior Commissioning Manager

Independent external review of acute bed capacity commissioned by CCG now complete. Action plan is being developed.

Control


Review Committee Strategy and Finance Committee Date 27/10/2016Committee Feedback


received Type


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Objective 3



CAF Ref:208

4 4 16 3 3 9 0 0 0

Control Ref:



Internal / External

C1 2 2 Internal

C2 2 Sep-16 2 Internal



C5 2 Aug-16 2 Internal

C6 2 2 Internal

Date Risk Added:1/11/15

Risk:

Mental Capacity and Deprivation of LibertyIf the CCG fails to meet its responsibilities under the Mental Capacity ActMental capacity assessments and deprivation of liberty assessments may be undertaken inconsistently across commissioned services because of insufficient understandingThe consequence of this could be clinical failings in terms of safeguarding vulnerable people and the law may be broken due to unlawful deprivation of libertyThis could mean the CCG could experience damage to its reputation and possible legal action and cost.

Risk OwnerDirector of Quality and Integrated Governance Inherent risk score





Risk LeadDesignated Professional

(Adult)


pricipal risks.



it presented

Mental capacity Act (MCA) lead commissioned from Local Authority (LA)

04/02/16: Reviewed and revised. Reference to “Cheshire West” judgement removed as this has not proved to be a serious issue.. Consequence now thought to be less severe at 3, but likelihood that risk materialises has risen. Risk has increased from December assessment 4x1=4 to 3x3=9. Safeguarding lead for Adults is uncertain of the quality/quantity of service provided on our behalf by the LA MCA lead function.3 continuing health care cases currently in the Court of protection concerning disputed best interest decisions and 1 case of DOLS at home currently before a court.

Monitored by senior management at bimonthly meetings

CCG works to LA policy on MCAProvider self-audits required by Local Authority

CCG Safeguarding policy addresses MCA requirements Adults at Risk Policy presented to Safeguarding CommitteeReports from MCA lead to Safeguarding Adults Board

Additional training for providers by the LA safeguarding team can be provided at CCG request.

CCG commissioning staff receive mandatory Safeguarding training , which includes MCA principles.

Safeguarding Adults Annual report to Governing Body

Continuing Healthcare management has been commissioned from Whittington HealthcareQuarterly provider metrics to CCG. Data reviewed 6-monthly at Clinical Quality Review Group (meeting) with providers.

6 monthly reports Adult safeguarding lead to Quality and Performance Committee

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Objective 3


Cross Ref:

Delivery Date Owner Ref:

Review Committee Quality and Performance Committee Date 25/10/2016

Actionsactions taken to directly improve the effectiveness of controls Type


Committee Feedback


To review delivery of service from LA on MCA lead function. Currently restructuring.

Unclear position on other assurance sources. To review/discuss with MCA lead in Local Authority

Assurance

CCG lacks robust information from the LA on the activity/quality of work of the MCA lead function we have commissioned.

300 of 344

Objective 3



CAF Ref:215

3 5 15 2 4 8 0 0 0

Control Ref:


Date


Internal / External

C1 3 2 Internal

C2 2 2 Internal

C3 3 Aug-16 2 Internal

C4 2 2

C5 2 2 Internal

C6 3 July & Aug 2016 2 Internal * Support and development of local clinical leadersGaps in control

CCG assurance framework (Jan 15) included succession planning for GPs, staff and organisational development.

Reports from Medical Director to EMT


pricipal risks.



it presented

* Monitoring of key staffing indicatorsStaffing indicator comparisons with national averages and comparable CCGs.

* The CCGs management team and Governing Body forming close and overlapping professional relationships that diffuse knowledge and expertise across the CCG's functions

Lay member and a representative from the Local Medical Committee typically involved in Governing body recruitment.

No recrtuiment so far during 2016/17

* Close working with key stakeholders within Islington and with partners in the wider NHS

Close working with NCL CCGs, and NHS England to ensure CCG follows appropriate processes.A review of 'section 75' agreements with the Local Authority has covered all joint commissioning activity and helped strengthen teams..

Section 75 strategy and structure chart report to EMT

* Keeping roles and portfolios under review with the support of the CCG's Business Support Team and Project Management Office

* Having clear and robust recruitment processes that where appropriate follow the CCG's constitution

The CCG's constitution is approved by NHS England and kept under active review in terms of both the role and appointment of Governing Body members.

Constitution on Website

Date Risk Added:

Risk:

Workforce and succession planningIf the CCG does not effectively recruit, retain or plan for succession for its workforce it may not deliver on its local leadership role, key projects, overall strategy and statutory obligations

Risk OwnerDirector of Quality and Integrated Governance Inherent risk score





Risk LeadDirector of Quality and Integrated Governance

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Objective 3



C2


received Type


Committee Feedback


We are developing mitigation plans with HR and are getting support from subject matter experts at the CSU with the aim of securing

continuity of service.


302 of 344

Objective 3



CAF Ref:407

5 4 20 3 3 9 0 0 0

Control Ref:


Date


Internal / External

C1


Date Risk Added:

Risk:

STP doesn't recognise or support the work of Haringey and Islington Partnership as the agreed direction of travel across all partners and so benefits to the population and sustainable services are not realised.

Risk OwnerChief Officer







received Type


To be populated To be populated


pricipal risks.



it presented



Review Committee Strategy and Finance Date 27/10/2016Committee Feedback


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Objective 3



CAF Ref:408

4 4 16 3 3 9 0 0 0

Control Ref:


Date


Internal / External

C1


Date Risk Added:

Risk:

The implementation of new NCL commissioning arrangement could result in a lack of focus and continuity in Islington leading to a decline in performance or deteriating relationships.

Risk OwnerChief Officer






Actionsactions taken to directly improve the effectiveness of controls or assurances Type


To be populated

To be populated


pricipal risks.



it presented



Review Committee Strategy and Finance Date 27/10/2016Committee Feedback


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Objective 4 Preventing and Managing Long Term Conditions

305 of 344


CAF Ref:322

F3 4 12 3 4 12 0 0 0

Control Ref:



Internal / External


C2 2

C3 3 Jul-16 2 Internal

C4 2

Cross Ref: Delivery Date Owner Ref:Head of the PMO

Head of the PMO

Actionsactions taken to directly improve the effectiveness of controls or assurances received Type


To develop risk share arrangements with other CCG’s for high cost, low volume activity, such as critical care. Control


Review Committee Strategy and Finance Committee Date 25/08/2016Committee Feedback

In the event QIPP remains unidentified, mitigations available to the CCG if financial performance deteriorates, includes: Contract challenges and escalation;Value Based Commissioning where 20% of the service value will be linked to an agreed set of outcomes;A review of the Better Care Fund investments;A critical care risk-share is being discussed as an option across NCL CCGs

QIPP workshops held to identify plans to meet £9m savings target. Gap reduced from £2.4m to £0.6m as a result. Monthly finance and QIPP reports to

Strategy and Finance CommitteeOperating plan delivery group reports/papers to S&FProgress on contract negotiations

To build QIPP into contract baselines Control

Programme Management Office processes are in place and the operating plan delivery group meets monthly.

None stated

Project management Office in CCG horizon scanning to identify QIPP schemes from elsewhere None stated

Operating plan delivery group. In CCG to identify and delivery QIPP opportunities£5.7M savings identified to date. Plan is to meet £9M target. The development of QIPP schemes and additional transformational stretch QIPP schemes are being overseen by the Strategy and Finance Committee.

Monthly finance and QIPP reports to Strategy and Finance CommitteeOperating plan delivery group reports/papers to S&FProgress on contract negotiations

RISKS REMOVED FROM THE CAF

ControlsSpecific tasks and measure implemented to mitigate the effect of the pricipal risks.

Date Risk Added:

Risk:

Achievement of QIPP target for 16/17

The CCG has set a £9 million QIPP target for 2016/17. There is a risk that the CCG will notbe able to identify sufficient additional schemes within the financial year to close theexisting gap in the plan; and that any significant deviation in plan would be more difficultto rescue later in the financial year. A key challenge is managing providers' performancein line with agreed contract value.

Risk Owner

Director of Commissioning Inherent risk scorebefore we consider any mitigation


Risk Tolerance The level of risk the CCG will tolerate

in line with the risk appetite



Evidencewhat was received and where was it

presented

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BAF Ref:206

3 5 15 3 3 9 0 0 0

Control Ref:



Internal / External

C1 2 2 Internal

2 2 Internal

C2 2 2 Internal

C3 2 2 Internal

C4 2 1 Internal

Cross Ref: Delivery Date Owner Ref:

PPI & Engagement Manager

PPI & Engagement Manager

The Business Support Team has been handling complaint and feedback to the CCG. They have been trained by the CSU on signposting patients to where they can best raise concerns and supporting people to be more able to complain.

The Patient and Public Participation (PPP) Committee oversees patient

engagement and complaints while the Quality and Performance Committee

Committee Feedback Quality and Performance Committee agreed the risk was no longer material given responsibility for complaints lies outside of the CCG.




CCG Quality objectives

CCG engagement work to seek opinion and comment from local residents includes:• Public events• Media publicity• Use of social media• Community researchRelationships with voluntary sector and local council

Health Voice Ilsington Annula Data feedback report to PPP Committee provided positive insight as to patient views on strengths and weaknesses of services

Comments and feedback obtained by providers will also be reported to the Quality and Performance Committee.

Review Committee Patient and Public Participation Committee Date 30/04/2016

As part of meeting Equality Objectives CCG will be• Raising awareness with providers

• Introducing metrics to monitor training within providers• Working with providers to ensure comments are fed to CCG ( as well as complaints) Control None stated

As highlighted already through research carried out by Healthwatch and further community research how patients complain is now an Equality objective and a series of Healthwatch recommendations will

be addressed as part of this. Control

The CCG works closely with Healthwatch to give bi-monthly reports to the Patient and Public Participation (PPP) Committee.

Regular reports to the PPP Committee The PPP Committee also receives regular

reports from Healthwatch.

CCG contracts require providers to seek and consider and report on all feedback (not just complaints)

Date Risk Added:

Risk:Fragmented and ineffective complaints systemsIf the complaints systems of local health care organisations are not linked or set up to exchange information, then- patients may be reluctant to complain, or comment and feed back, because of reduced confidence in the system; and- the CCG and wider system may not hear about problems and learn from patient complaints, comments and feedback to plan, improve and deliver high quality healthcare services-This may damage the CCG’s reputation

Risk Owner






presented




Risk LeadPPI & Engagement

Manager

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BAF Ref:323C, R

3 4 12 3 4 12 0 0 0

Control Ref:



Internal / External






C1 31/10/2016

Head of Children's Commissioning

Committee Feedbackrisk reduced from high to medium following re-evaluation against the CAMHS and other risks. This remains on the risk register and is managed through the Q&P Committee.


An external review has been commissioned to improve the service model and productivity. This is due to report in October to EMT.

Assurance


Waiting times measured in contract meetings with providersContract monitoring reports to Quality and Performance CommitteeClinical Quality review group

Actions Type Gaps In Control / Assurance

Virements within children’s budgets to support waiting list reductionContract monitoring reports to Quality and Performance CommitteeClinical Quality review group

Child and Adult Mental Health services Transformation plan: some financial support has been provided CAMHS transformational plan has helped to reduce waiting times. Utilisation of funds set aside for SEND reforms also used.

Contract monitoring reports to Quality and Performance CommitteeClinical Quality review group




presentedEstablished triage process to ensure appropriate referral

The service waiting time has continued to increase and we now have C&YP who will not be assessed prior to school entry.

Contract monitoring reports to Quality and Performance CommitteeClinical Quality review group

Date Risk Added:

Risk:

Increased autism referralsIf the CCG cannot commission effectively in response to increased Autism referrals fromhealth and education for expert assessment and diagnosis, resulting in longer waitingtimes, • we may not be meeting the health needs of our residents in terms of immediatesupport and access to wider educational support and • may suffer damage to our reputation

Risk Owner

Director of Commissioning Inherent risk scorebefore we consider any mitigation




Risk LeadChildren's Commissioning

Manager

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BAF Ref:325

4 4 16 4 3 12 0 0 0

Control Ref:


Date


Internal / External

C1 1 2 Internal


C3 1 2 Internal


C2

Review Committee Quality and Performance Committee Date 28/06/2016Committee Feedback




Meeting Sarah Thompson Enfield CFO and NHSE to establish latest position against action log. Assurance

Enfield lead, taking on additonal project lead, IT and administrative capacity to support mobilisation.




presented

NCL mobilisation risk register is reviewed fortnightly as part of the mobilisation steering group

NHSE attend NCL project team meetings, assurance meetings, and Healthy London Partnershp Imput from NHSE in to assurance meetings and the movement of action log. Action Log

Date Risk Added:

Risk:

New NHS 111 and out of hours service start dateThe start date for the new integrated NHS 111 and GP out-of-hours service is scheduled to be 1st October 2016. It is possible that NHSE may not have completed all their assurance checks in time, potentially leading to a delay in the mobilisation date. This would significantly impact on the provision of OOH services as the current provider is unable to continue the provision past 1st October 2016.

Risk OwnerDirector of Commissioning





Risk LeadAssistant Director Special

Projects

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9 November 2016 TITLE: Report of the Chair of the Audit Committee LEAD GOVERNING BODY MEMBER:

Lucy de Groot, Chair of the Audit Committee

AUTHOR: Ahmet Koray, Chief Finance Officer Jonathan Smith, Finance Manager

CONTACT DETAILS:

[email protected] [email protected]

SUMMARY: The Audit Committee reviews the governance and assurance processes on which the Governing Body places reliance. Through scrutiny and comment on the adequacy and effectiveness of the overall governance, internal control and risk management arrangements across the CCG’s activities, the Committee supports the content of the Annual Governance Statement whilst demonstrating how it has met its terms of reference. The Chair of the Audit Committee provides a report to the Governing Body following each Committee meeting. This report outlines the agenda items, discussion and decisions made by the Audit Committee at its meeting on 29 September 2016. This report contributes to: Delivering high quality, efficient services within the resources available. Audit Trail: This is a summary report of the work of a committee. Patient & Public Involvement (PPI): Not required for a summary report. Equality Impact Assessment: Not required for a summary report. Risks: Any risks were outlined in the papers. RECOMMENDED ACTION: The Governing Body is asked to:

• RECEIVE ASSURANCE that the Committee has been considering all key issues within the scope of its terms of reference.

SUPPORTING PAPERS: None

Item: 5.3

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1. EXECUTIVE SUMMARY 1.1. This report outlines the agenda items, discussion and decisions made by the Audit Committee at its meeting on 29 September 2016.

2. EXTERNAL AUDIT PROGRESS REPORT 2.1. It was reported that since the last Committee meeting, the audit of the 2015/16 annual report and accounts was completed, with an unqualified opinion. There was also an unqualified value for money conclusion. 2.2. The technical update presented included:

• a new CCG improvement and assessment framework; • NHS funding growth to 2020; • an NHS England briefing to complement the Five Year Forward View

financial assessment, indicating the likely requirement for continuing savings;

• a Care Quality Commission (CQC) report on addressing inequalities in end of life care;

• clarification on conflicts of interest from NHS England; • staff survey results from NHS England.

2.3. The 2016/17 audit was at the planning stage and a meeting had been arranged with the CCG to agree the plan. 2.4. The Committee ACKNOWLEDGED the update. 3. RISK MANAGEMENT BENCHMARKING

3.1. External Audit presented the results of a London-wide benchmarking exercise, highlighting the fifteen highest frequency strategic and emerging risks. It was noted that the CCG’s risk register has a relatively high number of risks managed at Governing Body level, only a few of which are high. 3.2. Risks registered by the CCG include the following most common ones:

• failure or changes by providers; • QIPP delivery; • Staffing levels; • financial reporting and cost risks; • organisational priorities/governance.

3.3. The Committee ACKNOWLEDGED the report.

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4. ANNUAL AUDIT LETTER

4.1. External Audit presented the letter, which summarised the key issues arising from the audit of the 2015/16 annual report and accounts. These issues were detailed in the ISA 260 Audit Highlights Memorandum presented in the previous meeting and confirmed the positive opinion. The letter also outlined other aspects of the service provided to the CCG and the fee charged. 4.2. The Committee ACKNOWLEDGED the report.

5. INTERNAL AUDIT PROGRESS REPORT 5.1. Internal Audit presented an update on work done on behalf of the CCG, including final reports on Safeguarding Adults & Children (Amber/Green or reasonable assurance) and Continuing Healthcare (Amber/Red or partial assurance). Recommendations were issued in the reports according to the following priorities:

Report High Medium Low Safeguarding 0 3 4 Continuing Healthcare 2 6 3 5.2. The Safeguarding report raised no issues regarding children. Issues regarding adults included the lack of a designated professional but recruitment to the role was stated to be underway. 5.3. The high priority recommendations for Continuing Healthcare were to ensure that patients receiving care had signed contracts and to systematically review high cost packages. Concern was expressed that the report had not been reviewed by the Chief Finance Officer and had appeared in the Committee papers. It was agreed that this communication problem would be taken up outside the meeting and that an action plan would be developed to address the issues raised in the report. 5.4. The Committee took ASSURANCE from the update. 6. HEALTH MATTERS 6.1. Internal Audit presented the first quarterly Health Matters publication. This focused on continuing challenges including cyber risk, a recent tax change, financial governance, cost improvement plans and sustainability and transformation plans. 6.2. The Committee ACKNOWLEDGED the report.

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7. NORTH EAST LONDON COMMISSIONING SUPPORT UNIT (NELCSU) ASSURANCE PLAN PROGRESS REPORT

7.1. Internal Audit presented a report on work done on behalf of the CSU, including draft reports on Business Continuity and Procurement. It was planned to present final versions to the CSU Assurance Group later in October. 7.2. The CFO raised a concern regarding the CSU’s request for delegated authority to make payments up to £20m on behalf of the CCG. External Audit supported his concern. 7.3. The Committee took ASSURANCE from the report and agreed for the delegation matter to be reviewed in response to comments. 8. LCFS PROGRESS REPORT 8.1. Internal Audit presented a report on behalf of LCFS, detailing progress during the year. 8.2. Work undertaken in accordance with the plan included:

• delivering a fraud and bribery awareness session for CCG staff; • delivering a bespoke fraud awareness training session for GPs; • reviewing pre-employment checks processes.

8.3. Proactive work undertaken included:

• supplying the CCG with an updated induction pack on counter fraud; • issuing CCG staff with the quarterly counter fraud newsletter; • completing and submitting the NHS Protect self-review tool; • attending the NHS Protect London forum; • issuing guidance to relevant staff on the National Fraud Initiative.

8.4. The Committee took ASSURANCE from the report. 9. RISK DEVELOPMENT, BOARD ASSURANCE FRAMEWORK REVIEW AND RISK MANAGEMENT POLICY 9.1. A paper was presented explaining work to streamline risk management and enhance the way that risk is managed and reported. The review comprised the following four stages:

• restructuring the Board Assurance Framework process and document; • introducing risk tolerance to the BAF process; • reviewing the content within the Corporate Risk Register to provide greater

consistency and clarity around the information provided; • reviewing the risk management policy to reflect best practice guidance.

9.2. The Committee ACKNOWLEDGED the risk development review and APPROVED the Board Assurance Framework.

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10. QUALITY & PERFORMANCE COMMITTEE ASSURANCE REPORT 10.1. A report was presented summarising how the Committee had discharged its responsibilities over the previous year and its planned work for the future. The Committee Chair felt that items were sometimes slow-moving, resulting in actions not being cleared. The CFO responded that these actions had led to regular meetings with UCLH and the Whittington to discuss performance and escalate issues. 10.2. The Committee took ASSURANCE from the report. 11. CONFLICTS OF INTEREST UPDATE 11.1. It was stated that a revised policy would go to the Governing Body in November. 11.2. The Committee took ASSURANCE from the update. 12. PRIMARY CARE CO-COMMISSIONING UPDATE 12.1. It was reported that NCL-wide agreement on the level three delegation process would be affected due to some Camden practices abstaining from the vote. Options were being explored in light of this development and a report was to be circulated to Committee members outside the meeting. 12.2. The Committee took ASSURANCE from the report. 13. WAIVERS REPORT 13.1. The report outlined the agreement by the Executive Management Team to waive all the Last Years of Life contracts to March 2018, which was necessary because staff departures meant a full procurement exercise was impossible in the short term. A procurement project plan for 2018/19 was expected to be submitted in October. 13.2. The Committee APPROVED the waivers agreed by the Executive Management Team since the last meeting. 14. AUDIT COMMITTEE WORK PLAN 14.1. The Committee AGREED that its next two meetings would be in January and March, with the plan to be reviewed by the Chair before the next meeting. 15. EXTERNAL AUDIT RECRUITMENT PROCESS 15.1. The CSU Director of Procurement & Finance presented a paper updating the Committee on the work being undertaken to procure and award the external audit contract for 2017/18 by 31 October 2016. The Committee ACKNOWLEDGED the paper.

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Item: 5.4

MEETING: Islington Clinical Commissioning Group Governing Body Meeting DATE: 9th November 2016 TITLE: Report of the Chair of the Patient and Public Participation Committee LEAD COMMITTEE MEMBER:

Dr Katie Coleman, Vice Chair, Committee Chair

AUTHOR: Elizabeth Stimson, Engagement Lead CONTACT DETAILS: [email protected]

SUMMARY:

The Patient and Public Participation Committee is responsible for ensuring that the CCG fulfils its commitment to develop relationships with patients and the public in Islington through reviewing the processes of, and the decisions and actions taken by the organisation. The Committee also monitors risks in areas relating to its remit and approves relevant CCG policies.

This report provides a summary of how the Committee discharged its responsibilities at the June 2016 Committee meeting, highlighting issues of note for the Governing Body. Reports considered by the Committee are available on request from the Committee Secretary.

The report also informs the Governing Body of key areas of planned work for the next Committee meeting.

The minutes of the Committee’s meeting in June 2016 are available upon request.


Audit Trail: This is a summary report of the work of the Committee.

Public and Patient Involvement (PPI): Not required for a summary report

Equality Impact Assessment: Not required for a summary report

Risks: 1. There is a risk that the CCG will not meet its individual or collective duties to involve

patients, service users, carers and residents.2. There is a risk that the CCG will not meet its statutory requirements on equality and diversity

if it does not actively respond to inequalities existing within the health and care economy.

Resource Implications: None identified.

RECCOMMENDED ACTION: The Governing Body is asked to:

• RECEIVE ASSURANCE that the Patient and Public Participation Committee has beenconsidering all key issues within the scope of its terms of reference.

SUPPORTING PAPERS: Minutes of the meeting held on 3 June 2016 are available upon request.

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1. Executive summary:At the Committee meeting held on 3rd June 2016, the Committee received the reports scheduled in the work plan for 2016/17.

2. Terms of ReferenceThe Terms of Reference were agreed by the Committee.

3. Equality and Diversity ReportThe Committee received a report on the CCG’s Equality Objectives and the equality and diversity research which has taken place across the year. They were given an update on how the objectives for the past year with recommendations for the year ahead.

Key points were: • While the work on interpreting services had developed, uptake of language line was still low

among GP practices. Patient experience also reported a poor experience in acute services,thus, further attention needed to be given to this objective for the year ahead;

• The experience of Learning Disability patients was highlighted as being poor and an area forfocus for the year ahead;

• More attention needed to be given to the visibility of the CCG’s leadership’s commitment toequality and diversity within the organisation. This objective would continue for the yearahead.

4. Joint Commissioning UpdateThe CCG received an update from the work of the Joint Commissioning team.

The team has recently restructured and created a new Quality and Performance function which aims to increase the reach and impact of service user and carer involvement across Adult Social Care and joint commissioned services.

There has been a significant increase in reporting on service user engagement, consultation and coproduction across commissioned services as well as in commissioning teams. It was highlighted this was considered as vital to ensure quality assurance, collaborative commissioning, effective service delivery, and service development. Islington’s Framework for User Involvement and Reward and Recognition policy were recently cited by the Social Care Institute for Excellence as a good practice example in their guide ‘Co-Production – what is it and how to do it’.

Alongside this the Making it Real programme has also continued to drive forward work on personalisation by further embedding personalisation and co-production following the Making it Real concordat which outlines how we work as equals with service users and carers to develop personalised services.

Overall there were high levels of engagement across Joint Commissioning areas, with strong plans and efficient resources in place to develop these further

5. HealthWatch ReportHealthWatch gave an update on their work for the last year. Key highlights were:

• The work with volunteers, and their approach to volunteering, was celebrated as the best inthe country at the Healthwatch network awards in June.

• The work which began nearly two years ago, to increase the use of interpreting services inIslington GP practices, was beginning to show results. Overall the number of bookings in thelast six months has increased, and more practices are offering interpreting.

• Healthwatch worked with Islington Council and two local providers, to reach some 600people receiving council funded care in their own homes, providing signposting to those thatneeded it and helping with enquiries.

• Mystery shoppers visited local hospitals and phoned local GP practices, to find out howeasy it was for patients on low incomes to receive support under the Healthcare TravelCosts Scheme. The findings brought about an immediate change of policy at Moorfields Eye

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Hospital, and an eventual one at the Whittington Health. Islington Clinical Commissioning Group also raised awareness of the scheme with GP practices.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Report of the Chair of the Quality and Performance Committee LEAD GOVERNING BODY MEMBER:

Sorrel Brookes, Lay Vice-Chair

AUTHOR: Helen Keynes, Head of Quality CONTACT DETAILS:

Helen [email protected]

SUMMARY: The Quality and Performance Committee is responsible for the oversight and monitoring of:

• The quality and effectiveness of commissioned services, including patientexperience and safety; and

• Performance against service delivery indicators.

It also monitors risks in areas relating to its remit, approves relevant CCG policies, and receives reports on workforce planning and development from the Community Education Provider Network (CEPN).

This report provides a summary of how the Committee has discharged its responsibilities during September and October 2016, highlighting issues of note to the Governing Body. Reports considered by the Committee are available on request from the Governing Body Secretary.

The report also flags up, for the Governing Body’s attention, key areas of planned work during November and December 2016.

The minutes of the Committee’s meetings in August 2016 and September 2016 are available on request and provide a complete and accurate record of the business transacted.


Audit Trail: This is a summary report of the work of a committee.

Patient and Public Involvement (PPI): Not required for a summary report.

Equality Impact Assessment: Not required for a summary report.

Risks: The Committee considered risks within its remit which are outlined in the report.

Resource Implications: None identified.

Item: 5.5

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RECOMMENDED ACTION:


• RECEIVE ASSURANCE that the Committee has been considering all key issueswithin the scope of its terms of reference

• NOTE the changes in the risk profile.

SUPPORTING PAPERS: Minutes of the August and September meetings are available upon request.

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1. Executive summaryAt its September and October meetings the Committee received the reports scheduled inits work plan for 2016/17.

2. Quality and effectiveness of commissioned services

As part of its programme of periodic reports the Committee considered the quality and effectiveness of services commissioned from major providers: University College Hospital NHS Foundation Trust (UCLH), Camden and Islington NHS Foundation Trust (C&I), and Moorfields Eye Hospitals NHS Foundation Trust (MEH). The Committee last focused on these providers in June 2016 (UCLH) and July 2016 (C&I and MEH). Since then there have been regular Clinical Quality Review meetings that have been attended by senior directors and clinicians. The Committee noted the issues that had been discussed and the action put in place to address risks and issues.

The Committee also received the following reports:

• CCG Adults at Risk Policy;• Update on Community Education Provider Network (CEPN);• Other providers: Barts Health NHS Trust, Homerton NHS Foundation Trust, Royal

Free NHS Foundation Trust;• Urgent Care General Practice Out of Hours and NHS 111 (Care UK and LCW);• Continuing Health Care;• CCG Safeguarding group terms of reference;• Quality and Performance Committee terms of reference.

Matters highlighted in the Director’s report to the Committee included:

• Care Quality Commission (CQC) reports for: East London Foundation Trust rated‘Outstanding’, Marie Stopes International Clinics services operating underrestrictions, Adastra (Private provider of substance misuse services) appealed theCQC notice of cancellation of registration. Moorfields Eye Hospitals NHSFoundation Trust have received their draft CQC planned hospital inspection reportfor factual accuracy checking.

• Never Event National Framework consultation• Psychiatric liaison services at Whittington A&E• National CQUINs for 2017/18 and 2018/19• Issues covered at joint meetings of the Directors of Quality for North Central London

CCGs.

3. Performance against service delivery indicators

The Committee considered the regular monthly CCG overview reports on performance focusing particularly on:

• Diagnostic waits;• Cancer indicators;• 18-week Referral-to-Treatment targets;• A&E waiting times;• Mixed sex accommodation;• Infection control; and• Ambulance call response targets.

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• Community waiting times; REACH, MSK and district nursing.

As part of its programme of periodic reports the Committee also considered performance at Whittington Health, UCLH, LCW, and Care UK.

4. Risks

The Committee reviewed the risks falling within its remit. In October risk 410 that highlights the overarching risk in relation to the quality and delivery of community services was added to the risk register. The committee continues to monitor the previous risks raised regarding UCLH diagnostic and referral to treatment waits and, nursing home and domiciliary care provision in the borough. No risks were proposed for deletion.

5. Planned work

In addition to the standing agenda item on overall performance, the Committee will be considering the following during November and December.

• Q1 2016/17 Serious Incident report• Last Years of Life update• Child Death Annual Report• Performance and/or quality reports from/on UCLH; the GP out of hours and NHS

111 service; Whittington Health.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: 9th November 2016 TITLE: Report of the Chair of the Strategy & Finance Committee LEAD GOVERNING BODY MEMBER:

Ian Huckle, Practice Manager Representative


[email protected]

SUMMARY: The Strategy and Finance Committee is responsible for financial monitoring, and the oversight of the development and implementation of strategic plans including associated financial plans. The Committee also monitors risks in areas relating to its remit, approves relevant CCG policies, and approves commissioning proposals making direct and final commissioning decisions in accordance with the CCG’s Scheme of Delegation. This report provides a summary of how the Committee has discharged its responsibilities during September and October 2016, highlighting issues of note to the Governing Body. Reports considered by the Committee are available on request from the Committee Secretary. The minutes of the Committee’s meetings in August 2016 and September 2016 are available upon request. This report contributes to: Delivering high quality, efficient services within the resources available. Audit Trail: This is a summary report of the work of the Strategy and Finance Committee. Patient & Public Involvement (PPI): Not required for a summary report. Equality Impact Assessment: Not required for a summary report. Risks: The Committee considered in detail risks within its remit which are outlined in the report. Resource Implications: None identified.

Item: 5.6

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RECOMMENDED ACTION: The Governing Body is asked to: • RECEIVE ASSURANCE that the Strategy & Finance Committee has been considering

all key issues within the scope of its terms of reference.

SUPPORTING PAPERS: Minutes of the August and September 2016 meetings are available upon request. 1. Executive summary At the Committee meetings held in September and October 2016, the Committee received the reports scheduled in the work plan for 2016/17. 2 Planning and delivery of plans In September:

• The Committee received an overview of planning guidance for 2017/18 and 2018/19 published on 22 September 2016, with the update focusing on:

o The requirement for CCGs and providers to meet their financial duties in 2016/17, as a building block for delivering financial targets for the next two years;

o The requirement to complete two-year operating plans, and sign supporting contracts with providers, for 2017/18 and 2018/19 by 23 December 2016;

o Emphasis in the guidance on delivering operational and financial sustainability across Sustainability and Transformation Plan (STP) footprints as well as for individual commissioners and providers, and a supporting collaborative approach to agreeing contracts;

o The need to deliver NHS Constitution waiting time standards (including for mental health), and additional requirements relating to delivery of five year forward views for mental health and primary care and the Transforming Care agenda for people with learning disabilities;

o The inclusion of performance metrics for STP footprints were to be agreed as part of the planning process for the North Central London plan;

o The Committee then received an update on work in preparation of contract negotiations for 2017/18 and 2018/19.

• The Committee received an update on progress with the Islington Integrated Care Pioneer Programme and in particular on:

o Delivery of performance metrics in the Better Care Fund; o Establishing health and care networks with fourteen networks established

providing multi-disciplinary meetings for 200 patients per month; o Development of the prevention offer including for social prescribing; o Islington becoming a national pilot for Integrated Personalised Commissioning

with a joined up approach to health and social care personal budgets; and o The procurement of external evaluation for the overall Pioneer Programme.

The Committee requested that the external evaluation return to the Committee when completed.

• The Committee received the medicines optimisation report with highlights being forecast expenditure for the year being within plan at month five, delivery of Quality

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Premium targets for reducing the use of antibiotics, and QIPP savings being on target for both primary care and acute services;

• The medicines optimisation report also set out progress with service developments including an expansion of pharmacists working in practices, the employment of a Darzi Fellow to work on psychotropic medication for people with learning disabilities and establishing Healthy Living Pharmacies. Development of the medicines optimisation strategy was progressing with an engagement event with GPs and community pharmacists being held on 13 October 2016 and the strategy being consistent with the direction of travel set out in the Five Year Forward View for Community Pharmacy;

• The Committee approved the medicines optimisation policy for working with the pharmaceutical industry that addressed the use of rebate schemes offered by the industry. The policy had been updated for comments from the Committee and from Islington Medicines Optimisation Group, and now included a framework and process for the review of potential rebate schemes.

In October: • The Committee received a further update on the NHS Operational and Planning and

Contracting Guidance published on 22 September 2016, and on local delivery plans in response. Over and above the update in the September papers the Committee was informed that:

o CQUIN funds remained at 2.5% of contract values and the national element (1.5%) would be used to support delivery of the Sustainability and Transformation Plan (STP), and the local element (1%) would be used to secure provider engagement in the STP (0.5%) and 0.5% added to a risk reserve for the STP;

o CCG allocations may alter for changes in the Identification Rules (IR) that allocated activity and costs between CCG and Specialist Commissioning responsibility.

• The Committee received a report on work to progress the local contract round for 2017/18 and 2018/19 including:

o The issue of commissioning letters to all providers by 30 September 2016; o Development of negotiation strategies for acute, mental health and

community contracts including development of the minimum income guarantee approach as an alternative contract form to payment-by-results for hospital contracts;

o Development of local timetables to meet the deadline of contract signature by 23 December 2016 including an escalation process;

o Updating the NCL Commissioning Strategy to reflect published planning guidance.

• The Committee received a verbal update on the second iteration of the North Central London Sustainability and Transformation Plan (STP) submitted to NHS England on 21 October 2016. Subsequent discussion focused on the need to further develop the engagement programme for the STP and align this to engagement activities for the Haringey and Islington Wellbeing Programme, translation of the activity assumptions into provider contracts for next year, and a review of workstream priorities;

• The Committee received an update on the Haringey and Islington Wellbeing Programme and in particular the agreement in principle by a joint meeting of the Health and Wellbeing Boards for Haringey and Islington to develop an Accountable Care Partnership (ACP) and that work to develop the detail of the ACP could be undertaken. The ACP would bring together commissioners and providers to work collaboratively and take responsibility for the cost and quality of care for a defined

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population (Haringey and Islington) within an agreed budget, thereby further progressing the work of the Wellbeing Partnership, underpinned by a formal partnership agreement. The Committee welcomed the ACP approach highlighting the commitment of Haringey and Islington Councils to the programme, the support the programme could give to managing delivery of STP service changes, and the importance of engaging UCLH and the GP Federation in the work of the Programme for Islington residents;

• The Committee received a draft of the Islington Health and Wellbeing Strategy (2017-2020) for comment as part of a six-week consultation process following Islington Health and Wellbeing Board (HWBB) approval of the draft strategy to go out to stakeholders. The strategy set out the priorities the HWBB would need to tackle to address the needs identified in the Islington Joint Strategic Needs Assessment. The strategy was well received by the Committee with comments focusing on ensuring alignment of priorities in the strategy with those included in the STP and Wellbeing Programme, a greater focus on cancer (prevention and treatment as a long-term condition), and confirmation that Child and Adolescent Mental Health and the “Think Family” approach featured as priorities in the strategy;

• The primary care update gave the Committee an overview of the development of team around the practice pilots to support general practice capacity, the requirements for delivery set out in the GP Forward View published by NHS England and priorities for primary care in the North Central London Sustainability and Transformation Plan. The Committee requested a progress report on the establishment of the Islington GP Federation at a future meeting and that the CCG build a database of GP Specialists to support the development of practice networks and to support maintaining referrals within Operating Plan assumptions.

3 Financial Monitoring In September:

• The Committee received the month five (August 2016) report showing that the CCG expected to meet the planned surplus for the year (£6.5m), but as in previous months was using all reserves and flexibility to achieve this to cover the reported pressure on acute contracts. Pressure remained on contracts with Whittington Health and UCLH and pressure emerged in month on the contracts with Barts Health and Imperial;

• The requirement to use non-recurrent solutions to balance the position in 2016/17 would add pressure to meeting financial targets in 2017/18;

• The Committee received a progress update on contract management plans for each provider including a maternity audit at Whittington health and UCLH scheduled for 14 October, contract challenges, deferral of Better Care Fund investments and release of year-end accruals. Mitigation plans reduced the pressure on acute contracts across North Central London from £61m to £15m; with solutions sought for the £15m balance;

• Non-acute cost pressures accrued from continuing health care (an investigation was underway) and one-to-one rehab costs at CNWL (a clinical audit was scheduled for November 2016);

• The Committee were informed that work was underway to reconcile and agree the quarter one position with providers by 14 October 2016, as a precursor to a settlement for the full year by the end of October 2016. The year-end settlement for 2016/17 was sought to provide a robust baseline for contract negotiations for 2017/18 and 2018/19 and to recover financial baseline assumptions in the NCL Sustainability and Transformation Plan (STP);

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• The Committee then received an update on contract negotiations for 2017/18 and 2018/19, with a national deadline of 23 December 2016 for contract signature. Work was underway with providers on developing contract forms that would support delivery of the STP. The focus with acute providers, through a working group, was to move from payment-by-results contracts to a minimum income guarantee approach as a step to moving towards a population based approach;

• The Committee received an overview of the financial strategy for North Central London, setting out how pressure on acute contracts would be managed across the CCGs in-year through mitigation plans and the conditions for any further support to individual CCGs.

In October:

• The Committee received the month six (September 2016) report for 2016/17 showing that the CCG still expected to meet the planned surplus for the year (£6.5m), but required the release of reserves and in-year flexibility to do so as in previous months;

• The main risks to delivering the planned surplus remained the pressure on acute contracts (£6.0m) and non-acute cost pressures for funded nursing care and one-to-one rehab costs charged by CNWL. The Committee were informed of actions to mitigate those risks through the maternity audit, additional capacity for continuing healthcare needs assessments and utilisation of Better Care Fund and winter pressures monies;

• Risks to in-year delivery of the planned surplus accrued from the acute contract position worsening, the need to confirm the charge-exempt overseas visitors allocation against the planned level of £2.5m, and the CCG being required to make any further contribution to the costs of the NCL Sustainability and Transformation Plan;

• The quarter one position had been agreed with Moorfields Eye Hospital but was yet to be reached with Whittington Health with outstanding items including A&E coding and critical care prior year charges;

• QIPP savings were showing a £1.2m shortfall against the target of £9m with slippage accruing from higher than planned levels of non-elective activity;

• A draft financial plan for 2017/18 had been produced based on business rules in the national planning guidance for 2017/18 and 2018/19. Initial working suggested the CCG could meet the £6.5m planned surplus (in-year breakeven position as the £6.5m surplus would be brought forward from 2016/17) if the acute contract position did not further deteriorate in 2016/17;

• In addition to maintaining the historic surplus position business rules for 2017/18 would require the CCG to hold a 1% non-recurrent reserve for system pressures and hold a 0.5% contingency reserve. Providers would receive a 0.1% contract uplift (2.1% increase for inflation less a 2% efficiency assumption), demographic growth of 1.6% would also be applied to contracts as would STP planning assumptions;

• The Committee were informed that in line with planning guidance a control total had been set for North Central CCGs; a £1.6m surplus for the year. The impact on the financial plan for Islington CCG was expected to be minimal and was being worked through. Providers had also received individual control totals for 2017/18;

• Plans for 2017/18 also included investment in primary care (3% of CCG baseline) required in planning guidance across 2017/18 and 2018/19;

• Baselines to inform opening contract offers to providers for 2017/18 and 2018/19 had been prepared by North East London Commissioning Support Unit;

• The Committee requested the escalation of long community waiting times at Whittington Health into the Wellbeing Programme.

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4 Risks In September:

• The Committee were informed of work to redesign the corporate risk register and align it to the Board Assurance Framework;

• Updates to individual risks falling within the remit of the Committee focused on progress with mobilisation plans for the integrated NHS 111 and GP out-of-hours service (start date 4 October 2016) and the continuing risk of the over performance on acute contracts to the 2016/17 baseline for the NCL Sustainability and Transformation Plan (STP);

• The Committee requested that a risk relating to delivering robust patient and public engagement on the STP be added to the risk register for the NCL plan.

In October:

• The Committee received an overview of risks falling within its remit in a revised report format;

• The Committee was informed that the integrated NHS 111 and GP out-of-hours service had gone live as planned on 4 October 2016 with daily monitoring indicating that the new service was working effectively, and additional nurse assessment capacity was being brought in to help reduce the pressure on funded nursing care and continuing healthcare placements;

• Risks on the register relating to the NCL Sustainability and Transformation Plan (STP) would be further developed and reported back to the Committee in November 2016 after the second iteration of the plan, submitted on 21 October 2016, had been through an assurance process with NHS England.

5 Approval of commissioning decisions In September and October 2016 the Committee received reports for information and did not make any decisions requiring ratification or notification to the Governing Body. 6 Planned work In addition to the standing agenda items on Risk, Finance, and Quality, Innovation, Productivity and Prevention (QIPP) plans and contracts, the Committee will be considering the following in November 2016 and December 2016:

• Urgent Care Programme update; • Planned Care programme update; • The development of operating plans, and supporting contracts with providers, for

2017/18 and 2018/19 by the national deadline of 23 December 2016; • Further development of the North Central London Sustainability and Transformation

Plan (STP), this will include an update on the work of the Islington and Haringey Wellbeing Programme that will contribute to the STP;

• Medicines optimisation performance report; • Themed updates on continuing healthcare and workforce; • Update on the Section 75 Agreement between the CCG and Islington Council; • Update on the Service Level Agreement for North East London Commissioning

Support Unit (NELCSU); • Quarterly Programme Summary that aligns the work of the CCG across local

delivery vehicles, Islington and Haringey Wellbeing Programme, and North Central London Sustainability and Transformation Plan.

The Committee agreed an updated workplan for the remainder of 2016/17 at the October 2016 meeting.

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Appendix 3

Voting Members Lay Member Representatives Ms Cathy Herman (Chair) Haringey CCG Ms Sorrel Brookes (Vice Chair) (Apologies) Islington CCG Ms Bernadette Conroy (Apologies) Barnet CCG Ms Kathy Elliott Camden CCG Ms Karen Trew Enfield CCG GP Representatives Dr Michelle Newman Governing Body GP Member, Barnet CCG Dr Neel Gupta (Apologies) Governing Body GP Member, Camden CCG Dr Alpesh Patel (Apologies) Governing Body GP Member, Enfield CCG Dr Dina Dhorajiwala Governing Body GP Member, Haringey CCG Dr Katie Coleman (Apologies) Governing Body GP Member, Islington CCG Officer Representatives Mr Leigh Griffin (Apologies) Director of Strategic Development, Barnet CCG Ms Susan Achmatowicz (Apologies) Director of Primary Care, Camden CCG Ms Deborah McBeal Interim Deputy Chief Officer, Enfield CCG Ms Jennie Williams (Apologies) Executive Nurse & Director of Quality, Haringey CCG Ms Alison Blair Chief Officer, Islington CCG Practice Nurse Representative Ms Katherine Gerrans Lead Nurse & Quality Workforce Manager, Haringey CCG NHS England Ms Liz Wise (Apologies) Director of Primary Care Commissioning, London Ms Ceri Jacobs Director of Commissioning Operations North Central and East

London Dr Henrietta Hughes (Apologies) Medical Director North and East London Non-Voting Members Ms Emma Whitby Chief Executive, Healthwatch Islington Mr Greg Cairns (Apologies) Director of Primary Care Strategy, Londonwide LMCs Dr Manish Kumar Chair, Enfield LMC In attendance Ms Fiona Erne (deputy for Ms Liz Wise)

Head of Primary Care, North Central and East London, NHS England, London Region

Ms Lucy DeGroot (for Sorrel Brookes) Mr Gordon Houliston (deputy for Ms Susan Achmatowitcz

Lay Member Islington CCG Head of Primary Care, Camden CCG

Mr Richard Jeffery (deputy for Ms Liz Wise) Director of Financial Management, NHS England, London Dr Jahan Mahmoodi (for Dr Alpesh Patel) Clinical Director, Enfield CCG Mr Matthew Powls (deputy for Mr Leigh Griffin)

Interim Director of Transformation and Performance

Cassie Williams

Assistant Director Primary Care, Quality and Development Haringey CCG

Minutes Ms Keziah Bowers NEL Commissioning Support Unit

North Central London Primary Care Joint Committee Minutes (Part 1) Date: Wednesday 27 July 2016

Time: 10.00 – 11.30

Venue: Committee room 1, Hendon Town Hall, Hendon, NW4 4AX

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1. Welcome and Apologies 1.1

The Chair welcomed the members and attendees to the North Central London Primary Care Joint Committee.

1.2

Apologies were received from Ms Sorrell Brookes, Ms Bernadette Conroy, Dr Neel Gupta, Dr Alpesh Patel, Dr Katie Coleman, Mr Leigh Griffin, Ms Susan Achmatowicz, Ms Jennie Williams, Dr Henrietta Hughes, and Mr Greg Cairns.

2. Declarations of interest 2.1

The Chair drew the attention of the Committee to the conflicts of interest register and asked if there were any other conflicts to be declared.

2.2

Ms Karen Trew clarified that her entry on the register should state that her role on a performer list decision panel is carried out outside of NCL.

2.3

Ms Katherine Gerrans requested an amendment to her entry on the register relating to Richard Cloudesley Trustee Ltd. This interest was declared on 31/5/2016 and not in 2015 as stated on the register.

2.4

Dr Dina Dhorajiwala noted that her practice is a neighbour of the Allenson House practice about which a decision is to be made. She informed the Chair that she would leave the room for this discussion item.

2.5

Action: Conflicts of Interest register to be updated for Ms Karen Trew and Ms Katherine Gerrans.

3. Minutes and actions from the previous meeting 3.1

The minutes of the previous meeting on 17 May 2016 were reviewed. The minutes were APPROVED.

4. Questions from the public 4.1

There were no questions from the public.

5. PMS Contract Partnership Changes

5.1

Ms Fiona Erne presented a paper requesting PMS contract partnership changes. These requests are brought to the Committee because PMS partners are all signatories in their own right and therefore all changes need to be approved individual. Practices are required to submit contractual change requests with 28 days’ notice to allow the commissioner to consider the appropriateness of the request. No concerns were identified by the NHS England contracts team and the recommendation is therefore to approve all the changes.

5.2

Ms Karen Trew asked whether it is possible to have some information about the patient / GP ratio where a partner has resigned and not been replaced or where there is an addition of a partner. Ms Fiona Erne confirmed that this is taken into consideration and any concerns would be brought as a separate paper to the Committee.

5.3

The members of Barnet, Camden and Enfield CCGs APPROVED the proposed partnership changes for: The Town Surgery (Enfield CCG) Oakwood Medical Practice (Enfield CCG) Parkview Surgery (Barnet CCG) St Andrews Medical Practice (Barnet CCG) Brondesbury Medical Centre (Camden CCG) The Holborn Medical Centre (Camden CCG) Keats Group Practice (Camden CCG)

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6. List Closure (Roman Way Medical Centre)

6.1

Ms Fiona Erne presented a list closure request for Roman Way Medical Centre. The practice has applied to temporarily close their list for six months as one partner left earlier in the year and the practice has not been able to find a suitable salaried GP or long term locum. The practice conducted a survey to seek patient’s views on temporarily closing the practice list. Almost all the patients that responded to the survey were in favour of list closure. NHS England are in support of the temporary list closure on condition that the recruitment of a GP is prioritised within this time and that family members of existing patients will continue to be able to register with the practice.

6.2

Ms Emma Whitby asked what would happen if the practice is unable to recruit? Ms Fiona Erne explained that steps are being taken to support recruitment. She also confirmed to a query from Ms Deborah McBeal that neighbouring practices have been consulted about whether they can receive additional patients.

6.3

Ms Alison Blair highlighted that this is a temporary closure. The CCG is having discussions with the wider clinical team to improve recruitment. They are also considering options for recruiting pharmacy support. Mr Gordon Houliston asked whether there is a maximum time that a practice list can be closed. Ms Fiona Erne responded that the maximum is 3 years, however this request is for 6 months initially. In answer to a question from Ms Katherine Gerrans as to whether there is a similar problem with nurse recruitment at the practice, Ms Alison Blair stated that the issue is primarily about GP recruitment, although she acknowledged that there is an ongoing practice nurse recruitment challenge in Islington and elsewhere.

6.4

The Islington CCG members of the Committee APPROVED the request for a temporary list closure.

7. Options Appraisal (Allenson House Surgery) 7.1

[Dr Dina Dhorajiwala left the room for this agenda item as her practice is a neighbouring practice to Allenson House Surgery and therefore may be impacted by the outcome of the discussion].

7.2

Ms Fiona Erne presented an outline options appraisal for Allenson House Surgery in Haringey. The single handed GP at this practice informed NHS England, in May 2016, of her intention to retire at the end of September 2016. NHS England have subsequently carried out patient engagement and reviewed the possible options. The recommendation is that the list be dispersed to neighbouring practices. The list size is under 3,000 and it would be difficult to find a new provider unless there is potential for growth of the list and in this case this seems unlikely.

7.3

Dr Michelle Newman asked for clarity on the NHS England process for list dispersal. She enquired about how much notice is usually given to patients and in particular vulnerable patients. Ms Fiona Erne confirmed that list dispersal generally only happens when a contract is resigned – this is usually given with 3 months’ notice. This provides a very short timescale to consult with patients and to look at viable options. NHS England will write to patients almost immediately. If this list is to be dispersed, vulnerable patients are automatically registered with other practices to ensure continuity of care but they can choose to register with a different practice if they wish to. NHS England will usually have at least one month’s notice to give to patients and to complete registration of vulnerable patients.

7.4

Ms Karen Trew noted that in this case the GP provided 5 months’ notice. However she queried what the decision making process is where only three months’ notice is provided given that the NCL Primary Care Joint Committee only meets every 2 months. Ms Fiona Erne explained that in this case it would be agreed early on whether a decision would need to be made using the Committee’s urgent decision making process.

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7.7 [Dr Dina Dhorajiwala was invited back into the room at the end of this discussion]

8. Standard Operating Procedure for Primary Medical Contracts (Responding to CQC ‘Requires Improvement’ notifications)

8.1

Ms Fiona Erne presented for approval a standard operating procedure for responding to CQC ‘requires improvement’ notifications. The purpose of this SOP is to support primary care commissioners to place due consideration on what have led to this notification and ensure that appropriate actions are taken to remedy any contractual quality and safety concerns. It is also intended to provide a consistent Londonwide guidance on issues to take into account when considering CQC reports that may require the issue of a contractual breach and remedial notice and / or alternative support. London LMC have been consulted and most of their comments are incorporated into the document.

8.2

Dr Jahan Mahmoodi asked what capacity NHS England have to carry out these additional reviews following a CQC notification. Ms Fiona Erne stated that national funding to support practice resilience has provided some resources to help manage this. She noted that commissioners’ responsibilities are twofold through either helping practices to stay above the CQC threshold and become sustainable and through dealing with the consequences of a CQC finding or other performance issues.

8.3

Dr Manish Kumar felt that the robustness of benchmarking data in the paper is limited by because the proportion of practices in London that have been inspected is lower than the proportion that have been inspected nationally, and due to the variation in the quality of CQC inspections that occur. He also felt that there was often a lengthy timeline between CQC inspections and reports and that the opportunity for practices to respond to a report is limited. Practices can be marked on the CQC website as requiring improvement long after the original inspection and when changes have since been made to the practice.

8.4

Ms Ceri Jacobs asked what lessons are being learnt from the CQC inspections. Ms Fiona Erne responded that NHS England and the CCGs are working to share knowledge and information between practices. Ms Deborah McBeal highlighted the importance of commissioners acting with consistency between how secondary care and primary care providers are managed following a CQC improvement notification.

8.5

Ms Cassie Williams queried whether there is more information about the exact process and timeline for deciding whether there would be a breach notice issued or whether CCGs will be asked to give further support. Ms Fiona Erne responded that the NHS England team would gauge whether or not to carry out either a desktop review or a practice visit in order to inform any decision about a breach notice. Such a decision would only be made at this Committee.

8.6

Ms Lucy de Groot reminded the Committee that as part of the wider NCL devolution discussions it was important to consider how NCL can be proactive and not need to wait for CQC inspections in order to identify where practices need improve. She felt that local commissioners and clinicians are best placed to review and support services. Ms Alison Blair agreed that how we support practices and primary care to improve quality and reduce variation is one of the key pieces of work that is being discussed as part of the NCL Sustainability and Transformation Plan. Dr Dina Dhorajiwala suggested that the preferred approach to supporting the system and providing value for tax payers’ money is to support practices to improve before moving to formal interventions. Ms Ceri Jacobs added that it would be useful to have some standard triggers laid out in the SOP about what process would be followed.

8.7

The Committee APPROVED the SOP for responding to CQC ‘requires improvement’ notifications but asked that they be updated as to whether there have been proposed amendments by any other Joint Committees in London.

8.8 Action: Update on any amendments to the SOP for responding to CQC ‘requires

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improvement’ notifications be brought to the September Committee.

9. Locally Commissioned Services (Enfield CCG)

9.1

Ms Deborah McBeal presented the specifications for two locally commissioned services for Enfield CCG. These were an integrated care locally implemented scheme and an atrial fibrillation and pre-diabetes locally commissioned service. She noted that these schemes were being brought to the committee to provide assurance that due diligence has been completed. The CCG are keen to delivery interventions as early as possible to improve patient outcomes. The service specs for AF and diabetes have been approved by the CCG’s finance & procurement committees for 1 year initially. She noted some slight amendments to the AF scheme in that this will be delivered by individual practices and not by locality. Payments for a record review of all AF patients will be delivered at a rate of £10 per patient and not £50 per patient as indicated. Total of £167k for the year (in the region of). There is some duplication with the core GP contract and Quality and Outcome Framework (QOF) requirements but the targets within the paper are over and above those QOF and contract targets.

9.2

The Committee APPROVED that appropriate due diligence had been completed for these schemes.

10. Committee Work Plan

10.1

Ms Alison Blair presented the proposed workplan for the Committee for 2016-17. She noted that this plan is intended to be a general guide but additional items will be added as required. CCG primary care commissioning intentions will need to be brought later in the year as part of the work of the NCL STP. This will be planned provisionally to be included in September and November.

10.2

Ms Fiona Erne noted that bids for the Estates & Technology Transformation Fund (ETTF) are currently being shortlisted. These have already been reviewed by local CCG meetings, however she suggested that they might also come to the September or November NCL Primary Care Joint Committee. Mr Gordon Houliston confirmed that Camden CCG intend to bring a locally commissioned scheme to the Committee in September 2016.

10.3

Ms Kathy Elliott queried whether there were other estates programmes in NCL which should also be brought to this committee. Ms Alison Blair confirmed that estates planning is taking place through the forum of the NCL Sustainability and Transformation Plan. Ms Kathy Elliott suggested that it was important that this work and primary care be aligned. She would wish to be assured that primary care estates is being given sufficient thought alongside acute and other estates. Ms Lucy de Groot suggested that one paper on estates and STP be brought to the Committee to provide the wider context and to demonstrate how these fit together. It was agreed by the committee that this would be helpful.

10.4

Ms Alison Blair suggested that an item on provider development also be added to the workplan. An item on this could be brought to the September or November meetings. Ms Karen Trew commented that workforce also needed to be considered and how this links to the STP. She noted that whilst this committee primarily focused on the primary are budget held by NHS England, consideration needed to be given to primary care investment that is coming from other funding routes e.g. STP funding. Ms Alison Blair highlighted that these areas of work are not part of the formal business of the committee but agreed that they are part of the wider context. NCL is developing a financial strategy as part of the STP. Primary care will be included within this.

10.5

Mr Richard Jeffery confirmed that the intention is that published allocations are part of the wider STP discussions. Ms Fiona Erne added that the ETTF is not the only capital revenue that is driving commitments. These will all have an impact on the wider NCL GP budget. Dr Jahan Mahmoodi stated that the NCL providers have been meeting together and it would be helpful to ensure that any agenda item on provider development is aligned with this. Ms Alison Blair agreed with this and noted that there is also London provider development work underway which also needs to be aligned with.

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10.6

The Committee APPROVED the proposed work plan and agreed that the following items be added to the plan:

• CCG Primary Care Commissioning Intentions (September or November 2016) • Camden CCG Locally Commissioned Service (September 2016) • Estates & Technology Transformation Fund (ETTF) projects (September or November

2016) • Sustainability & Transformation Plan updates to include estates, workforce and finance

context (September or November 2016) • Provider Development Update

10.6 Action: Committee workplan for 2016-17 to be updated with agreed additional items.

11. Draft Risk Register

11.1 Ms Alison Blair presented the draft risk register for the Committee. She noted that this is still in development and welcomed any comments.

11.2

Ms Cassie Williams suggested that the risks be rated both before and after the mitigation i.e. to show whether the proposed mitigations had effectively reduced the risks. Ms Karen Trew felt that it was a good start to the register. She queried whether risks relating to the delivery of the STP should also be added to the register e.g. in relation to workforce recruitment and development. Ms Alison Blair responded that this register needed to relate to the Committee’s Terms of Reference although she acknowledged that there are wider risk to primary care which sit outside of the remit of this Committee.

Action: Risk register to be updated to show rating before and after risk mitigations.

12. Finance Report

12.1 [This item was moved forward in the agenda as Mr Richard Jeffery was unable to be in attendance for the full length of the Committee meeting.]

12.2

Mr Richard Jeffery provided a finance update to the Committee. He noted that the report included in the Committee papers is for Month 2 which is still very early in the financial year. The actuals for primary care are still not settled for 2015/16 Quality & Outcome Framework (QOF) payments. There are also still no changes to the quarterly census in terms of list size. This will be the same for Month 3. From Month 4 onwards a clearer picture will emerge of actual in year performance.

12.3

Ms Karen Trew observed that nothing had been achieved in Quality, Innovation, Productivity and Prevention (QIPP) savings and this has had to be balanced by reductions in premises and elsewhere. She asked whether the Committee needs to have a report around QIPP and where these savings will be found. Mr Richard Jeffery responded that a modest QIPP has been built into budgets this year compared to last year. These are expected to come from rates appeals which are happening around London. They are currently being processed quite slowly but where they are coming through they are generally delivering significant savings for the tenants and therefore for rent reimbursement. It is anticipated that rate reductions will be recorded as a separate QIPP item so that we can see across London what those savings have been. Whilst these are not being shown in the monthly reports, that information is being gathered.

12.4

Ms Karen Trew referred to the exclusions on the report and asked what the implications of those exclusions are. Mr Richard Jeffery explained that these are NHS England business rules which are funded from the primary care budget but have to be held separately until there is national or DH treasury process to release that funding. These are there as contingency against any unexpected costs. None of these impact on the operational balance.

12.5 The Committee NOTED the finance update. Page 6 of 11

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12.6 [Mr Richard Jeffery left the meeting at the end of this discussion].

13. Quality & Performance

13.1

Quality & Performance Report Ms Fiona Erne presented the quality and performance report and noted that London appears to be performing more poorly than other parts of the country. She has requested deeper analysis of this at an SPG level. The Quality and Outcome Framework (QOF) data included in the report is relatively out of date as we await the new QOF data. Findings from CQC inspections have also been included. These are primarily risk based but it is hoped that next phase of CQC inspections will also consider performance.

13.2

Dr Michelle Newman queried the emphasis on the Friends and Family Test (FFT) as she feels that this is not a good outcome measure and perhaps a better measure should be sought. Ms Fiona Erne noted the limitations of friends and family test and agreed that it needs to continue to be improve but highlighted that it has now been implemented nationally and therefore must continue to be used as an indicator. Ms Cassie Williams agreed with the concerns about the FFT. She noted that the report proposes that breach or remedial notices be issued where returns for the FFT have not been submitted but she was not aware of any work that is being done to support practices with this and CCGs don’t currently receive information on which practices are not submitting their returns. Ms Fiona Erne responded that NHS England are looking to set up a working group to review how the FFT is being implemented and how it can be revitalised. The LMC will be included in this discussion.

13.3

Dr Dina Dhorajiwala asked whether consideration has been given to reviewing performance data by contract type (i.e. PMS/GMS) as there are different financial implications for these. Ms Fiona Erne confirmed that this would need to be considered through the wider discussion about proposed changes to reporting.

13.4

Ms Karen Trew noted that London is performing poorly in patient feedback. She asked whether there is anything that this Committee can do to support this. Ms Fiona Erne stated that the survey results focus on access and London does have the highest number of smaller and singlehanded practices and it is much harder for these practice to make changes to access the way that larger practices can. She also felt that this data may reflect how patients perceive the role of practice nurses i.e. the data suggests that patients are not happy with the quality of the practice nurse but actually it in some cases it is simply that the patient had wanted to see a doctor and not a nurse.

13.5

The Chair agreed that there are limitations with the FFT and felt that it is important that the Committee looks at how NCL can be on the front foot and be transformative.

13.6 The Committee NOTED the Quality and Performance Report.

13.7

Proposed changes to reporting Ms Fiona Erne presented an outline of the proposed changes to quality and performance reporting. NHS England’s primary care directorate, working with internal colleagues and CCG co-commissioners have established a working group to review the content of the quality & performance report. The group will consider the domains, metrics and information that can be included in the report and make recommendations about the content that will form the basis of a consultation with stakeholders on the future of the report. The three areas which it is proposed are reflected in the report are performance management, resilience of practices and delivery of transformation. These need to be reported at both CCG and practice level. Within each of these areas are a series of proposed metrics. Some of these would need to be reported through part two of the meeting as not all of the data is currently in the public domain. She welcomed feedback from the Committee on the proposed changes.

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13.8

Dr Jahan Mahmoodi felt that the proposed metrics under proactive care may need further development as measuring proactive care using metrics such as levels of flu vaccinations may not reflect all that a practice was doing to provide proactive care. Ms Fiona Erne agreed that how to best measure proactive care was challenging. She has asked the Healthy London Partnership team to consider this further. They are also considering separate metrics for practices who look after specific population group such as homeless or university practices, and also for practices situated in deprived areas. Dr Jahan Mahmoodi also asked for clarification around the access metrics and whether all practices participating in federated hub arrangements would automatically be marked as having good access. Ms Fiona Erne confirmed that this would be the case.

13.9

Ms Emma Whitby asked whether the metrics could include an indicator around whether patients feel involved in their care or about self-care. She acknowledged that it is important not to use indicators that are difficult to collect but this should be wider than just the Friends and Family Test. Also access should be more than just weekend access. Ms Cassie Williams suggested that measuring difficulty in making an appointment might be a good way to measure access and measuring Saturday and evening access should be considered. Ms Deborah McBeal agreed with this and confirmed that this initial proposal to the report changes is a good start.

13.10

Ms Ceri Jacobs highlighted that vaccination and screening are really important and she would therefore expect practices to be doing this and to be showing how they are meeting the needs of the local area. She contended that the metrics used for practices in deprived areas should not necessarily be any different.

13.11

Ms Karen Trew asked whether more regular data could be provided on a quarterly basis where indicators are only measured annually. She also asked whether it will be possible for longer trends over more than simply 6-12 months could be shown e.g. in relation to workforce. Ms Fiona Erne responded that the report would only be able to utilise nationally available data. Any additional data would need to be collated locally and currently there is no resource to improve the frequency of data collection.

13.12

Mr Gordon Houliston stated that if there are shared clinical priorities across NCL then this should be reflected in the report domains if possible. Ms Katherine Gerrans also suggested that the workforce data should also reflect HCAs and pharmacists here possible as this can also add more context to information about a practice. Mr Matthew Powls thought that the report could include information about what interventions are being made by CCGs in some of these areas and that the report could be presented more visually. Ms Fiona Erne agreed that this would help and explained that the graphics and how data will be presented is yet to come.

13.13

Dr Jahan Mahmoodi asked whether the same report is being developed across London. Ms Fiona Erne confirmed that this is the case. Ms Kathy Elliott queried whether there is information in NCL about how we look at quality outcomes. Ms Alison Blair confirmed that this has been reflected in the NCL STP case for change. Ms Kathy Elliott added that she is keen to see how the changes and investment being made is shared and communicated with patients and practices. Ms Alison Blair explained that this was incorporated in the STP workstream looking at improving quality and reducing variation. She agreed that the proposed new report would help to inform this work and further thought needs to be given to this.

13.14

The Chair concluded the discussion by reminding the Committee to send any additional feedback relating to the proposed changes to the quality and performance report to Ms Fiona Erne. She reiterated that it is important to think about and understand how discussions happening as part of the STP shape the work of this Committee. This is an iterative process and something which the Committee will return to again.

13.15 The Committee NOTED the draft proposed changes to the Quality and Performance Report.

14. Primary Care Commissioning Options Update

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14.1

Ms Alison Blair presented an update on the primary care commissioning options for delegated commissioning. She noted that local engagement work is continuing with CCG members and stakeholders about level 3 co-commissioning. Feedback from this engagement will be brought to the additional NCL Primary Care Joint Committee workshop scheduled in August 2016. The intention is also to bring an update to September CCG Governing Bodies to inform their decisions about whether an application for level 3 co-commissioning will be made in October 2016.

14.2 The Committee NOTED the primary care commissioning options update.

15. Recent decisions made through urgent decision making process

15.1

The Committee NOTED the recent urgent decisions relating to:

• The Surgery (Dr Raja), (Haringey CCG) • Bowes Medical Centre (Enfield CCG)

16. Any other business 16.1

There was no other business.

17. Resolution to exclude observers, the public and members of the press from the remainder of the meeting.

17.1 The Committee resolved to move to Part 2 of the agenda.

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Appendix: 6.2

Part Two Minutes (items 3 only) Meeting of the Islington Clinical Commissioning Group

Governing Body 13 July 2016


Members Present: Dr Jo Sauvage Chair, Islington Clinical Commissioning Group Sorrel Brookes Lay Vice Chair Dr Afsana Bhuiya Central Locality GP Representative Dr Katie Coleman Vice Chair (Clinical) Lucy de Groot Lay Member Deborah Snook Practice Manager Representative Jennie Hurley Practice Nurse Representative Dr Karen Sennett South West Locality GP Representative

Minutes: Frazer Tams Interim Corporate Affairs Manager

Introduction

Jo Sauvage explained that for item 2 on the Part 2 agenda the Executive Team were asked to leave due to the nature of the item discussed. Alison Blair, Paul Sinden, Ahmet Koray, Melanie Rogers and Karl Thompson left the meeting at this point.

3. North Central London Sustainability and Transformation Plan3.1 Jo Sauvage gave an overview of the Proposed New Commissioning

Arrangements highlighting:

• NHSE are looking for the CCGs to work together as a system to implementthe STP

• NHSE advise that this is a universal need for CCGs to be able to enactsystem change without delay incurred throughdebate and failing to gainconsensus on matters of transformation.

NHSE have made it clear there needs to be a unified approach to how NCL commission and this will include:

• A unified strategy across the 5 boroughs;• A single operating plan;• Achieving financially balance across CCGs, to achieve a unified control

total

.

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Appendix: 1.3

The North CCGs have been asked to redefine commissioning arrangements in order to deliver the outcomes of the STP. The CCGs have proposed an alignment of 2 teams comprising Islington/Haringey) andBarnet, Enfield and Camden respectively. It was felt that this alignment would map to the local provider landscape and current local plans of working.

Sensitivities detailed in this paper involve the impact on members of staff, particularly the senior leadership.

NHSE are running the HR process and have appointed a convener of the process who will be the Chair of Enfield CCG. JS confirmed that as part of the STP Board she will be looking to oversee this process. JS further confirmed that the convenor will be overseeing the process but all the Chairs will be involved in the appointment of individuals to roles.

The question being asked by NHSE regarding this model structure is how does the 2-team model facilitate a whole-system commissioning approach across the STP? NHSE preferred approach appears to be a governance structure with 1 Accountable Officer overseeing the STP. Below this there would be a Chief Finance Officer and Director of Commissioning able to deliver on the strategy and plan across the boroughs. With this, it is implied that the power of Veto from individual CCGs would be removed as responsibility to plan, commission and deliver the STP priorities would be delegated to this committee. JS highlighted the importance of this to the CCG, pointing out this is not the chosen direction the CCG wished to go in and NHSE will likely need to impose this, as it was at odds with the CCG duty to be responsible for the commissioning of services for its local population

JS clarified that she is no longer able to go to Simon Stevens with an agreement to a 2 and 3 structure, but the latest position will be that the CCGs need to step back over the next couple of months and agree what a meaningful response to this is before the end of September.

SB added that as we don’t know the costs etc we can’t be asked to agree to the proposal. The same would apply down the line for a 5 structure. Therefore if they want this to happen then NHSE will need to impose this.

LdG felt there was a need to be clear on what our responsibilities are. It is clear they Can’t abolish CCGs without a change in statute. We will need in writing a description of what it is NHSE want and how they think it will deliver better outcomes in term of a robust sustainable health system for the 5 boroughs.

LdG further suggested the CCG consider taking its own legal advice as a duty of care to our employees.

KS stated that if the direction is to go to a collective structure for all 5 CCGs then it would be preferable to do this now rather than move to a 3 and 2 and then restructure again in 18 months. The key consideration in doing this needs to be what will remain as a function and staff for the Islington services resulting from this process and what will the accountabilities be.

SB felt that rather than have an unaccountable individual responsible for 5 CCGs they should be concentrating on merging the governance.

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Appendix: 1.3

JS outlined the likely scenario which will be:

• Overarching STP AO/DOF • A Directorate that sits locally (likely to be for Islington and Haringey) likely

to be aligned to the wellbeing partnership. JS proposed that the best approach would therefore be to strengthen the local team to deliver what we wish for locally. The end point will be a Population based health approach otherwise referred to as an Accountable Care System. LdG questioned, who will pay for redundancies? DS further questioned, how can we endorse something that doesn’t fit within the constitutional set up for the CCG. LdG asked about the arrangement for North West London who have gone through this process? KC highlighted that the effectiveness of arrangements for North West London was based on the historical relationships shared with partners, with Inner London CCGs working effectively but the Outer CCGs not so effectively. KS clarified that Barnet and Enfield had made it clear they wanted to be part of a 5 structure. KS as a result, expressed that this might ultimately be the best model JS summarised the position statement of the Governing Body and key points to take forward to NHSE. These are:

• Fundamental fact that accountability r5esides within the CCGs; • We require in writing a description of the proposal, what it is and an

explanation of the relationship between staffing the executive and the governance.

• How the proposal will deliver better outcomes in relation to sustainability and quality;

• We need to work up between now and September what needs to remain in Islington and what are the accountabilities of the new structure and how will the governance work. What are the costs and liabilities.

JS added that when considering what remains in Islington, the question for AB will be about a permission to strengthen our local work with local colleagues around our local delivery plans. The Governing Body NOTED the report and supported the summary of comments detailed by Jo Sauvage.

These minutes are agreed to be a correct record of the Part 2 item 2 meeting of the Islington Clinical Commissioning Group Governing Body held on 13 July 2016 Signed:……………………………………Date:………………………….


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